Inadequate Device Use a Challenge in COPD Management, Dr David Mannino Explains

Chronic obstructive pulmonary disease (COPD) is a costly disease and the treatments for it are not always easy to use, which causes issues with inadequate inhaler use, explained David Mannino, MD, cofounder and medical director of the COPD Foundation.

There are a variety of devices to treat COPD and each one has its own benefits and challenges, and they all work different, which makes selecting the appropriate device for the patient crucial.

In this interview with The American Journal of Managed Care® (AJMC®), Mannino also discusses key drivers of health care utilization for COPD, utilization of health care resources associated with inadequate inhaler use, and utilization management strategies to ensure appropriate treatment.

AJMC^®: What are the key drivers of health care utilization in COPD? For example, exacerbations or uncontrolled symptoms?

Mannino: The main driver of cost would be hospitalizations, if you look at the overall picture. There are also other ways of measuring cost. such as medication use and doctor visits. And then there are even additional things, such as impact on life—for example, if somebody has COPD to the point where they were no longer able to work, that's another type of cost. And we typically separate costs into direct costs, which are health care dollars that are being spent, such as hospitalizations, medication, doctor visits, and then indirect costs, which are people who have to take off from an hourly job to go to a doctor visit or people who are no longer able to work. So, it becomes a sort of a tricky sort of concept to sort of try to measure cost.

But, yes, COPD is a costly disease. And if you look at the overall health care spending, hospitalizations are a primary driver.

AJMC^®: What is the economic burden of COPD in the United States?

Mannino: The estimated burden, and this was data from a couple of years ago, is about $50 billion dollars per year. And that encompasses, for example, the cost of hospitalization and medication and physician visits. But may not fully capture, for example, the cost of people who are no longer able to work because of COPD. Or there's a cost related to people who die early because of disease and that isn't necessarily always fully captured when we sort of look at these other medical costs.

AJMC^®: How are patients monitored for inadequate disease control to help decrease this burden?

Mannino: That is challenging, because first of all, although we have 15 million people in the United States who are diagnosed with COPD, there are many millions more who may have disease and don't necessarily know that they have it, because they attribute their symptoms to other things, such as just simply getting old or they just have a smoker’s cough or they've always coughed. That sort of rationalization that patients have. In people with diagnosed disease, monitoring patients becomes key, and really educating patients about what they should be able to do is critical. But in patients who have disease, but don't necessarily know that they have it yet, it becomes much more of a challenge.

AJMC^®: What are the factors influencing patient outcomes in COPD?

Mannino: There are a number of factors that influence outcomes. First of all, it's determining what are the key outcomes. For example, we measure lung function decline. So that's an outcome. Quality of life is an outcome that can be measured. COPD hospitalizations and exacerbations, which hospitalizations are subset of exacerbations. And then ultimately mortality is the ultimate outcome.

A person's lung function predicts their likelihood of exacerbations, hospitalizations, and death. Whether a person is still smoking is an important predictor of both hospitalizations and deaths and accelerated loss of lung function decline. What therapies they may be on and how well they can use those, and whether a person actually has an active exercise program. And when patients ask me, “What are the things that I can do to improve my outcomes?” I say, “Stop smoking, take your medication as directed, because they can decrease exacerbations, and be in an exercise program, such as either a formal pulmonary rehabilitation program or an informal exercise program.” If you don't move, you die; that's important whether you have COPD or not. So, exercise and movement are always important.

AJMC^®: What is the impact of inappropriate device selection for patients with COPD?

Mannino: One of the challenges that we have as we treat our patients with COPD is that there are a number of different devices that we have to choose from. And there is something called meter dose inhalers, which are the little spritzers that have been around for forever. And then there are other sort of iterations of dry powder inhalers. There's something called a spinhaler, that you put a pill in, and a person has to breathe in that medication in. There are soft mist inhalers that need to be assembled to provide the medication in a mist. And then there are also nebulizers or nebulized therapies where you have to pour medication into a little holding chamber and administer it through a nebulizer.

There are benefits and challenges to all these various forms of medication delivery. For many of them, you only have one opportunity to get it right. For example, people that use a metered dose inhaler, you only have one chance to get it right. Of course, you can try to take a second dose of it, but then if you did get that first dose in, you have the chance of getting a double dose, which then increases the risk for side effects. So, there are some issues related to these various devices.

If a person is on a device that they can't use correctly, they run the risk of really not getting the therapy that is best needed to treat their disease. We recommend, for example, that patients be observed when they're using their devices, and that that is a means of determining whether they're actually using their devices correctly. And for COPD Foundation, for example, we have a number of different videos that are available to patients on either our website or on an app that they can download for free, that shows them how to use these various devices correctly.

Physicians have to be sort of matching the device to the patient and be sure that the patients know how to use these devices correctly.

AJMC^®: How is the utilization of health care resources associated with inadequate inhaler use?

Mannino: We know that patients who've recently been hospitalized for COPD exacerbation may not have the necessary inspiratory strength to use some of the various devices that are out there and maybe devices that they've been on previously. So, for example, these are patients that might be better served being discharged, at least initially on a nebulized therapy, where they have several minutes to get their medication in, as opposed to having to do one deep inhalation off of, for example, a dry powder inhaler or even a soft mist inhaler.

So, these are challenges. And people who are unable to use these devices correctly are probably at an increased risk of having to be readmitted or rehospitalized for their COPD, since they're not really getting the medication they need to keep them out of the hospital. So, these are things that we're concerned about. And we actually have a couple of studies that are looking specifically at these patients, to be sure that: A, they're on the appropriate therapy, and B, that they can use that therapy appropriately.

AJMC^®: What utilization management strategies do you employ or does the COPD Foundation employ to ensure appropriate treatment for patients? Are there COPD management programs to patients to support adherence?

Mannino: Adherence to therapy has always been a challenge, and there are different levels to that. For example, there are issues related to patients being able to get their prescribed therapies. And these relate to insurance issues and copayments and how patients sort of can navigate through that system. And then once patients get therapies, do they have the necessary cognitive and physical abilities to be able to use these therapies correctly? And do they actually understand how they're supposed to use these therapies? So that's sort of another level of challenge. And there're different therapies that are out there. There are some therapies that, for example, that are 2 inhalations once a day, others are o1ne inhalation of once a day. There are others that are 2 inhalations twice a day. There are some therapies that are one inhalation twice a day, and the list goes on and on. And patients can get confused. It's like, “is this a therapy that I use once a day or twice a day? Or is it 1 inhalation or 2 inhalations?” Even though an instruction may be written out, they may not understand. And then to sort of complicate things further, some therapies require a quick inhalation along with a breath hold, and others require a sort of a slower and deeper inhalation.

That is one of the challenges that we have with all of these therapies—none of them are as easy to use, for example, compared to a cigarette. We don't have instructions that come along with a pack of cigarettes. People sort of know how to use those correctly. But every medication therapy that is out there to treat, in large part, diseases that cigarette smoking causes, have an extensive list of directions needed to use them. And they're often not used correctly.

AJMC^®: Do you have anything you'd like to say to your colleagues or to anyone out there about COPD?

Mannino: COPD is one of the leading causes of disability and death, not only in the United States, but also in the world. And at the COPD Foundation, we are committed to improving the lives of our patients with COPD, by looking at better therapies for patients. And we're working hard with other groups out there, including the US Food and Drug Administration and various manufacturers to look at how better therapies to treat—and someday we hope cure COPD—can be developed and made it available to patients.

And in addition, we also work with the patient community to answer their questions related to COPD, and also to come up with what we hope will, ultimately, be better therapeutic options to treat and one day cure COPD.