Case Management Interventions Can Improve COPD Treatment Adherence
October 1, 2023 6 minutes read
By Melinda Young
EXECUTIVE SUMMARY
Medication adherence rates for patients with COPD are low, partially due to their dislike or difficulty with medicated inhalers.
- COPD medication also is more expensive than many other types, and some insurers provide little coverage.
- Patients with COPD often are managing comorbid conditions related to smoking and other health habits.
- Case managers can help patients improve adherence by showing them proper use of inhalers and addressing any other barriers they face.
Medication adherence rates for treatment of COPD are low. The results of research suggest fewer than half of patients with the chronic illness take their medication properly.1
“We find adherence is lower in COPD when compared to other chronic illnesses,” says Michelle Eakin, PhD, MA, co-director of the Johns Hopkins Adherence Research Center and an associate professor of medicine at Johns Hopkins School of Medicine.
There are several reasons why medication adherence is so low among this population, including:
- Most COPD medications are inhaled and require several steps;
- People often dislike the taste of inhalers, and unlike pills, the inhalers cannot fit into a reminder box;
- COPD medication is more expensive than many other types of medication. While Medicaid covers these medications, those with Medicare may face a high copay. Many of these medications are not available as generics.
Case managers and other providers can help improve treatment adherence through interventions that target some of the common adherence barriers.
Eakin describes how these interventions can help:
• Screen for undiagnosed comorbid illnesses. Since many people with COPD are former or current smokers, they often are diagnosed with cardiovascular disease and other chronic illnesses related to smoking, Eakin notes. If these comorbid conditions are not managed well, then COPD patients may not feel better with treatment.
Mental health comorbidities also are common in the patient population. “Thirty to 40% have critically significant symptoms of anxiety or depression,” Eakin says. “It’s often linked to COPD symptoms because the disease makes it difficult for them to breathe, and that triggers anxiety, which then makes breathing worse.”
A common way COPD patients manage their disease is to limit their activities, which can lead to depression, social isolation, and anxiety.
“We see a high rate of those mental health symptoms, and link it to the COPD symptoms,” Eakin explains. “We recommend everyone be screened for depression and anxiety. If they have symptoms, talk to doctors about starting antidepressants.”
Engaging in pulmonary rehab or home exercise may help with both mental and physical health. “A lot of literature shows that engagement in pulmonary rehab can improve COPD symptoms and their mental health,” Eakin says. “There is a tendency for people with COPD to isolate and not exercise.”
But they benefit from exercise performed safely under physician direction. “It improves their endurance — and also improves their mental health,” Eakin says.
• Provide effective education to patients. Patients with lung disease need both educational and behavioral interventions.
Case managers can provide behavioral support coaching to patients, making sure they are taking medications correctly.
“The inhalers have multiple steps that need to be done correctly,” Eakin explains. “Case managers can work with patients to make sure they know how to take them and are taking them correctly to get the full benefit of the medication.”
Patients also need to know how their medications work. Case managers could explain the inhaler medication targets inflammation from COPD. But patients should not expect an immediate benefit because it takes time for the medication to improve their symptoms.
“The purpose is to support patients,” Eakin says. “We need to support them to take the full regimens to have that maximal benefit.”
Evidence-based tactics include the provider or case manager watching the patient use the inhaler if it is time. If it is not, the provider can ask the patient to walk them through the steps to observe what they are doing and ensure they are not missing steps.
“Often, they’re not breathing at the right time when they press the inhaler. They may breathe too much or too quickly,” Eakin explains. “Each medication has its own instructions, and if it’s appropriate, the patient can use a spacer — a plastic tube attached to inhalers — to help them take the medications correctly.”
Spacers make it easier to take the correct dose. They are recommended especially for children and older adults who may not breathe in as deeply or quickly as needed.
“We recommend it for everyone,” Eakin says.
• Develop tactics to improve adherence. “We often can do a lot of stuff as low-tech as possible, such as setting a reminder on the phone that primes the person to take medication,” Eakin says. “They can keep their medication by their toothbrush, so they know they need to take it, and we can engage another adult in the household to support or remind them to take medication as needed.”
The best methods are to tailor the adherence intervention to the patient’s needs. “If they use their phone a lot, putting a reminder on the phone may be effective,” Eakin says. “Understand the patient’s routine and find ways to fit it within their daily routine.”
Prescribing tactics also can help patients improve adherence. For instance, a patient could be put on a once-a-day medication instead of twice-a-day. They can take one inhaler with two medications in it instead of taking separate inhalers for each drug.
• Help patients with cost barriers. With a little effort, providers can find an affordable inhaler option for patients with most types of insurance. This includes patients on Medicare, where certain plans will cover the medication and others will not.
“There are often multiple options for classes of medication inhalers,” Eakin says. “There can be four or more options for a broncho inhaler.”
If a patient was prescribed a medication that is not covered by insurance, they can be switched to something that is covered. “It’s just about making sure they’re on the one that is on their formulary,” Eakin notes. “Sometimes, they’re on two inhalers and can be switched to a combination, so they only have to pay for one.”
If a patient is uninsured or cannot afford copays, then some pharmaceutical companies offer lower cost plans. A case manager or social worker would need to contact companies directly to see if there are coupons or other ways of making the medication affordable.
Also, case managers can see if patients without insurance qualify for Medicaid or a subsidized health plan under the Affordable Care Act.
“It’s really important to make sure that [patients] are on the most effective medication for them and they’re given the appropriate treatment,” Eakin says.
• Address smoking, vaping, and other behaviors. “The most effective treatment for COPD is to quit smoking. It’s the only disease-modifying strategy at this time,” Eakin says.
Case managers should continue to address smoking with all COPD patients who struggle to stop the behavior. “That should be addressed, and they can provide patients with evidence-based treatment to help them quit smoking,” Eakin says. “There’s not a lot of research on e-cigarettes or cannabis, but anything inhaled is not good for your lungs. If you’re struggling with a chronic lung disease, these will only exacerbate the underlying disease.”
People with COPD also may not adhere to medication because of an attitude of fatalism. “They often blame themselves for the disease because of smoking,” Eakin explains. “They think, ‘I did this to myself,’ so they’re less invested in staying healthy.”
• Consider sleep apnea and cognitive impairment. Patients with COPD could be screened for sleep problems like sleep apnea and for cognitive decline — both of which are common in this population.
“There’s a high prevalence of cognitive impairment among COPD patients,” Eakin says. “It’s often related to their history of smoking and other chronic diseases.”
It can be helpful to refer patients at risk for sleep disturbances to a sleep study. They also might need additional support with medication management, such as another person in their home helping them remember their medication regimen.
Mild cognitive impairment often is unrecognized in COPD patients, although this could affect their medication adherence, Eakin says.
REFERENCE
- Case MA, Eakin MN. Up-to-date guidance towards improving medication adherence in patients with chronic obstructive pulmonary disease. Expert Rev Respir Med 2023 Jul 28;1-8. doi: 10.1080/17476348.2023.2239708. [Online ahead of print].
Medication adherence rates for treatment of COPD are low. The results of research suggest fewer than half of patients with the chronic illness take their medication properly.
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