mtm essentials for copd management: part 2

50 Drug topics July 2015 DrugTopics.com

EARN CE CREDIT FOR THIS ACTIVITY AT WWW.DRUGTOPICS.COM

Goal: To assist pharmacists in understanding strategies for improving patient outcomes related to COPD management.

After participating in this activity, the pharmacist should be able to:

● Discuss GOLD guidelines for

nonpharmacologic management of COPD

● Describe methods to identify adherence

issues with COPD medications

● Identify risk factors for COPD exacerbation,

hospitalization, and readmission

● Describe the role of the pharmacist in

medication therapy management in order to

decrease readmissions for COPD

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider

of continuing pharmacy education.Pharmacists are eligible to participate in the knowledge-based activity, and will receive up to 0.2 CEUs (2 contact hours) for completing the activity, passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

ACPE# 0009-9999-15-032-H01-P

Grant funding: This activity is supported by an indepen-dent educational grant from Boehringer Ingelheim Pharma-ceuticals, Inc.

Supported by an educational grant from Genentech

Novartis Pharmaceuticals Corporation

Activity Fee: There is no fee for this activity.

Initial release date: July 10, 2015

Expiration date: July 10, 2018

To obtain CPE credit, visit www.drugtopics.com/cpe and click on the “Take a Quiz” link. This will direct you to the UConn/Drug Topics website, where you will click on the Online CE Center. Use your NABP E-Profi le ID and the session code 15DT32-KZV23 to access the online quiz and evaluation. First-time users must pre-register in the Online CE Center. Test results will be displayed immediately and your participation will be recorded with CPE Monitor within 72 hours of com-pleting the requirements.

For questions concerning the online CPE activities, e-mail: [email protected].

CREDIT: 2.0

educationaL oBJectiVeS

MtM essentials for copD management: part 2Kathryn Wheeler, PharmD, BCPSASSOCIATE CLINICAL PROFESSOR, UNIVERSITY OF CONNECTICUT SCHOOL OF PHARMACY, STORRS, CONN.

IMAGE: GETTY IMAGES / STOCKBYTE / ARTHUR TILLEY / 360

Faculty: Kathryn Wheeler, Pharmd, BcPSDr. Wheeler is an associate clinical professor, University of Connecticut School of Pharmacy, Storrs, Conn.

Faculty Disclosure: Dr. Wheeler has no actual or potential con� ict of interest associated with this article.

Disclosure of Discussions of Off-Label and Investigational Uses of Drugs: This activity may contain discussion of unlabeled/unapproved use of drugs in the United States and will be noted if it occurs. The content and views presented in this educational program are those of the faculty and do not necessarily represent those of Drug Topics or University of Connecticut School of Pharmacy. Please refer to the of� cial information for each product for discussion of approved indications, contraindications, and warnings.

AN ONGOING CE PROGRAM OF THE UNIVERSITY OF CONNECTICUT SCHOOL OF PHARMACY AND DRUG TOPICS

Continuing Education

AbstractChronic obstructive pulmonary disease (COPD) is a diagnosis that pharmacists commonly encounter among patients in pharmacy practice. Treatment of COPD requires chronic management, which can be expensive for patients. Exacerbations of COPD are also very costly for healthcare systems. Pharmacists can assist patients with improving self-care of COPD in an effort to improve patient outcomes associated with appropriate management and adherence to medications. Through these efforts, pharmacists can also help to reduce hospital readmission rates and prevent the costly payment penalties implemented by the Centers for Medicare and Medicaid Services associated with excessive COPD readmissions. This article discusses some of the opportunities pharmacists have to address these concerns.

continuing education

July 2015 Drug topics 51DrugTopics.com

BackgroundChronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States.1 A progressive dis-ease, COPD is associated with a high rate of hospital admissions and readmissions for exacerbations of the disease.2 In Octo-ber 2014, pursuant to the Hospital Read-mission Reduction Program as mandated by the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) began reducing payments to hospitals with excessive readmissions for COPD.3 Hospi-tals primarily address exacerbation treat-ment, an acute care need, of patients with COPD. The patient is primarily responsible for his or her chronic disease management on a day-to-day basis to maintain control of the disease in the outpatient setting. How-ever, patients with COPD utilize healthcare resources at a high rate. This indicates a need for improved chronic disease manage-ment.4 In an effort to promote wellness of patients and avoid penalties associated with excessive readmissions for COPD, healthcare systems are developing strate-gies to better assist patients with their dis-ease management and therefore alleviate payment penalties. Pharmacists are well positioned to positively affect patient out-comes and readmission rates by assisting patients with chronic disease management.

How can pharmacists help?Appropriate management of COPD can al-leviate symptoms and reduce the number of exacerbations and hospitalizations that a

patient experiences.5-7 Speci� cally, improve-ments in the patient’s ability to self-manage COPD can improve exacerbation and hospi-talization rates.4 Pharmacists can use their knowledge and skills to help close gaps in care related to a patient’s COPD manage-ment by addressing risk factors and pro-moting prescriber adherence to guidelines and patient adherence to therapy.

Prevent exacerbations, hospitalizations, and readmissionsTo prevent exacerbations, hospitaliza-tions, and readmissions, clinicians and patients must work to prevent or manage risk factors associated with these events. An exacerbation is de� ned as “an acute event characterized by a worsening of the patient’s day-to-day variations” and lead-ing to a change in medication.5 Exacerba-tions signi� cantly affect a patient’s rate of declining health status and mortality.8-15 A patient may require weeks to recover from an exacerbation, during which time respira-tory symptoms are more severe.16 Exacer-bations can be precipitated by respiratory tract infections, air quality pollutants, and interruptions in maintenance therapy for COPD management.17-23 Reducing exacer-bations is a key strategy of COPD man-agement.5 However, insuf� cient research has been conducted to identify and mea-sure the effect of risk factors associated with exacerbations on patient outcomes. Identi� ed risk factors include a reduction in forced expiratory volume in one second (FEV1)% predicted,24,25 older age, low body mass index,24 chronic bronchitis,26 gastro-

esophageal re� ux disease, poor quality of life,27 anxiety, and depression.28 A previ-ous history of exacerbation is the stron-gest predictor for future exacerbation.24,27

Patients identi� ed as having two or more exacerbations within one year have been characterized as having a frequent exac-erbation phenotype and are at high risk of a future exacerbation independent of the stage of their disease.27 Further re-search is needed to allow clinicians to stratify risks according to predictive value and identify modi� cations to therapy for improved patients outcomes. Until such time, the Global Initiative for Chronic Ob-structive Lung Disease (GOLD) guidelines identify four strategies for preventing COPD exacerbations: encouraging smok-ing cessation and in� uenza and pneumo-coccal immunization for all patients with COPD; using long-acting bronchodilators in patients classi� ed as patient groups B, C, and D; ensuring clear patient knowl-edge of medication therapy and proper inhaler technique; and possibly admin-istering phosphodiesterase-4 inhibitors in patients with all of the following, FEV1

less than 50% of predicted value (GOLD 3 and GOLD 4 classi� cations for air� ow

Welcome to the CPE series, Medication Therapy Management for the Patient with Respiratory Disease, which was designed for pharmacists who take care of patients with respiratory disease. Beginning in April 2015 and continuing through December 2015, pharmacists can earn up to 18 hours of CPE credit with 9 monthly knowledge-based activi-ties from the University of Connecticut School of Pharmacy and Drug Topics.

This series kicked off in April and May with MTM essentials for asthma management—Part 1 and Part 2. Last month and this month, the focus shifts to MTM essentials for chronic obstruc-tive pulmonary disease (COPD) manage-ment. The August CE activity is a primer on inhalers and nebulizers. In Septem-ber, pharmacists have the opportunity to learn about allergic rhinitis manage-ment. In October, the CE activity covers

MTM essentials for cold, � u, and sinus-itis management. The November CE ac-tivity includes drug-induced pulmonary disease recognition and management and idiopathic pulmonary � brosis. The series concludes in December with a focus on MTM essentials for cough management.

The series also offers application-based and practice-based activities in 2016.

cpE sEriEs: MtM For tHE pAtiENt WitH rEspirAtorY DisEAsE

A previous history of exacerbation is the strongest predictor for future exacerbation.



severity), chronic bronchitis, and frequent exacerbations.5 A previous article in this series, MTM essentials for COPD manage-ment – Part 1, discusses identi� cation of patient groups and appropriate medication strategies by group.

Pharmacists can fulfill a key role in ensuring that these recommended strate-gies are implemented by ensuring proper maintenance management of COPD as supported by clinical guidelines; providing immunizations and appropriate treatment of comorbid conditions; and offering pa-tient education about COPD, medications, inhaler technique, and smoking cessation.

A systematic review of the literature assessed the factors associated with hos-pitalization and readmission of patients ex-periencing a COPD exacerbation.29 Previous hospitalizations, shortness of breath, and use of oral corticosteroids were predictive factors for readmission. Poor health status or health-related quality of life, chronic oxy-gen therapy, and lack of routine exercise were all correlated with increased risks of hospitalization and readmission. Although these factors may help to identify patients at risk of hospitalization and readmission, no data are available regarding how to modify care in an effort to reduce hospi-talizations and readmissions in these pa-tients. More research is necessary. With the reduction in payment by CMS for COPD readmissions, an increase in research to address risk factors and process of care issues related speci� cally to the care of patients with COPD is likely. However, the study of interventions aimed at reducing readmissions is not a new concept. Stud-ies have demonstrated the effectiveness of patient counseling and follow-up aimed at improving the discharge process and

transition of patient care from hospital to home in order to reduce adverse events leading to readmission.30-32 Although these studies were not speci� c to the population of patients with COPD, the interventions can easily be applied to this population. Pharmacists can provide the necessary education regarding proper use and moni-toring for ef� cacy and toxicity of a patient’s medication therapy, seek clarification of any changes to home medications after discharge, and periodically follow up with the patient to provide support and assess for and address concerns. The Better Out-comes for Older Adults through Safe Tran-sitions (BOOST) program and the ReEngi-neered Discharge process (RED) program are carefully constructed hospital discharge processes that include postdischarge fol-low-up with patients and are aimed at low-ering hospital readmission rates.33,34 The RED program demonstrated a lower rate of hospital utilization rates (emergency room services and readmissions) among patients receiving the intervention,33 and the BOOST program demonstrated a reduction in 30-day readmission rates.34 The “teach-back” method was speci� cally used to clarify pa-tient understanding regarding how to take prescribed medications (Table 1).35 Phar-macists had strong roles in each program, demonstrating that pharmacists can play a role in readmission reduction strategies.

CMS contracted with a company to study the effects of medication therapy manage-ment (MTM) services on bene� ciaries with chronic disease states including COPD. Pa-tients with COPD who were engaged in MTM services received improved quality drug ther-apies and experienced improved adherence to long-acting bronchodilators (LABA only and LABA + LAMA combination).36 However,

at one year, outcomes related to healthcare utilization rates and costs were inconsistent when compared to Medicare bene� ciaries who did not receive MTM services.36 This study, which included patients with other chronic diseases, demonstrated variation in the practice of MTM across organizations. The study allowed for identi� cation of those with high-performing comprehensive medica-tion review programs, which demonstrated consistent improvements in drug therapy outcomes as well as healthcare utilization rates and cost. The � nal report included a list of strategies for improving the suc-cess of MTM services. Recommendations included the development of clear MTM eli-gibility criteria, improvement of patient and provider awareness of MTM services and its bene� ts, the need to optimize engage-ment in comprehensive medication review, development of best practice standards for comprehensive medication review, utilization of technology and information systems, in-tegration of MTM with healthcare systems, development of quality measures for as-sessment of MTM services, and develop-ment of incentivizing payment strategies for medication management.36 It has been further suggested that patients with identi-� ed adherence issues should be speci� cally targeted for MTM services that can assist patients with these concerns. Current eligi-bility criteria for MTM services target ben-e� ciaries with high drug costs and multiple disease states. Patients who do not adhere to medications may not be adequately iden-ti� ed and targeted for the service that may assist them with improving adherence.37

Promote the guidelinesThe GOLD guidelines are established clinical practice recommendations for the diagnosis, management, and prevention of COPD. Most patients with COPD are diagnosed and treated by their primary care provider. In a survey involving a na-tional sample of physicians, only 54% of primary care physicians were aware of the GOLD guidelines for COPD.38 One study comparing the implementation of asthma and COPD guidelines in patient care dis-covered the undertreatment of patients with COPD, particularly in the early stages of the disease.39 The GOLD guidelines recommend that any patient experiencing

MtM eSSentiaLS FoR coPd ManageMent: PaRt 2

TABLE 1 stePs oF tHe teACH-BACK MetHoD1. Using simple language, clearly explain the concept/demonstrate the process.

2. Ask the patient to use his or her own words to state how he or she understands the concept/demonstrate the process.

3. Identify and correct misunderstandings and improper techniques or re-explain the concept/demonstrate the process again.

4. Ask the patient to re-explain/demonstrate again to ensure proper understanding of concepts/techniques.

5. Repeat steps 3 and 4 until you are satisfi ed that the patient comprehends or can safely perform the process you demonstrated.

Source: Ref 35

DrugTopics.com July 2015 Drug topics 53


dyspnea, chronic cough or sputum produc-tion, and a history of exposure to smoke or other noxious chemicals or particulates or a strong family history of COPD should be evaluated for COPD.5 Pharmacists can recognize these symptoms and risk fac-tors in a patient’s history and advocate for proper evaluation.

Spirometry is required for a diagnosis of COPD. A patient with a postbronchodila-tor spirometric result of FEV1/forced vital capacity (FVC) lower than 0.7 receives a diagnosis of COPD. However, a study of spirometry use in 197,878 patients with COPD aged more than 40 years found that only one-third of patients diagnosed with COPD had undergone spirometry, and less than 20% of newly diagnosed patients had a spirometry test performed within 90 days of an exacerbation.40 Spirometry is a standardized and objective measure of air� ow limitation. Its utility in diagnos-ing, staging, and guiding treatment strat-egies for COPD is the basis for multiple guidelines recommending its use for the con� rmation of COPD when a diagnosis is clinically suspected.5,41-43 Pharmacists can collaborate with other healthcare providers and advocate for spirometry testing in pa-tients with suspected COPD. Early identi� -cation of COPD allows for implementation of earlier interventions, which may alleviate a patient’s burden of symptoms and slow the progression of the disease.44

Advocate for nonpharmacologic manage-ment strategiesThe GOLD guidelines recommend non-pharmacologic management strategies

for all patients with COPD. Physical activ-ity is recommended for all patients with COPD. Smoking cessation is also listed as an essential management strategy for all patients with COPD; this intervention may include pharmacologic treatment for the management of nicotine withdrawal.5

Pulmonary rehabilitation is recommend-ed for patients falling into patient groups B through D. Pulmonary rehabilitation is a structured program consisting of exercise training, patient education, and emotional support intended to improve wellness by alleviating symptoms and increasing a pa-tient’s participation in life activities.45,46 An effective pulmonary rehabilitation program extends a minimum of six weeks. The ef-fectiveness of the program increases with its duration.47-49 This program has been shown to improve exercise tolerance and decrease shortness of breath and fatigue among patients with COPD.50 Pulmonary rehabilitation assists patients with many of the nonpulmonary concerns associ-ated with COPD that may not be fully ad-dressed by usual therapy, including physical deconditioning, muscle wasting, nutrition, social isolation, depression, and weight loss. Patients are provided education and strategies for coping with these issues (eg, exercise training) (Table 2).46,51-53 If a pa-tient continues the training received in the rehabilitation program after the program’s end, studies suggest the bene� ts can be sustained after completion of a single pul-monary rehabilitation program.54-56 Barri-ers to patient adherence to a pulmonary rehabilitation program have been identi� ed, such as a patient’s lack of con� dence, lack of perception of change, lack of motivation towards participation in a rehabilitation pro-gram, and lack of access to a pulmonary rehabilitation program. This knowledge has provided healthcare providers with key ways for improving patient adherence to a pulmonary rehabilitation program: building a patient’s con� dence, promoting tangible results, and helping patients prepare to engage in the program and gain access to available programs.57 Pharmacists can support patients in these ways by helping them to understand that COPD is a man-ageable disease. Patients often feel vul-nerable and overwhelmed after receiving a diagnosis. Understanding how to man-

age their disease state as well as their feelings regarding their diagnosis can build patient con� dence and possibly improve adherence to a pulmonary rehabilitation program. Patients are more likely to stick with a therapy that they feel is working. Ap-preciable improvements in breathing and exercise tolerance can increase a patient’s motivation for participating in a pulmonary rehabilitation program and increase his or her willingness to stick with the program. Explaining the importance and expectations of a pulmonary rehabilitation program can help a patient to prepare mentally and emo-tionally for engagement in the experience. For patients to participate in pulmonary re-habilitation programs, they must � rst have access to one.57 For some patients, this can be as simple as assisting in arranging for transportation services.

Immunize patientsYearly in� uenza vaccination is recommend-ed for all patients with COPD because it has been shown to reduce the incidence of serious respiratory tract infections, hos-pitalizations, and mortality in patients with COPD.5,58-61 The vaccination rate for pa-tients aged 54 to 60 years was 45.3% dur-ing the 2013-2014 in� uenza season; 65% of Americans aged 65 years and older re-ceived in� uenza vaccinations during that season.62 The GOLD guidelines and the United States Advisory Committee on Im-munization Practices (ACIP) recommenda-tions also endorse vaccination of patients with COPD with pneumococcal polysaccha-

TABLE 2 BeneFits oF PuLMonARY

ReHABiLitAtion FoR MAnAGeMent

oF CoPDImprovements in: Quality of life Functions of daily living Exercise tolerance Symptoms of breathlessness Management of anxiety and depression

Reduced: Mortality Healthcare utilization

Source: Ref 46, 51-53

Patients are more likely to stick with a therapy that they feel is working.

pause&ponder

How can you improve collaboration with other healthcare professionals in an effort to improve patient care?


Continuing Education MtM eSSentiaLS FoR coPd ManageMent: PaRt 2

ride vaccine.5,61 Current smokers should also receive pneumococcal vaccination.61

Vaccination with 23-valent pneumcoccal polysaccharide vaccine (PPSV23) is rec-ommended for both current smokers and patients with COPD.61 A study evaluating the effect of pneumococcal vaccination on rates of hospitalizations due to pneumonia in patients with COPD con� rmed a reduc-tion in pneumonia-related hospitalizations among patients who received pneumococ-cal vaccination.63 However, this study also demonstrated that rates of pneumococcal immunization are a cause for concern: only one in six veterans with COPD received pneumococcal immunization.63 Because pharmacists are highly accessible to pa-tients and can provide immunizations after proper training, pharmacists can close this gap in care by verifying appropriate immu-nization status of all patients with COPD and by providing the needed immuniza-tions to patients.

Help patients quit smokingA model of smoking statistics and dis-ease prevalence has demonstrated that today’s smoking rates determine tomor-row’s COPD burden.64 In 2013, 42.1 mil-lion Americans were smokers, of whom 76% were daily smokers.65 Healthcare spending attributed to smoking amounts to 170 billion dollars annually.66 Smoking cessation is the single most important in-tervention for altering the progression of COPD.5 Despite this, 39% of patients with

COPD continue to smoke.67 Pharmacists are routinely interacting with patients who require chronic medication management. This routine interaction allows pharmacists to assess patients’ willingness to quit smoking and offer patients the support, counseling, and resources required for sustaining smoking cessation. The “Five A’s” strategy (ask, advise, assess, assist, and arrange) is a simple and effective process that pharmacists can use to help patients quit smoking (Table 3).68

Address barriers to adherenceIn 2000, the cost associated with medi-cation nonadherence in the United States is estimated over 177 billion dollars.69

Hospital admissions related to medica-tion nonadherence contributed 121.5 bil-lion dollars to this total.69 Nonadherence to medications contributes to 33%-69% of all medication-related hospital admis-sions.70 Nonspeci� c to COPD patients, ad-herence to medications has been found to result in lowered healthcare utilization costs despite the increase in drug expen-diture.71 Adherence to treatment for COPD improves survival and health outcomes and reduces healthcare utilization.72-75 Non-adherence is high in patients with COPD; among these patients, nonadherence to inhalers and oral medications is estimated to range from 41% to 57%.76-77 An oppor-tunity exists for pharmacists to address the reasons for nonadherence in an effort to improve patient outcomes and costs.

More than 50% of patients use medica-tions more than prescribed during respira-tory distress,78 and up to 49% of patients underuse nebulized treatments.79-81 Under-use is the most common type of nonadher-ence.82 Half of patients prescribed inhaler therapies stop using these medications within the � rst year.83-85 Additionally, self-reported adherence rates are often higher than adherence rates calculated through objective measures. In a study that required patients to self-report adherence to bron-chodilator therapy at years one and � ve, the patient-reported adherence rate at year one was 60%. By year � ve, the reported rate of adherence had dropped to less than 50%. During the study, patient adherence was also monitored by weighing the inhaler can-ister. Rates of adherence, as measured by canister weights, were at least 10% lower than the self-reported adherence rates. Canister weighing is an objective method for assessing patient adherence to therapy, but this method can overestimate adher-ence as patients may waste extra doses from the inhaler when they are aware that they are being monitored.86 Weighing can-isters is no longer considered an accurate method for assessing doses remaining or patient adherence and is therefore not used in current clinical practice. Other objective means for assessing patient adherence include pill counts and medication re� ll his-tory. Each of these methods may likewise overestimate adherence in patients who know they are being monitored for proper use or are prompted to re� ll their medica-tions by automatic re� ll programs.

A patient’s medication re� ll history is another potential tool for assessing medi-cation adherence. However, a re� ll history is only available if patients purchase their medications. The cost of medications is a barrier to adherence for many patients. For example, over a span of two years, two mil-lion patients with Medicare coverage did not adhere to their prescribed treatments

TABLE 3tHe “FiVe A’s” MoDeL FoR tReAtinG

toBACCo use AnD DePenDenCeAsk about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise the patient to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.

Assess the patient’s willingness to make a quit attempt.

Is the tobacco user willing to make a quit attempt at this time?

Assist in the patient’s quit attempt.

For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit.

For patients unwilling to quit at this time, provide interventions designed to increase the likelihood of future quit attempts.

Arrange follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the fi rst week after the quit date.

For patients unwilling to make a quit attempt at this time, address tobacco dependence and willingness to quit at next clinic visit.

Source: Adapted from Ref 68

Today’s smoking rates determine tomorrow’s COPD burden.

DrugTopics.com July 2015 Drug topics 55


because of the cost of the medications.87

Using open-ended questions to directly ask patients about their ability to afford medications may provide useful informa-tion about nonadherence because of cost. For instance, asking “How do you pay for your medication?” and asking follow-up questions to address concerns about the cost of medications can prove helpful. Pharmacists can also review a patient’s complete medication list and determine the out-of-pocket cost to obtain a better under-standing of the patient’s cost concerns and ability to pay.88 With this in mind, pharma-cists may recommend lower-cost therapies or combination inhalers when possible to improve adherence. However, many medi-cations for COPD are still branded, leav-ing no lower cost generic option available. Combination inhalers may reduce the num-ber of copays for a patient, but depend-ing on the patient’s insurance coverage, this single copay may be more expensive. Therefore, when recommending changes to a patient’s medications with the intent of lowering out-of-pocket cost to the patient, it is important to be familiar with that pa-tient’s prescription drug coverage.

This technique of asking direct and open-ended questions in a nonjudgmental manner can also improve patient self-re-porting. Patients feel more encouraged to discuss their experiences and concerns in this type of environment. Asking “Will you tell me how you take your medications?” or asking for a demonstration of how patients take their medications has been shown to be effective in soliciting greater information than closed-ended questions that are per-ceived as judgmental by patients.89,90

There is a paucity of research speci� -cally addressing medication adherence in patients with COPD. Despite this, some factors correlating with nonadherence to COPD therapies have been identi� ed. In-dependent predictors of nonadherence include low expectation of medication ef-fectiveness, presence of comorbidities,

depression, and lack of con� dence in the healthcare provider.85,91 Factors that cor-relate with decreased adherence include smoking, sporadic attendance at clinic appointments, older age, and expensive medication regimens.85,91-93 Interventions to improve adherence must be based on an assessment of an individual’s barriers to adherence to their medications.

role of the MtM pharmacist The interventions described in this article � t well into the framework for pharmacist-provided MTM. The MTM framework facili-tates the collaboration of the healthcare team in an effort to achieve optimal pa-tient outcomes through safe and effective use of medications.94 Patients with COPD could bene� t from this service, which is designed to address gaps in care, coor-dination of care, education needs, com-prehensive medication reviews, adherence issues, cost concerns, medication action plans, and consistent follow-up and sup-port. Table 4 summarizes opportunities for pharmacists to address needs in patient care and potentially improve outcomes as-

sociated with COPD. The next article in this series will discuss assisting patients with proper inhaler technique for the variety of inhalers available today. For example, the techniques necessary for the proper use of metered dose inhalers and dry powder inhalers are different. A patient must un-derstand the speci� c requirements for ap-propriate use of prescribed inhalers for the treatment of his or her COPD to ensure each dose of medication is properly deliv-ered to the lungs.

conclusionPharmacists are well positioned to ad-dress current gaps in care and assist patients in improving adherence to pre-scribed therapies and self-management of COPD, which may improve readmission rates and healthcare costs associated with COPD.

The references are available online at www.drugtopics.com/cpe. •

TABLE 4

oPPoRtunities FoR PHARMACist inteRVention in tHe teAM-BAseD CARe oF PAtients WitH CoPD

Identify and target patients with risk factors for exacerbation, hospitalization, or readmission for comprehensive MTM services.

Recommend spirometry for diagnosis and staging of COPD.

Recommend therapies supported by clinical guidelines.

Recommend pulmonary rehabilitation for patients in patient groups B, C, and D.

Empower patients with disease state education and medication counseling.

Identify and address barriers to treatment adherence.

Recommend and provide infl uenza and pneumococcal vaccinations to all patients with COPD.

Help all patients to quit smoking.

Ensure that the patient is using proper inhaler technique.

Ensure proper management of comorbidities with medication.

Provide caring support to patients.

pause&ponder

How would you assess a patient’s adherence to inhaler medications? What would you do to improve a patient’s adherence to his or her medications?

For immediate cpE credit,take the test now online at

www.drugtopics.com/cpeonce there, click on the link below Free cpE Activities

DrugTopics.com56 Drug topics July 2015

test questions

1. Which of the following is a key nonpharmacologic strategy for the management of COPD and is supported in the GOLD guidelines as a nonpharmacologic therapy? a. Assessment of inhaler technique b. Pulmonary rehabilitation c. Medication counseling d. Medication therapy management services

2. All of the following strategies have demonstrated a reduction in healthcare utilization EXCEPT: a. The BOOST program b. The RED process c. Pulmonary rehabilitation program d. Weighing inhaler canisters to assess

patient adherence

3. What is the most common type of nonadherence among patients with COPD? a. Overuse of rescue medication b. Underuse of inhaler therapies c. Improper nebulizer technique d. Sporadic attendance at clinic

appointments

4. Which of the following is an independent predictor of nonadherence? a. Depression b. Smoking c. Male sex d. Two or more missed clinic appointments

5. Which of the following directly correlates with the future healthcare burden of COPD? a. Nonadherence to clinical guidelines for

disease management b. Interprofessional collaboration in health

care c. Nonadherence to medications d. Current smoking trend

6. All of the following therapies are general recommendations for all patients with COPD EXCEPT: a. Influenza vaccination b. Physical exercise c. Smoking cessation d. Pulmonary rehabilitation

7. Which of the following is the most important intervention that can alter the progression of COPD? a. Smoking cessation b. Proper inhaler technique c. Initiating treatment with a

phosphodiesterase-4 inhibitor d. Immunization with influenza and

pneumococcal vaccines

8. The GOLD guidelines recommend which of the following as a possible strategy to reduce exacerbations in patients with COPD? a. Use of long-acting bronchodilators as the

first-line therapy in all patients with COPD b. Use of medication refill histories to

assess for adherence issues c. Addressing risk factors for hospital

readmission with patients d. Initiation of treatment with a

phosphodiesterase-4 inhibitor in selected patients

9. Which of the following is the best predictor of a future exacerbation in a patient with COPD? a. Gastroesophogeal reflux disease b. A previous exacerbation c. Younger age d. Anxiety

10. Which of the following has been identified as a predictive factor of patient readmission for COPD? a. Use of oral corticosteroids b. Established exercise routine c. Overuse of rescue medications d. Lack of a collaborative multidisciplinary

discharge process

11. Which of the following is a strategy designed to help healthcare professionals assist patients with smoking cessation? a. Teach-back method b. The Five A’s method c. The BOOST program d. The RED process

12. All of the following can precipitate an exacerbation EXCEPT: a. Interruption of maintenance therapy for

COPD management b. Respiratory tract infections c. Exposure to pollution (poor air quality) d. An increase in FEV1

13. Which of the following factors correlates with increased risks of hospitalization and readmission? a. Lack of routine exercise b. Increased use of rescue inhaler c. Use of spirometry for diagnosis d. Lack of a collaborative multidisciplinary

discharge process

14. Patients described as having a “frequent exacerbation phenotype”: a. Are poorly adherent to medications b. Do not attend pulmonary rehabilitation c. Are at high risk of exacerbation

independent of COPD stage d. Cannot describe their prescribed chronic

management of COPD

15. According to the GOLD guidelines, for which of the following patients is a spirometry test recommended? a. 27-year-old patient recently diagnosed

with a respiratory infection who is experiencing new-onset cough and sputum production

b. 56-year-old patient experiencing chronic cough and with a history of heavy smoking

c. 47-year-old patient experiencing shortness of breath and recent exposure to poor air quality due to a high pollen count

d. 52-year-old patient experiencing a cough and who recently began therapy with lisinopril

16. Which of the following patients would you most suspect may have barriers to adherence? a. A patient who routinely refills his prescription

two days before he runs out of medication b. A patient who calls you for help to refill

her prescription early because her purse was stolen with her medication inside

c. A patient who brings his prescription to you and confides that he has little confidence the medication will be able to help him

d. A patient who periodically misses a clinic appointment because of scheduling conflicts with her work

17. The minimum duration of an effective pulmonary rehabilitation program is: a. Four weeks b. Six weeks c. 12 weeks d. 24 weeks

18. A reduction in FEV1% predicted is a risk factor for which of the following? a. Readmission b. Hospitalization c. Exacerbation d. Chronic cough

19. Which of the following is true regarding smoking? a. Smoking correlates with decreased

medication adherence rates. b. Quitting smoking does not prevent

exacerbations of COPD. c. Current smoking rates do not correlate

with expected future prevalence of COPD. d. There is no benefit to quitting smoking once

a patient has received a diagnosis of COPD.

20. Which of the following interventions has been shown to be effective at reducing readmission rates? a. Reviewing a patient’s refill history b. Chronic oxygen therapy c. The BOOST program d. Oral corticosteroids

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2015 Drug topics DrugTopics.com

1. Hoyert DL, Xu J. Deaths: preliminary data for 2011. Natl Vital Stat Rep. 2012;61:1-51.

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35. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic pa-tients who have low health literacy. Arch Intern Med. 2003;163:83-90.

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