Optimization of patient-specific inhaler regimens: A pharmacy-pulmonology collaborative pilot program in the ambulatory care setting
Blum E, Thavarajah K, and Smith AL. Optimization of patient-specific inhaler regimens: A pharmacy-pulmonology collaborative pilot program in the ambulatory care setting. Chest 2016; 150(4):635A.
Inhaler technique is an important component of optimal control of asthma and COPD. Evidence suggests that 50- 90% of patients use their inhalers improperly and that detailed training alone is insufficient for maintaining correct inhaler technique with each device. Currently, there are no objective assessments or treatment guidelines to direct clinicians in selecting the optimal inhaler delivery device. The purpose of this pilot study is to evaluate the effects of the addition of a pulmonary clinic pharmacist to assess inhaler technique and to optimize inhaler regimens using a Vitalograph Aerosol Inhalation Monitor™ (VAIM). METHODS: This prospective, observational cohort study enrolled patients seen in the outpatient pulmonary clinic at Henry Ford Hospital (HFH) from October 2015 to March 2016. Patients were included if they had a diagnosis of COPD or asthma, spoke English, and were 18 years of age or older. Patients were excluded if they presented for imaging results review, had a tracheostomy, or had a diagnosis of interstitial lung disease, sarcoidosis, or lung cancer. A pharmacist provided inhaler regimen recommendations to physicians based on objective VAIM assessments to help develop an individualized therapy plan. If the recommendations were accepted, the pharmacist then reviewed any inhaler changes with the patient. Follow-up phone calls were made at one and four weeks after the initial visit. The primary endpoint was asthma or COPD control as defined by changes in asthma control test (ACT) or COPD assessment test (CAT) scores, patient-reported symptoms, and weekly rescue inhaler use. Secondary endpoints included changes in patient adherence as measured by the Morisky Medication Adherence Scale (MMAS4) and to describe the utility of the VAIM in objectively assessing inhaler technique. RESULTS: A total of 53 patients with COPD and/or asthma were screened; 44 patients met inclusion criteria. The majority of patients were female (59%) with a diagnosis of COPD and a median age of 60 years. Eighty-one percent of patients were interacting with a clinical pharmacist in the pulmonary clinic for the first time. While 72% of patients were on appropriate therapy per GINA and GOLD clinical guidelines, 27 (61%) patients received a recommendation to change inhaler devices based on VAIM assessments. Following pharmacist intervention and change in inhaler devices, rescue inhaler use decreased from 24.4 times per week at baseline to 10.6 times per week at week 4 (p=0.0019); CAT scores (n=19) improved from 24.4 at baseline to 20.2 at week 4 (p=0.0079); and ACT scores (n=12) improved from 12.3 at baseline to 16.6 at week 4 (p=0.04). The MMAS4 score improved from 0.8 to 0.4 at week 4 (p = 0.0217). CONCLUSIONS: A pharmacist-performed objective assessment of inhaler technique and subsequent pharmacologic recommendations added to a routine pulmonary clinic visit are not only feasible, but also may improve patient outcomes.