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Roche N, Usmani O, Franzini L, Labadini L, Mathews KS, Panigone S, van Boven JFM. Pharmaceutical, Clinical, and Regulatory Challenges of Reformulating Pressurized Metered-Dose Inhalers to Reduce Their Environmental Impact. J Aerosol Med Pulm Drug Deliv 2024. [PMID: 39504952 DOI: 10.1089/jamp.2024.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2024] Open
Abstract
The chlorofluorocarbons (CFCs) that were used as propellants in early pressurized metered-dose inhalers (pMDIs) had substantial ozone-depleting potential. Following the Montreal Protocol in 1987, the manufacture of a range of ozone-depleting substances, including CFCs, was gradually phased out, which required the propellants used in pMDIs to be replaced. Current pMDIs use hydrofluoroalkanes (HFAs) as propellants, such as 1,1,1,2-tetrafluoroethane (HFA-134a). Although these HFAs have no ozone-depleting potential, they have a high global warming potential (GWP), and consequently, their use is being phased down. One option for the discontinuation of HFA use in inhalers would be to discontinue all pMDIs, switching patients to dry powder inhalers (DPIs). However, a switch from pMDIs to DPIs may not be a clinically appropriate option for some patients; furthermore, the full lifecycle carbon footprint and the overall environmental impact of different inhalers should be considered. An alternative is therefore to reformulate the current HFA pMDIs to use low-GWP propellants, such as 1,1-difluoroethane (HFA-152a). This article summarizes the various steps and challenges associated with this change, illustrated using data from the inhaled triple combination of beclomethasone dipropionate, formoterol fumarate, and glycopyrronium bromide, a complex formulation of three molecules in a solution that contains liquid-phase propellant.
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Affiliation(s)
- Nicolas Roche
- Service de Pneumologie, Hôpital Cochin, APHP Centre et Université Paris Cité, Institut Cochin, INSERM UMR 1016, Paris, France
- Inserm, Équipe d'Épidémiologie Respiratoire Intégrative, CESP, Villejuif, France
| | - Omar Usmani
- NHLI Imperial College London, London, United Kingdom
| | | | | | | | | | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
- Medication Adherence Expertise Center of the northern Netherlands (MAECON), Groningen, The Netherlands
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
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Rozenberg D, Reid WD, Camp P, Campos JL, Dechman G, Davenport PW, Egan H, Fisher JH, Guenette JA, Gold D, Goldstein RS, Goodridge D, Janaudis-Ferreira T, Kaplan AG, Langer D, Marciniuk DD, Moore B, Orchanian-Cheff A, Otoo-Appiah J, Pepin V, Rassam P, Rotenberg S, Ryerson C, Spruit MA, Stanbrook MB, Stickland MK, Tom J, Wentlandt K. Translating the Interplay of Cognition and Physical Performance in COPD and Interstitial Lung Disease: Meeting Report and Literature Review. Chest 2024; 166:721-732. [PMID: 38901488 PMCID: PMC11489522 DOI: 10.1016/j.chest.2024.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 06/22/2024] Open
Abstract
TOPIC IMPORTANCE Cognitive and physical limitations are common in individuals with chronic lung diseases, but their interactions with physical function and activities of daily living are not well characterized. Understanding these interactions and potential contributors may provide insights on disability and enable more tailored rehabilitation strategies. REVIEW FINDINGS This review summarizes a 2-day meeting of patient partners, clinicians, researchers, and lung associations to discuss the interplay between cognitive and physical function in people with chronic lung diseases. This report covers four areas: (1) cognitive-physical limitations in patients with chronic lung diseases; (2) cognitive assessments; (3) strategies to optimize cognition and motor control; and (4) future research directions. Cognitive and physical impairments have multiple effects on quality of life and daily function. Meeting participants acknowledged the need for a standardized cognitive assessment to complement physical assessments in patients with chronic lung diseases. Dyspnea, fatigue, and age were recognized as important contributors to cognition that can affect motor control and daily physical function. Pulmonary rehabilitation was highlighted as a multidisciplinary strategy that may improve respiratory and limb motor control through neuroplasticity and has the potential to improve physical function and quality of life. SUMMARY There was consensus that cognitive function and the cognitive interference of dyspnea in people with chronic lung diseases contribute to motor control impairments that can negatively affect daily function, which may be improved with pulmonary rehabilitation. The meeting generated several key research questions related to cognitive-physical interactions in individuals with chronic lung diseases.
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Affiliation(s)
- Dmitry Rozenberg
- Temerty Faculty of Medicine, Respirology, University of Toronto, Toronto, ON, Canada; Respirology, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
| | - W Darlene Reid
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Pat Camp
- Department of Physical Therapy, The University of British Columbia, Vancouver, BC, Canada; Centre for Heart Lung Innovation, The University of British Columbia, Vancouver, BC, Canada
| | - Jennifer L Campos
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Gail Dechman
- School of Physiotherapy, Faculty of Health, Dalhousie University, Halifax, NS, Canada; Department of Medicine, Respirology, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Paul W Davenport
- Department of Physiological Sciences, University of Florida, Gainesville, FL
| | - Helga Egan
- Lung Health Foundation, Toronto, ON, Canada
| | - Jolene H Fisher
- Temerty Faculty of Medicine, Respirology, University of Toronto, Toronto, ON, Canada; Respirology, University Health Network, Toronto, ON, Canada
| | - Jordan A Guenette
- Department of Physical Therapy, The University of British Columbia, Vancouver, BC, Canada; Centre for Heart Lung Innovation, Providence Research, The University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada; Division of Respiratory Medicine, The University of British Columbia, Gordon and Leslie Diamond Health Care Centre, Vancouver, BC, Canada
| | - David Gold
- Department of Psychiatry, Krembil Brain Institute, University of Toronto, Toronto, ON, Canada; Neuropsychology Clinic, University Health Network, Toronto, ON, Canada
| | - Roger S Goldstein
- Temerty Faculty of Medicine, Respirology, University of Toronto, Toronto, ON, Canada; Department of Respiratory Medicine, Westpark Healthcare Centre, Toronto, ON, Canada
| | - Donna Goodridge
- College of Medicine, Respiratory Research Center, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Alan G Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Family Physician Airways Group of Canada, Markham, ON, Canada
| | - Daniel Langer
- KU Leuven, Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, Leuven, Belgium; Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Darcy D Marciniuk
- Division of Respirology, Critical Care and Sleep Medicine, Respiratory Research Center, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | | | - Veronique Pepin
- Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, QB, Canada
| | - Peter Rassam
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Rehabilitation Sciences Institute, School of Graduate Studies, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shlomit Rotenberg
- Department of Occupational Science & Occupational Therapy, and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada; Rotman Research Institute, Baycrest, Toronto, ON, Canada
| | - Chris Ryerson
- Centre for Heart Lung Innovation, Providence Research, The University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada; Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Martijn A Spruit
- Department of Research and Development, Ciro, Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Matthew B Stanbrook
- Temerty Faculty of Medicine, Respirology, University of Toronto, Toronto, ON, Canada; Respirology, University Health Network, Toronto, ON, Canada
| | - Michael K Stickland
- Division of Pulmonary Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; G.F. MacDonald Centre for Lung Health, Covenant Health, Edmonton, AB, Canada
| | | | - Kirsten Wentlandt
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Department of Supportive Care, University Health Network, Toronto, ON, Canada
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Green S. Climate-conscious inhaler prescribing for family physicians. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2024; 70:381-387. [PMID: 38886092 PMCID: PMC11280715 DOI: 10.46747/cfp.7006381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVE To provide family physicians with prescribing and diagnostic strategies that can reduce carbon emissions associated with inhalers. SOURCES OF INFORMATION This review is based on the authors' experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed. MAIN MESSAGE There is growing acknowledgment of the substantial impact that inhalers have on climate emissions generated by the health sector. Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available. Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care and enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions. Family physicians may reduce carbon emissions associated with inhalers by reducing unnecessary inhaler prescribing; ensuring patients' control of asthma and COPD is optimized; considering whether a more sustainable inhaler may be appropriate; optimizing dosing technique to reduce emissions and waste; and disposing of inhalers appropriately if possible. CONCLUSION Family physicians may reduce carbon emissions associated with inhalers through the following strategies: confirming diagnosis, controlling disease, considering inhaler type, optimizing dosing technique, and encouraging appropriate disposal.
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Affiliation(s)
- Samantha Green
- Family physician at Unity Health in Toronto, Ont, and Assistant Professor at the University of Toronto
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Vázquez-González N, Leiva-Fernández J, Cotta-Luque VM, Leiva-Fernández F, Rius-Díaz F, Martos-Crespo F, Martín-Montañez E, Barnestein-Fonseca P. Effectiveness of an educational intervention about inhalation technique in healthcare professionals in primary care: a cluster randomized trial. Front Pharmacol 2023; 14:1266095. [PMID: 37915412 PMCID: PMC10617029 DOI: 10.3389/fphar.2023.1266095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/21/2023] [Indexed: 11/03/2023] Open
Abstract
Background: Incorrect inhalation technique (IT) is an important issue for chronic obstructive pulmonary disease (COPD) patients and healthcare professionals. Studies in which counseling is carried out with healthcare professionals beforehand so that they can properly educate their patients are required. The objective of the present trial is to assess the improvement in the performance of the IT in subjects with COPD and prescribed inhaled therapy after the implementation of an educational intervention conducted by their general practitioners. Methods: A cluster randomized clinical trial was conducted. A total of 286 COPD patients received scheduled inhalation therapy from 27 general practices in seven primary care centers. A teach-back educational intervention was implemented for both healthcare professionals and patients. The primary outcome of this study was the performance of the correct inhalation technique. It is considered a good technique if all steps in the inhalation data sheet are correctly performed. The secondary outcomes were assessed using forced spirometry, the basal dyspnea index, the Medical Research Council dyspnea scale, St George's Respiratory Questionnaire (SGRQ), and EuroQoL5D-5L for health-related quality of life. A one-year follow-up was conducted using an intention-to-treat analysis. Results: After the intervention, incorrect IT was observed in 92% of professionals and patients, with rates reaching 50% and 69.2%, respectively. The effectiveness in patients was significant, with a number needed to treat of 2.14 (95% CI 1.79-2.66). Factors related to correct IT in patients included the type of intervention, length of intervention (>25 min), good pulmonary function, age (youngest <=65, oldest >83), and less limitation of activity due to dyspnea. There was no relation with the cluster. Conclusion: This study shows the effectiveness of direct inhaler technique training provided by a trained professional on an appropriate timescale (for example, a specific consultation for medication reviews), aiming to help subjects improve their performance using the teach-back method. This could be an encouraging intervention to improve medication adherence and health promotion in people with COPD. Clinical Trial Registration: clinicaltrials.gov, identifier ISRCTN93725230.
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Affiliation(s)
- Noemí Vázquez-González
- Department of Pharmacology and Pediatrics, Faculty of Medicine, University of Malaga. IBIMA Plataforma BIONAND, Malaga, Spain
- Transfusion, Tissues and Cells Centre of Malaga, Andalusian Health Services, Malaga, Spain
| | | | - Víctor M. Cotta-Luque
- Multiprofessional Teaching Unit of Community and Family Care Primary Care District Malaga-Guadalhorce Knowledge Management Unit Malaga-Guadalhorce Health District, Andalusian Health Services, IBIMA Plataforma BIONAND, Malaga, Spain
| | - Francisca Leiva-Fernández
- Multiprofessional Teaching Unit of Community and Family Care Primary Care District Malaga-Guadalhorce Knowledge Management Unit Malaga-Guadalhorce Health District, Andalusian Health Services, IBIMA Plataforma BIONAND, Malaga, Spain
| | - Francisca Rius-Díaz
- Department of Epidemiology and Public Health, Faculty of Medicine, University of Malaga, Malaga, Spain
| | - Francisco Martos-Crespo
- Department of Pharmacology and Pediatrics, Faculty of Medicine, University of Malaga. IBIMA Plataforma BIONAND, Malaga, Spain
| | - Elisa Martín-Montañez
- Department of Pharmacology and Pediatrics, Faculty of Medicine, University of Malaga. IBIMA Plataforma BIONAND, Malaga, Spain
| | - Pilar Barnestein-Fonseca
- Research Unit, Instituto CUDECA de Estudios e Investigación en Cuidados Paliativos, IBIMA Plataforma BIONAND, Málaga, Spain
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Bickel S, Cohen RT, Needleman JP, Volerman A. Appropriate inhaler use in children with asthma: barriers and opportunities through the lens of the socio-ecological model. J Asthma 2023; 60:1269-1279. [PMID: 36420559 PMCID: PMC10192155 DOI: 10.1080/02770903.2022.2152352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 11/25/2022]
Abstract
Objective: Proper use of inhaled medications is essential for management of asthma, as inhaled therapies are recommended as first-line for both prevention and treatment of asthma symptoms. Optimizing adherence requires identifying and understanding multiple layers of systemic complexity to obtaining and using these therapies and offering specific solutions to address these barriers. Bronfenbrenner's socio-ecological model provides a framework for examining multilevel systems - both internal and external - that contribute to the management of childhood asthma. The four levels in this model consist of factors related to the individual, interpersonal relationships, organizational entities, and societal structures and rules. This narrative review identifies influences and factors related to asthma inhaler adherence by each level and offers evidence-based solutions to each obstacle.Data Sources: We conducted PubMed searches to identify relevant articles for barriers and solutions impacting asthma control at each level of the socio-ecological model.Study Selection: Common barriers to asthma control at each model level were identified. Pertinent studies for each barrier were identified and reviewed by the writing group for inclusion into the narrative review.Results: For each level of the socio-ecological model, three primary issues were identified based on the literature review. Approaches for addressing each issue in an evidence-based, systematic fashion are presented.Conclusion: Understanding the obstacles and potential interventions to achieve proper use of inhaled medications is a critical step necessary to develop and implement systematic solutions aimed at improving asthma control and morbidity for the more than 6 million affected children in the United States.
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Affiliation(s)
- Scott Bickel
- Division of Pediatric Pulmonology, Allergy & Immunology, Norton Children’s and University of Louisville School of Medicine, Louisville, KY, USA
| | - Robyn T. Cohen
- Division of Pediatric Pulmonary and Allergy, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Joshua P. Needleman
- Division of Pediatric Pulmonology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anna Volerman
- Department of Medicine and Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Barnestein-Fonseca P, Cotta-Luque VM, Aguiar-Leiva VP, Leiva-Fernández J, Martos-Crespo F, Leiva-Fernández F. The importance of reminders and patient preferences to improve inhaler technique in older adults with COPD. Front Pharmacol 2023; 13:989362. [PMID: 36686678 PMCID: PMC9846566 DOI: 10.3389/fphar.2022.989362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/29/2022] [Indexed: 01/06/2023] Open
Abstract
Objectives: Medication non-adherence in patients with chronic obstructive pulmonary disease is common. The aim is to evaluate the efficacy of two interventions to improve the inhalation technique (IT) in patients with pulmonary disease is common. Also determine optimal IT reminder time and to test the role of preferences in the intervention selection. Method: 726 pulmonary disease in common patients (consecutive sampling) from two trials: 1) TECEPOC-study (patients' preference trial/comprehensive cohort design) 2) TIEPOC-study (randomised controlled trial). Interventions: intervention-A (ad-hoc leaflet with instructions about correct IT according Spanish Respiratory Society), intervention B (intervention A+ individual training by instructors). Four visits were performed (baseline, 3, 6 and 12 months). Data on IT, sociodemographic and clinical characteristics, quality of life and respiratory drugs were recorded. Analysis under intention to treat principle. Multivariate analysis was conducted to measure the potential modifying factors of improvement in the IT along follow-up. Results: 660 patients (90.9%) did not perform a correct IT at baseline 89.75% with Handihaler, 86.95% with Turbuhaler, 84.75% with Accuhaler and 87.35% with pMDI. At 12 months, 221 patients 29.9% performed correctly the IT; a decrease in the slope of the curve (correct IT) was detected at 3 months follow-up. Intervention B was the most effective in both trials compared to control group or intervention A, regardless of preferences: 1) TECEPOC Study (preference trial): Intervention B versus control group, NNT = 3.22 (IC95%, 2.27-5.52); and versus Intervention A, NNT = 3.57 (CI95%, 2.41-6.8). Preferences improved 6.7% in the correct IT without statistical significance. 2) TIEPOC Study (randomized controlled trial): Intervention B versus control group, NNT = 1.74 (IC95%, 1.47-2.17), and versus intervention A, NNT = 3.33 (CI 95%, 2.43-5.55). No differences were measured between Intervention A and control group. Conclusion: Individual training significantly improves IT. Reminders every 3 months are recommended. Preferences do not influence the intervention effectiveness.
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Affiliation(s)
- P. Barnestein-Fonseca
- Research Unit Instituto CUDECA de Estudios e Investigación en Cuidados Paliativos Fundación CUDECA, IBIMA Plataforma BIONAND, Málaga, Spain
| | - VM. Cotta-Luque
- Multiprofesional Teaching Unit of Community and Family Care Primary Care District Málaga-Guadalhorce Knowledge Management Unit Málaga-Guadalhorce Health District, Andalusian Health Services, IBIMA Plataforma BIONAND, Málaga, Spain
| | - VP. Aguiar-Leiva
- Research Unit Instituto CUDECA de Estudios e Investigación en Cuidados Paliativos Fundación CUDECA, IBIMA Plataforma BIONAND, Málaga, Spain
| | - J. Leiva-Fernández
- UGC Vélez Sur Area Sanitaria Málaga Este-Axarquía, Andalusian Health Services, IBIMA Plataforma BIONAND, Málaga, Spain
| | - Francisco Martos-Crespo
- Department of Pharmacology and Paediatrics, School of Medicine, University of Malaga (UMA)- IBIMA Plataforma BIONAND, Malaga, Spain,*Correspondence: Francisco Martos-Crespo,
| | - F. Leiva-Fernández
- Multiprofesional Teaching Unit of Community and Family Care Primary Care District Málaga-Guadalhorce Knowledge Management Unit Málaga-Guadalhorce Health District, Andalusian Health Services, IBIMA Plataforma BIONAND, Málaga, Spain
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Chow MY, Pan HW, Lam JK. Delivery technology of inhaled therapy for asthma and COPD. ADVANCES IN PHARMACOLOGY 2023. [PMID: 37524490 DOI: 10.1016/bs.apha.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
Inhaled therapy is the cornerstone of the management of asthma and chronic obstructive pulmonary disease (COPD). Drugs such as bronchodilators and corticosteroids are administered directly to the airways for local effect and rapid onset of action while systemic exposure and side effects are minimized. There are four major types of inhaler devices used clinically to generate aerosols for inhalation, namely, pressurized metered-dose inhalers (pMDIs), nebulizers, Soft Mist™ inhalers (SMIs) and dry powder inhalers (DPIs). Each of them has its own unique characteristics that can target different patient groups. For instance, patients' inhaler technique is critical for pMDIs and SMIs to achieve proper drug deposition in the lung, which could be challenging for some patients. Nebulizers are designed to deliver aerosols to patients during tidal breathing, but they require electricity to operate and are less portable than other devices. DPIs are the only device that delivers aerosols in dry powder form with better stability, but they rely on patients' inspiration effort for powder dispersion, rendering them unsuitable for patients with compromised lung function. Choosing a device that can cater for the need of individual patient is paramount for effective inhaled therapy. This chapter provides an overview of inhaled therapy for the management of asthma and COPD. The operation principles, merits and limitations of different delivery technologies are examined. Looking ahead, the challenges of delivering novel therapeutics such as biologics through the pulmonary route are also discussed.
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Fradelos EC, Barisone M, Lora E, Valiakos E, Papathanasiou IV. COMPETENCIES AND SKILLS NEEDED IN THE MANAGEMENT OF CHRONIC PATIENTS' NEEDS THROUGH TELECARE. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2023; 51:403-416. [PMID: 37756462 DOI: 10.36740/merkur202304116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Aim: To identify the necessary competencies that future professionals must obtain in order to effectively manage patients with chronic conditions. We employed a multilayer review in PubMed, Scopus and Cochrane. PATIENTS AND METHODS Materials and Methods: We applied three searches in PubMed, Scopus, and Cochrane using various terms in order to identify the necessary skills and competences needed for healthcare professionals to provide distance care in patients with chronic conditions. From the initial search, a total of 1008 studies were identified while 54 met the inclusion criteria and were retained for data extraction. After the review of the 54 studies, we grouped the proposed skills and competencies in eight major categories. Those groups were Clinical Knowledge, Critical Thinking Skills, Technological Skills, Clinical skills, Communication skills, Implementation skills, Professionalism and professional ethics, Evidence based Practice. CONCLUSION Conclusions: Although telehealth is gaining ground in healthcare practice and healthcare professionals possess the necessary knowledge and skills to provide safe, effective, and personalized care, additional specialized training is nevertheless required to provide telecare. Therefore, the integration of telehealth into various healthcare professions curricula - both at undergraduate and postgraduate levels - is required for the development of education and the dynamic development of healthcare.
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Usmani OS, Bosnic-Anticevich S, Dekhuijzen R, Lavorini F, Bell J, Stjepanovic N, Swift SL, Roche N. Real-World Impact of Nonclinical Inhaler Regimen Switches on Asthma or COPD: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2624-2637. [PMID: 35750323 DOI: 10.1016/j.jaip.2022.05.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Switching inhaler regimens can be driven by poor disease control but also by nonclinical factors, such as cost and environmental impact. The consequences of switching for nonclinical reasons are largely unclear. OBJECTIVE To systematically review the real-world consequences of switching inhaler regimens for nonclinical reasons in asthma and/or chronic obstructive pulmonary disease patients. METHODS Embase, MEDLINE, EBM Reviews, and EconLit were searched to November 21, 2020. Conference searches and reference checking were also performed. Real-world studies of asthma and/or chronic obstructive pulmonary disease patients undergoing a switch in inhaler regimen for any reason apart from clinical need were included. Two reviewers screened and extracted data. Key outcomes included symptom control, exacerbations, and patient-doctor relationships. RESULTS A total of 8,958 records were screened and 21 studies included. Higher-quality (matched comparative) studies were prioritized. Five matched studies (6 datasets) reported on symptom control: 5 datasets (n = 7,530) with unclear patient consent reported improved disease control following switching, and 1 dataset (n = 1,648) with non-consented patients reported significantly worsened disease control. Three matched studies (5 datasets, n = 10,084) reported on exacerbation rate ratios; results were heterogeneous depending on the definition used. Two studies (n = 137) reported that switching inhaler regimens could have a negative impact on the doctor-patient relationship, especially when the switches were non-consented. Study quality was generally low. CONCLUSIONS Switching inhaler regimens is a complex issue that can have variable clinical consequences and can harm the patient-doctor relationship. Limited high-quality evidence was identified, and study designs were heterogeneous. A robust framework is needed to guide the personalized switching of inhalers.
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Affiliation(s)
- Omar S Usmani
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, UK
| | - Sinthia Bosnic-Anticevich
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Clinical Management, Woolcock Institute of Medical Research, Sydney, Australia
| | - Richard Dekhuijzen
- Faculty of Medical Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - John Bell
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | | | | | - Nicolas Roche
- Department of Respiratory Medicine, Cochin Hospital and Institute, APHP Centre University Paris Cité, Paris, France.
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Hsiao YH, Tseng CM, Sheu CC, Wang HY, Ko HK, Su KC, Tao CW, Tsai MJ, Chen YF. Shared Decision-Making Facilitates Inhaler Choice in Patients with Newly-Diagnosed Chronic Obstructive Pulmonary Disease: A Multicenter Prospective Study. Int J Chron Obstruct Pulmon Dis 2022; 17:2067-2078. [PMID: 36081765 PMCID: PMC9448347 DOI: 10.2147/copd.s376547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Inadequate inhaler technique and nonadherence to therapy are associated with poorer clinical outcomes in chronic obstructive pulmonary disease (COPD). Shared decision-making (SDM), based on clinical evidence, patient goals and preferences, improves quality of care. This study aims to investigate the initial patients’ choices of inhaler devices in patients with newly-diagnosed COPD after an SDM process. Patients and Methods We conducted a prospective, observational, multi-center study in four hospitals in Taiwan from December 2019 to July 2021. All treatment-naïve patients with newly-diagnosed COPD who were able to use three different inhalers of dual bronchodilators (Respimat®, Ellipta®, and Breezhaler®) in the outpatient setting were enrolled. After an SDM process, every patient was prescribed with one inhaler chosen by him- or herself. Errors of using inhalers were recorded after prescription of the inhaler, and at the follow-up visit a month later. The patients’ adherence, satisfaction score, and willingness to keep the initially chosen inhaler were investigated. Results In 109 enrolled patients, 43, 45, and 21 patients chose Respimat®, Ellipta®, and Breezhaler®, respectively. Patients chose different inhalers had similar rates of critical error on both visits, while the rates greatly decrease on the follow-up visit, no matter which inhaler devices they chose initially. The majority of patients had good adherence (use as the prescription daily, n = 79, 82%), satisfaction (satisfaction score ≥4, n = 70, 73%), and strong willingness to keep the initial inhaler (n = 89, 93%) on the follow-up visit regardless of disease severity and their comorbidities. Conclusion SDM might facilitate inhaler choosing, reduce inhaler errors (versus baseline) with good adherence, satisfaction and strong willingness to keep the initial inhaler in patients with newly-diagnosed COPD.
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Affiliation(s)
- Yi-Han Hsiao
- Division of General Chest Medicine, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department and Institute of Physiology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Min Tseng
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Chest Medicine, Department of Internal Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Yi Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsin-Kuo Ko
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Cheng Su
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Clinical Respiratory Physiology, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chi-Wei Tao
- Division of Chest Medicine, Department of Internal Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Ming-Ju Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Correspondence: Ming-Ju Tsai, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, 807, Kaohsiung, Taiwan, Tel +886 7 3121101, Ext. 5651, Fax +886 7 3161210, Email
| | - Yen-Fu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Yen-Fu Chen, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan, Tel +886 5 5323911, Ext. 2501, Email
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11
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Lindh A, Theander K, Arne M, Lisspers K, Lundh L, Sandelowsky H, Ställberg B, Westerdahl E, Zakrisson AB. One additional educational session in inhaler use to patients with COPD in primary health care - A controlled clinical trial. PATIENT EDUCATION AND COUNSELING 2022; 105:2969-2975. [PMID: 35672192 DOI: 10.1016/j.pec.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To investigate whether one additional educational session about inhaler use, delivered to patients with COPD in primary healthcare, could affect the patients' skills in inhaler use. Specifically, to study the effects on errors related to handling the device, to inhalation technique, and to both. METHODS This nonrandomized controlled clinical trial included 64 patients who used devices and made errors. COPD nurses assessed inhaler use using a checklist and educated patients. Intervention group received one additional educational session after two weeks. RESULTS At baseline, patients in the IG had more devices (n = 2,1) compared to patients in the CG (n = 1,6) (p = 0.003). No other statistically significant differences were seen at baseline. At follow-up, intervention group showed a lower proportion of patients who made errors related to handling the device (p = 0.006). No differences were seen in the other categories. CONCLUSION One additional educational session in inhaler use for patients with COPD was effective in reducing the proportion of patients making errors related to handling of their devices. PRACTICE IMPLICATIONS Categorization of errors might help healthcare professionals to assess the suitability of patients' devices, tailor patient education, and thus improve patient health.
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Affiliation(s)
- Annika Lindh
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Sweden; Centre for Clinical Research and Education, Region Värmland, Sweden.
| | - Kersti Theander
- Centre for Clinical Research and Education, Region Värmland, Sweden.
| | - Mats Arne
- Centre for Clinical Research and Education, Region Värmland, Sweden; Department of Medical Sciences, Respiratory, Allergy & Sleep Research, Uppsala University, Sweden.
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Sweden.
| | - Lena Lundh
- Academic Primary Health Care Centre, Stockholm, Sweden; Karolinska Institute, NVS, Division of Family Medicine and Primary Care, Stockholm, Sweden.
| | - Hanna Sandelowsky
- Academic Primary Health Care Centre, Stockholm, Sweden; Karolinska Institute, NVS, Division of Family Medicine and Primary Care, Stockholm, Sweden.
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Sweden.
| | - Elisabeth Westerdahl
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden.
| | - Ann-Britt Zakrisson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden.
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12
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Exploring General Practitioners' Preferences and Experience with Respiratory Inhaler Devices. Pulm Ther 2022; 8:283-296. [PMID: 35908142 PMCID: PMC9458836 DOI: 10.1007/s41030-022-00197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/18/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Correct inhaler technique is essential for the optimal delivery of inhaled medicines and the successfully management of respiratory conditions. The general practitioner (GP), the prescriber of inhaled medicines, plays a crucial role in educating patients on inhaler technique. However, in the real-world setting, there are barriers. For the GP, it is time and competence and for the patient, it is their ability to recognise inhaler technique as an issue and their ability to maintain correct inhaler technique over time. This study aimed to determine GPs’ experience, skills and priority placed on inhaler technique and to identify factor(s) associated with inhaler technique competence. Methods This cross-sectional observational study design surveyed GPs’ perspectives on inhaler use and preferences for inhaler prescribing within their practice setting. GP inhaler technique was assessed. GPs were recruited through an established network of GP practices. Data collected include (i) practice demographics, (ii) inhaler technique opinions and experience, (iii) inhaler prescribing preferences and (iv) inhaler education history data. Data were analysed descriptively and multivariate logistic regression modelling was used to explore the relationship between outcomes and GPs’ ability to use devices correctly. Results A total of 227 GPs completed the inhaler survey. Sixty-three percent of GPs reported receiving previous inhaler education and 73.3% educated or checked their patients’ inhaler technique; 64.5% felt they were somewhat competent in doing so. GPs who reported not demonstrating inhaler technique believed that a pharmacist or a practice nurse would do so. When prescribing new inhaler devices, GPs considered the disease being treated first and then patient’s experience with inhalers; they often already have an inhaler preference and this was related to familiarity and perceived ease of use. For GPs, inhaler competence was not associated with their previous inhaler education or the priority placed on inhaler technique. Conclusion GPs do recognise the importance of inhaler technique in respiratory management but their technique can be better supported with regular educational updates to inform them about new inhalers and management practices and to support appropriate inhaler choices for their patients. Supplementary Information The online version contains supplementary material available at 10.1007/s41030-022-00197-6.
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13
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Kebede AT, Trapnes E, Lea M, Abrahamsen B, Mathiesen L. Effect of pharmacist-led inhaler technique assessment service on readmissions in hospitalized COPD patients: a randomized, controlled pilot study. BMC Pulm Med 2022; 22:210. [PMID: 35624509 PMCID: PMC9145163 DOI: 10.1186/s12890-022-02004-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/13/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate the effect of pharmacist-led inhaler technique assessment service on readmissions and CAT-score in hospitalized COPD patients. Furthermore, to provide an effect estimate for sample size calculations for future studies and to gain experience on the feasibility of such studies. METHODS A randomized controlled pilot study. Patients were randomized 1:1 to intervention or standard care. The primary endpoint was the difference in time to first readmission after hospital discharge between the treatment groups. RESULTS There was no statistically significant effect on the time to readmission (median 41 days in the intervention group (19 patients) and 95 days in the control group (20 patients), HR 1.74, 95% CI 0.81-3.75, p = 0.16). There was no statistically significant difference between the groups in CAT-score 2 months after discharge, median scores being 25.5 and 24 in the intervention and the control group, respectively (p = 0.29). There was, however, a reduction of 3.5 units in CAT-score from baseline to 2 months after discharge in the intervention group, compared to no change in the control group. CONCLUSION Pharmacist-led inhaler technique training had no effect on time to readmission or CAT-score. Future studies in larger populations should consider focusing on patients with less severe COPD, exploring CAT-score as a primary endpoint, consider stratifying for important baseline variables and evaluate the acceptability of the intervention. TRIAL REGISTRATION Date of registration 01/10/2018. CLINICALTRIALS gov identifier: NCT03691324.
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Affiliation(s)
- Adyam Tesfamariam Kebede
- Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway
- Department of Pharmaceutical Services, Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South-Eastern Norway, Oslo, Norway
| | - Elin Trapnes
- Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway
| | - Marianne Lea
- Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway
- Department of Pharmaceutical Services, Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South-Eastern Norway, Oslo, Norway
| | - Bjørg Abrahamsen
- Chief Physician at the Department of Pulmonary Medicine, Oslo University Hospital, Oslo, Norway
| | - Liv Mathiesen
- Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway
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14
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Kan A, Şen V. The Use of Puzzles in Inhaler Technique Training. J Asthma 2022; 59:2413-2420. [PMID: 35259046 DOI: 10.1080/02770903.2022.2051542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective: Inhaled drugs are essential for the treatment of several chronic respiratory diseases. However, patient inhaler techniques are frequently suboptimal; here, educational games may enhance patients' understanding of educational interventions. In addition, patients may practice repetitively, learning in a more relaxed and fun environment. In this study we aimed to compare two methods of inhaler technique training: (1) face-to-face training only and (2) face-to-face training and a subsequent puzzle game.Methods: The participants in group 1 were provided only face-to-face training. In group 2, the participants were given a puzzle after receiving the face-to-face training. Subsequently, the inhaler technique scores of both groups were compared. The chi-squared (χ2 ) test was used for categorical variables and the Mann-Whitney U test (non-parametric) or Student's t test (parametric) were employed to compare the numerical variables between the groups.Results: In total, 170 patients with asthma and their parents were included in the study. It was found that the median total scores for the inhaler technique (p < 0.001) and the number of correct users (p < 0.001) were higher in group 2, whereas the inhaler technique error rate in shaking the inhaler tube (p < 0.001) was higher in group 1.Conclusion: The present study revealed that the success rate of correct users and participants' total scores were higher in the puzzle game group. Therefore, a game may help patients to better remember and visualize the steps of the inhaler technique. Our study supports the use of puzzles as real-world applications to teach patients optimal inhaler technique.
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Affiliation(s)
- Ahmet Kan
- Department of Pediatric Allergy and Immunology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Velat Şen
- Department of Pediatric Pulmonology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
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15
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NUCERA F, BIANCO A, DAVID T, SALVATO I, ADCOCK IM, CARAMORI G. Treatable traits in COPD patients. Minerva Med 2022; 113:449-459. [DOI: 10.23736/s0026-4806.22.08001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Valipour A, Aisanov Z, Avdeev S, Koblizek V, Kocan I, Kopitovic I, Lupkovics G, Man M, Bukovskis M, Tudoric N, Vukoja M, Naumnik W, Yanev N. Recommendations for COPD management in Central and Eastern Europe. Expert Rev Respir Med 2022; 16:221-234. [PMID: 35001780 DOI: 10.1080/17476348.2021.2023498] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries. AREAS COVERED Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE. EXPERT OPINION Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna Health Care Group, Vienna, Austria
| | - Zaurbek Aisanov
- Department of Pulmonology, Pirogov Russian State National Research Medical University, Moscow, Russia
| | - Sergey Avdeev
- Pulmonology Department, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vladimir Koblizek
- Department of Pneumology, Faculty of Medicine in Hradec Kralove, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Ivan Kocan
- University Hospital Martin, Jessenius Faculty of Medicine, Commenius University, Martin, Slovakia
| | - Ivan Kopitovic
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Gergely Lupkovics
- Adult Pulmonary Department, Institute for Pulmonary Diseases, Törökbálint, Hungary
| | - Milena Man
- Pulmonology Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maris Bukovskis
- Department of Internal Diseases, Faculty Medicine, University of Latvia, Riga, Latvia
| | - Neven Tudoric
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marija Vukoja
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Wojciech Naumnik
- First Department of Lung Diseases and Chemotherapy of Respiratory Neoplasms, Medical University of Bialystok, Bialystok, Poland
| | - Nikolay Yanev
- Department of Pulmonary Diseases, Medical University of Sofia, Sofia, Bulgaria
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17
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A Systematic Review of Published Algorithms for Selecting an Inhaled Delivery System in COPD. Ann Am Thorac Soc 2021; 19:1213-1220. [PMID: 34856108 DOI: 10.1513/annalsats.202108-930oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Medication for treatment of COPD is available in many different delivery systems; however, national and international guidelines do not provide recommendations on how to select the optimal system for an individual patient. OBJECTIVES To perform a systematic review of published algorithms for inhaler selection in out-patients with COPD. METHODS PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were search for articles on inhaler selection published between January 1, 1990 and March 10, 2021. The results were reviewed for articles containing an algorithm for inhaler selection. The quality of publications containing an algorithm was assessed using the JBI SUMARI text and opinion critical appraisal checklist. Individual steps recommended in the algorithms and the order in which they were considered were extracted independently by the two authors using the JBI text and opinion data extraction tool. Textual syntheses and a table of factors included were used to appraise and compare algorithms. RESULTS The search identified 1016 publications. After removing duplicate studies (n = 409), 607 abstracts were examined. Nine different algorithms or hierarchical recommendations for device selection were identified. All nine publications were considered of good quality. Most algorithms contain only a few decision steps. There were significant differences between the algorithms. None of the algorithms have been validated. Three domains for factors included in the algorithms were identified: patient factors, device attributes, and HCP factors. Patient factors were considered most frequently (19 times) compared with device attributes (10 times) and HCP factors (7 times). Five specific attribute/factors with at least three rankings in different algorithms, were identified as key factors for device selection. CONCLUSION Although the algorithms generally provide step-by-step approaches based on a literature review and/or the experiences of the different authors, none were developed using item generation/reduction methodology nor included input from patients with COPD. There were considerable differences between the algorithms; however, the review identified key factors that should be considered by HCPs when selecting therapy. Registration: PROSPERO (CRD42021244475).
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18
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Peché R, Attar-Zadeh D, Scullion J, Kocks J. Matching the Inhaler to the Patient in COPD. J Clin Med 2021; 10:5683. [PMID: 34884385 PMCID: PMC8658339 DOI: 10.3390/jcm10235683] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
Selecting the most appropriate inhalation device from the wide range available is essential for the successful management of patients with chronic obstructive pulmonary disease. Although choice is good for healthcare professionals, knowing which inhaler to prescribe is a complex consideration. Among the key factors to consider are quality of disease control, inhaler technique, inhaler resistance and inspiratory flow, inhaler design and mechanisms of drug delivery, insurance and reimbursement restrictions, and environmental impact. In this article, we offer a simple, practical tool that brings together all these factors and includes hyperlinks to other published resources from the United Kingdom, Belgium, and The Netherlands.
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Affiliation(s)
- Rudi Peché
- Department of Pneumology, Centre Hospitalier Universitaire de Charleroi, 6042 Charleroi, Belgium
| | - Darush Attar-Zadeh
- North Central London Clinical Commissioning Group (CCG), London N11 1GN, UK;
| | - Jane Scullion
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Janwillem Kocks
- General Practitioners Research Institute, 9713 GH Groningen, The Netherlands;
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore 409051, Singapore
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19
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Hudd TR. Emerging role of pharmacists in managing patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm 2021; 77:1625-1630. [PMID: 32699897 PMCID: PMC7499078 DOI: 10.1093/ajhp/zxaa216] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Timothy R Hudd
- Department of Pharmacy Practice, MCPHS University, Boston, MA
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20
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Attar-Zadeh D, Lewis H, Orlovic M. Health-care Resource Requirements and Potential Financial Consequences of an Environmentally Driven Switch in Respiratory Inhaler Use in England. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:46-54. [PMID: 34616856 PMCID: PMC8460426 DOI: 10.36469/001c.26113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
Background: To reduce greenhouse gas emissions, national initiatives advocate the phasing down of respiratory inhalers that use a fluorinated gas as a propellant (pressurised metered-dose inhalers [pMDI]). Nevertheless, pMDIs continue to be an effective and common choice. Objective: To assess the potential financial impact of patients with asthma or chronic obstructive pulmonary disease (COPD) switching from pMDIs to dry powder inhalers (DPIs) in a representative primary care network (PCN) population of 50 000 and the English National Health Service (NHS). Methods: Epidemiological data were combined with current inhaler use patterns to estimate the resources and costs associated with this transition, varying patient acceptance scenarios. Results: Depending on the approach, resource requirements ranged from £18 000 - £53 000 for a PCN, and from £21 - £60 million for the English NHS. Discussion: Significant funds are needed to successfully manage targeted inhaler transitions, together with counselling and follow-up appointment with an appropriately skilled clinician to assess the patient's inhaler technique and ensure disease control. Conclusions: Targeted transition of inhalers must achieve a balance between environmental impacts, organisational factors, and patient requirements. The resources for managing a switch can be substantial but are necessary to appropriately counsel and support patients, whilst protecting the environment.
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21
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Usmani OS, Dhand R, Lavorini F, Price D. Why We Should Target Small Airways Disease in Our Management of Chronic Obstructive Pulmonary Disease. Mayo Clin Proc 2021; 96:2448-2463. [PMID: 34183115 DOI: 10.1016/j.mayocp.2021.03.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/12/2021] [Accepted: 03/16/2021] [Indexed: 12/23/2022]
Abstract
For more than 50 years, small airways disease has been considered a key feature of chronic obstructive pulmonary disease (COPD) and a major cause of airway obstruction. Both preventable and treatable, small airways disease has important clinical consequences if left unchecked. Small airways disease is associated with poor spirometry results, increased lung hyperinflation, and poor health status, making the small airways an important treatment target in COPD. The early detection of small airways disease remains the key barrier; if detected early, treatments designed to target small airways may help reduce symptoms and allow patients to maintain their activities. Studies are needed to evaluate the possible role of new drugs and novel drug formulations, inhalers, and inhalation devices for treating small airways disease. These developments will help to improve our management of small airways disease in patients with COPD.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute, Imperial College London, and Royal Brompton Hospital, Airways Disease Section, London, UK.
| | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - David Price
- Observational and Pragmatic Research Institute, Singapore; Optimum Patient Care, Cambridge, UK; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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22
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Slevin P, Kessie T, Cullen J, Butler MW, Donnelly SC, Caulfield B. A qualitative study of clinician perceptions regarding the potential role for digital health interventions for the management of COPD. Health Informatics J 2021; 27:1460458221994888. [PMID: 33653189 DOI: 10.1177/1460458221994888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Effective self-management of chronic obstructive pulmonary disease (COPD) can lead to increased patient control and reduced health care costs. However, both patients and healthcare professionals encounter significant challenges. Digital health interventions, such as smart oximeters and COPD self-management applications, promise to enhance the management of COPD, yet, there is little evidence to support their use and user-experience issues are still common. Understanding the needs of healthcare professionals is central for increasing adoption and engagement with digital health interventions but little is known about their perceptions of digital health interventions in COPD. This paper explored the perceptions of healthcare professionals regarding the potential role for DHI in the management of COPD. Snowball sampling was used to recruit the participants (n = 32). Each participant underwent a semi-structured interview. Using NVivo 12 software, thematic analysis was completed. Healthcare professionals perceive digital health interventions providing several potential benefits to the management of COPD including the capture of patient status indicators during the interappointment period, providing new patient data to support the consultation process and perceived digital health interventions as a potential means to improve patient engagement. The findings offer new insights regarding potential future use-cases for digital health interventions in COPD, which can help ease user-experience issues as they align with the needs of healthcare professionals.
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Affiliation(s)
| | | | - John Cullen
- Tallaght University Hospital, Ireland.,Trinity College Dublin, Ireland
| | - Marcus W Butler
- University College Dublin, Ireland.,St. Vincent's University Hospital, Ireland
| | - Seamas C Donnelly
- Tallaght University Hospital, Ireland.,Trinity College Dublin, Ireland
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Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are amongst the most common chronic diseases worldwide, and are largely preventable by improving the quality of the air we breathe. The most commonly deployed treatment, the metered dose inhaler (MDI), uses hydrofluorocarbon propellants, which are powerful greenhouse gases that contribute disproportionately to the climate crisis. Alternative treatment strategies are required if we are to avoid contributing to the worst effects of climate change. These strategies include promoting non-pharmacological therapies like smoking cessation and pulmonary rehabilitation; empowering patients to gain better disease control through written management plans and encouraging preventer, rather than reliever therapies. Pharmacological strategies include: improving inhaler technique and spacer use; minimising propellant release by using smaller volume MDIs and simpler dosing regimes; dose counters to prevent waste; switching to low global warming potential inhalers; and inhaler recycling. There are also opportunities to improve disease control alongside reduced greenhouse gas emissions, including better matching of patients' devices to inhaler technique rather than defaulting to MDIs, stopping unnecessary inhaled steroids in COPD and maintenance and reliever therapy in asthma. New, lower global warming potential propellants are on the horizon, and their introduction could offer a golden opportunity to enhance MDIs usability and sustainability by making them refillable, integrating whistles to optimise inhalation technique, adding integrated caps, optimising materials for recycling and adding dose counters to all MDIs.
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Mahler DA, Halpin DMG. Peak Inspiratory Flow as a Predictive Therapeutic Biomarker in COPD. Chest 2021; 160:491-498. [PMID: 33812852 DOI: 10.1016/j.chest.2021.03.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/21/2021] [Accepted: 03/28/2021] [Indexed: 11/19/2022] Open
Abstract
Biomarkers in COPD may be clinical (prior exacerbation history), physiologic (FEV1), or blood based (eosinophil count or fibrinogen level). Recent interest in using biomarkers to predict response to therapy in clinical practice has emerged. The benefits of inhaled therapy depend on the correct use of the inhaler, including an appropriate inspiratory flow. Of the available delivery systems, dry powder inhalers are unique because they have an internal resistance, are breath actuated, and are flow dependent. Ideally, the user inhales "forcefully" to generate turbulent energy (determined by an individual's inspiratory flow and the resistance of the device) within the device that disaggregates the powder so that the individual inhales the medication particles into the lower respiratory tract. Because of specific features of dry powder inhalers and the required optimal inspiratory flow, an unmet need exists to identify individuals who are likely or unlikely to benefit from dry powder medications. Peak inspiratory flow, defined as the maximum airflow generated during inhalation against the simulated resistance of a dry powder inhaler, is a physiologic measure that has biological plausibility, has good test characteristics (repeatability and reliability), and is generalizable. Current evidence supports peak inspiratory flow as a predictive therapeutic biomarker to optimize therapy in both outpatients with COPD as well as those hospitalized for an exacerbation before discharge. This approach is consistent with the precepts of precision medicine, which considers differences in a person's biological features, exposure, and lifestyle to prevent and treat disease.
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Affiliation(s)
- Donald A Mahler
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Respiratory Services, Valley Regional Hospital, Claremont, NH.
| | - David M G Halpin
- Department of Respiratory Medicine, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, England
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Global Quality Statements on Reliever Use in Asthma in Adults and Children Older than 5 Years of Age. Adv Ther 2021; 38:1382-1396. [PMID: 33586006 PMCID: PMC7882466 DOI: 10.1007/s12325-021-01621-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/08/2021] [Indexed: 11/03/2022]
Abstract
Introduction Widespread misuse of short-acting beta-agonists (SABAs) may contribute to asthma-related morbidity and mortality. Recognizing this, the Global Initiative for Asthma neither recommends SABA monotherapy nor regards this formulation as a preferred reliever. Many health systems and healthcare professionals (HCPs) experience practical issues in implementing guidelines. Clear quality standards can drive improvements in asthma care and encourage implementation of global and national medical guidelines. Methods A steering group of global asthma experts came together between May and September 2019 to develop quality statements codifying the minimum elements of good quality asthma care. These statements were either evidence based (when robust evidence was available) or reflected a consensus based on clinical expertise and experience of the group. Results The quality statements (and associated essential criteria) developed emphasize key elements concerning (1) objective diagnosis specific to individual symptoms, (2) treatment appropriate to the long-term management of asthma as an inflammatory disease, consistent with evidence-based recommendations, (3) controlled dispensing of SABA canisters and monitoring to prevent overuse, (4) regular review of patients after treatment initiation or change, and (5) follow-up of patients in primary care after treatment for an exacerbation in a hospital or an emergency department. Conclusions The steering group proposes quality statements that national and local clinical groups can implement as quantitative quality standards that are appropriate to their local circumstances, including during the coronavirus disease 2019 (Covid-19) pandemic. By translating these statements into locally relevant quality standards, primary care physicians and HCPs can encourage optimal management and reduce preventable healthcare interactions. The evidence-based evolution of care encapsulated in these statements will further engender high-quality, patient-centered holistic management that addresses asthma as an inflammatory disease. In particular, the statements empower self-management by patients and encourage health-promoting behaviors, which are essential to reduce exacerbations, the primary goal of asthma management. Graphic abstract ![]()
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Carranza Valencia A, Hirt R, Kampner D, Hiebl A, Tichy A, Rüthemann P, Pagitz M. Comparison of pulmonary deposition of nebulized 99m technetium-diethylenetriamine-pentaacetic acid through 3 inhalation devices in healthy dogs. J Vet Intern Med 2021; 35:1080-1087. [PMID: 33624851 PMCID: PMC7995371 DOI: 10.1111/jvim.16064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background Inhalation treatment frequently is used in dogs and cats with chronic respiratory disease. Little is known however about the performance of delivery devices and the distribution of aerosolized drugs in the lower airways. Objective To assess the performance of 3 delivery devices and the impact of variable durations of inhalation on the pulmonary and extrapulmonary deposition of nebulized 99mtechnetium‐diethylenetriamine‐pentaacetic acid (99mTc‐DTPA). Animals Ten university‐owned healthy Beagle dogs. Methods Prospective crossover study. Dogs inhaled the radiopharmaceutical for 5 minutes either through the Aerodawg spacer with a custom‐made nose‐muzzle mask, the Aerochamber spacer with the same mask, or the Aerodawg spacer with its original nose mask. In addition, dogs inhaled for 1 and 3 minutes through the second device. Images were obtained by 2‐dimensional planar scintigraphy. Radiopharmaceutical uptake was calculated as an absolute value and as a fraction of the registered dose in the whole body. Results Mean (±SD) lung deposition for the 3 devices was 9.2% (±5.0), 11.4% (±4.9), and 9.3% (±4.6), respectively. Differences were not statistically significant. Uptake in pulmonary and extrapulmonary tissues was significantly lower after 1‐minute nebulization, but the mean pulmonary/extrapulmonary deposition ratio (0.38 ± 0.27) was significantly higher than after 5‐minute nebulization (0.16 ± 0.1; P = .03). No significant differences were detected after 3‐ and 5‐minute nebulization. Conclusion and Clinical Importance The performance of a pediatric spacer with a custom‐made mask is comparable to that of a veterinary device. One‐minute nebulization provides lower pulmonary uptake but achieves a better pulmonary/extrapulmonary deposition ratio than does 5‐minute nebulization.
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Affiliation(s)
- Alejandra Carranza Valencia
- Department for Companion Animals and Horses, Clinic for Internal Medicine, University of Veterinary Medicine, Vienna, Austria
| | - Reinhard Hirt
- Department for Companion Animals and Horses, Clinic for Internal Medicine, University of Veterinary Medicine, Vienna, Austria
| | - Doris Kampner
- Department for Companion Animals and Horses, Clinic for Internal Medicine, University of Veterinary Medicine, Vienna, Austria
| | - Andreas Hiebl
- Department for Companion Animals and Horses, Clinic for Internal Medicine, University of Veterinary Medicine, Vienna, Austria
| | - Alexander Tichy
- Department of Biomedical Sciences, University of Veterinary Medicine, Vienna, Austria
| | - Peter Rüthemann
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
| | - Maximilian Pagitz
- Department for Companion Animals and Horses, Clinic for Internal Medicine, University of Veterinary Medicine, Vienna, Austria
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Switching Inhalers: A Practical Approach to Keep on UR RADAR. Pulm Ther 2020; 6:381-392. [PMID: 33051824 PMCID: PMC7672131 DOI: 10.1007/s41030-020-00133-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022] Open
Abstract
The choice of an inhaler device is often as important as the medication put in it to achieve optimal outcomes for our patients with asthma and/or COPD. With a multitude of drug–device combinations available, optimization of respiratory treatment could well be established by switching devices rather than changing or even augmenting pharmacological or non-pharmacological therapies. Importantly, while notable between-device differences in release mechanism, particle size, drug deposition and required inspiratory flow exist, a patient uncomfortable with their device is unlikely to use it regularly and certainly will not use it properly. Switching requires a careful process and should not be done without patient consent. Switching devices entails several steps that need to be considered, which can be guided using the UR-RADAR mnemonic. It starts with (i) UncontRolled asthma/COPD (or UnaffoRdable device), followed by RADAR: (ii) review the patient’s condition (e.g. diagnosis, phenotype, co-morbidities) and address reasons for suboptimal control (e.g. triggers, smoking, non-adherence, poor inhaler technique) to be ruled out before switching; (iii) assess patient’s skills related to inhalation (e.g. inspiratory force); (iv) discuss inhaler switch options, patient preferences (e.g. size, daily regimen) and treatment goals; (v) allow patients input and use shared decision-making to decide final treatment choice, acknowledging individual patient skills, preferences and goals; and (vi) re-educate to the new device (at minimum, physical demonstration, verbal explanation and patient repetition, both verbally and physically) and prime the patient for the follow-up (i.e. explain the future patient journey, including multidisciplinary work flows with physicians, nurses and pharmacists).
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Qazi A, Armour C, Saini B. Perspectives of general practitioners about a collaborative asthma care model in primary care. J Asthma 2020; 58:1648-1660. [PMID: 32921189 DOI: 10.1080/02770903.2020.1823408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Asthma affects 2.7 million people in Australia and is predominantly managed by general practitioners (GPs) within primary care. Despite national focus on this condition, asthma control in the population is suboptimal, with many preventable hospitalizations. In the light of robust evidence supporting the role of pharmacists in the management of chronic diseases including asthma, the Australian Medical Association (AMA) proposed a General Practice Pharmacist (GPP) model in 2015. In this proposal, a non-dispensing pharmacist, co-located within the primary care setting and collaborating with GPs and allied health professionals, can make a positive impact on patients' health and minimize costs due to medication misadventure. The aim of this study was to obtain the views of GPs regarding the GPP model for better management of asthma in a qualitative study. METHODS Semi-structured interviews were conducted with 23 GPs, audio-recorded, transcribed verbatim, and later analyzed for emergent themes. The GPs support the idea of a GPP as time and task pressures restrict them in adhering to asthma management guidelines. RESULTS Support from another health professional in such a pressured environment can positively impact patient's health. Funding, clear role delineation within general practice, training of pharmacists working as GPPs, and effective communication systems were described as the potential catalysts for the success of the model. CONCLUSION Sustainable funding and the willingness of practice owners/managers were described as the barriers. The GPs agreed that pharmacists can make a positive difference in patient's asthma management once the barriers were effectively addressed.
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Affiliation(s)
- Anila Qazi
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Carol Armour
- The Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - Bandana Saini
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.,The Woolcock Institute of Medical Research, Glebe, NSW, Australia
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Sportel ET, Oude Wolcherink MJ, van der Palen J, Lenferink A, Thio BJ, Movig KLL, Brusse-Keizer MGJ. Does immediate smart feedback on therapy adherence and inhalation technique improve asthma control in children with uncontrolled asthma? A study protocol of the IMAGINE I study. Trials 2020; 21:801. [PMID: 32943094 PMCID: PMC7499851 DOI: 10.1186/s13063-020-04694-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 08/16/2020] [Indexed: 12/12/2022] Open
Abstract
Background Many asthmatic children suffer from uncontrolled asthma with frequent exacerbations, despite an optimal treatment plan using inhalation medication. Studies have shown that therapy adherence and inhalation technique are often suboptimal in asthmatic children, but these have traditionally been hard to measure. A novel device functioning as an add-on to the inhaler has been developed to measure both aspects by recording vibration patterns during inhalation. This data can be converted to smart feedback and provided to patients immediately via a mobile application. The aim of this study is to improve asthma control in children between 6 and 18 years old by providing immediate smart feedback on the intake of inhalation medication. Asthma control will be measured by forced expiratory volume in 1 s, (Childhood) Asthma Control Test ((c-)ACT) score, and lung function variability and reversibility. Methods The study will be performed in Medisch Spectrum Twente (Enschede, The Netherlands). The goal is to include 68 uncontrolled moderate to severe asthmatic children between 6 and 18 years old who receive controller inhalation medication through the Nexthaler®, Ellipta®, or Spiromax®. The study consists of three phases. Phase 1 is observational and will last 4 weeks to observe the baseline adherence and inhalation technique as monitored by the add-on device. A randomised controlled trial lasting 6 weeks will be performed in phase 2. Patients in the intervention group will receive immediate smart feedback about the performed inhalations via a mobile application. In the control group, adherence and inhalation technique will be monitored, but patients will not receive feedback. In phase 3, also lasting 6 weeks, the feedback will be ceased for all children and revision of current therapy may occur, depending on the findings in phase 2. Asthma control can be assessed by means of spirometry (both at home and in the hospital) and (c-)ACT questionnaires. Discussion Immediate smart feedback may improve therapy adherence and inhalation technique, and thus asthma control in children and prevent unnecessary switches to targeted biologics. Performing this study in children is desired, since they are known to react differently to feedback and medication than adults. Trial registration Dutch Trial Register NL7705. Registered on 29 April 2019
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Affiliation(s)
- Esther T Sportel
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, The Netherlands.
| | | | - Job van der Palen
- Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands.,Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Anke Lenferink
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Boony J Thio
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Kris L L Movig
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, The Netherlands
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Inhaled Formoterol-Fluticasone Single Inhaler Therapy in Asthma: Real-World Efficacy, Budget Impact, and Potential to Improve Adherence. Can Respir J 2020; 2020:8631316. [PMID: 33005277 PMCID: PMC7509561 DOI: 10.1155/2020/8631316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/21/2020] [Accepted: 09/07/2020] [Indexed: 11/18/2022] Open
Abstract
Asthma is the commonest chronic disease affecting airways in humans and has an increasing global disease burden. Inhaled corticosteroids (ICS) are the first-line therapeutic option for asthma, and addition of a long-acting beta 2-agonist (LABA) has been shown to improve asthma control. A combination of the two agents in a single inhaler is beneficial with regard to ease of administration and patient compliance. Various ICS-LABA formulations are available across various countries in the world, one among them being formoterol-fluticasone. Both formoterol and fluticasone have pharmacologic peculiarities which places the combination in a uniquely advantageous position when it comes to asthma therapy. The present review focuses on some of the, hitherto, less explored aspects of this combination inhaler such as real-world efficacy, impact on budget allocation, results of switch-over therapy, and potential to improve adherence to asthma treatment. It also provides practical recommendations on positioning it in real-world asthma management.
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Inhaler devices in asthma and COPD patients - a prospective cross-sectional study on inhaler preferences and error rates. BMC Pulm Med 2020; 20:222. [PMID: 32819337 PMCID: PMC7439539 DOI: 10.1186/s12890-020-01246-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/27/2020] [Indexed: 01/10/2023] Open
Abstract
Background Inhalation therapy is the backbone of asthma and COPD control. However, inhaler adherence and device mishandling continue to be a problem in real life. Some studies have shown that using a patient-preferred inhaler may reduce device handling errors and improve adherence to prescribed chronic inhaler drug therapy. The aim of this study was to compare the preferences for commonly used inhaler devices in Germany in patients with chronic obstructive respiratory disease. We also pursued the question which properties of an inhaler device are particularly important to the user and what effects age, gender and type of disease (asthma or COPD) may have on device preference and handling errors. Methods Prospective, open-label cross-sectional study in which 105 patients with asthma (58%) or COPD (42%) participated. Validated checklists were used to objectively assess inhaler technique and errors with 10 different placebo devices. For each device, patients were asked to test the handling, to assess the device properties and to name the device that they would most or least prefer. Results Across the 10 placebo inhaler devices tested, patients needed an average of 1.22 attempts to error-free use. The device with the lowest mean number of attempts was the Turbohaler® (1.02), followed by the Nexthaler® (1.04), the Diskus® (1.07) and the Spiromax® (1.10). Patients over 60 years vs. younger age (p = 0.002) and COPD vs. asthma patients (p = 0.016) required more attempts to ensure correct use. 41% of the study participants chose one of the devices they already used as the most preferred inhaler. Overall, 20% opted for the Spiromax®, 15% for the Nexthaler® and 14% for the Turbohaler® or a pMDI. The least preferred device was the Elpenhaler® (0%). From a selection of 7 predefined inhaler attributes, patients stated easy handling as the most important for them. This was followed by short inhalation time and low inhalation resistance. Conclusions Patient preference may vary between inhaler devices. The lowest number of attempts to error-free use was reported for the Turbohaler® and the Nexthaler®. The Spiromax® and the Nexthaler® achieved the best overall ratings and were the devices most preferred by patients.
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32
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Movia D, Prina-Mello A. Preclinical Development of Orally Inhaled Drugs (OIDs)-Are Animal Models Predictive or Shall We Move Towards In Vitro Non-Animal Models? Animals (Basel) 2020; 10:E1259. [PMID: 32722259 PMCID: PMC7460012 DOI: 10.3390/ani10081259] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/18/2022] Open
Abstract
Respiratory diseases constitute a huge burden in our society, and the global respiratory drug market currently grows at an annual rate between 4% and 6%. Inhalation is the preferred administration method for treating respiratory diseases, as it: (i) delivers the drug directly at the site of action, resulting in a rapid onset; (ii) is painless, thus improving patients' compliance; and (iii) avoids first-pass metabolism reducing systemic side effects. Inhalation occurs through the mouth, with the drug generally exerting its therapeutic action in the lungs. In the most recent years, orally inhaled drugs (OIDs) have found application also in the treatment of systemic diseases. OIDs development, however, currently suffers of an overall attrition rate of around 70%, meaning that seven out of 10 new drug candidates fail to reach the clinic. Our commentary focuses on the reasons behind the poor OIDs translation into clinical products for the treatment of respiratory and systemic diseases, with particular emphasis on the parameters affecting the predictive value of animal preclinical tests. We then review the current advances in overcoming the limitation of animal animal-based studies through the development and adoption of in vitro, cell-based new approach methodologies (NAMs).
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Affiliation(s)
- Dania Movia
- Laboratory for Biological Characterisation of Advanced Materials (LBCAM), Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College, The University of Dublin, Dublin D8, Ireland;
| | - Adriele Prina-Mello
- Laboratory for Biological Characterisation of Advanced Materials (LBCAM), Department of Clinical Medicine, Trinity Translational Medicine Institute, Trinity College, The University of Dublin, Dublin D8, Ireland;
- AMBER Centre, CRANN Institute, Trinity College, The University of Dublin, Dublin D2, Ireland
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Navaie M, Dembek C, Cho-Reyes S, Yeh K, Celli BR. Inhaler device feature preferences among patients with obstructive lung diseases: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20718. [PMID: 32569208 PMCID: PMC7310962 DOI: 10.1097/md.0000000000020718] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Bronchodilators administered through inhalation devices are the mainstay treatment for patients with obstructive lung diseases. Patients do not view devices as interchangeable. This systematic review and meta-analysis examined device feature preferences among patients with obstructive lung diseases treated with handheld inhalers. STUDY APPRAISAL AND SYNTHESIS METHODS PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify publications between 2010 and 2019 that met the following criteria:A manual search extended the study period from 2001 to 2019. Random-effects models were used to generate pooled mean effect sizes and 95% confidence intervals (CIs) for preferred device features. Heterogeneity was measured by the I statistic. RESULTS Nineteen studies (n = 11,256) were included in this meta-analysis. Average age ranged from 50.4 to 74.3 years. The majority of patients were male (57%) and had chronic obstructive pulmonary disease (92%).Patients preferred the following device features: CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:: Adults with obstructive lung diseases preferred small inhaler devices that were portable, durable, perceived as easy to use, and fast in medication administration. Healthcare providers should give due consideration to the patient's device feature preferences when developing a treatment plan that prescribes an inhalation device.
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Affiliation(s)
- Maryam Navaie
- Consulting at McCann Health, New York, NY
- Columbia University, School of Professional Studies, Applied Analytics Program, New York, NY
| | - Carole Dembek
- Global Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., Marlborough, MA
| | | | - Karen Yeh
- Advance Health Solutions, LLC, New York, NY
| | - Bartolome R. Celli
- Chronic Obstructive Pulmonary Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Asthma, a chronic respiratory disease characterized by chronic airway inflammation, bronchial hyperresponsiveness, and reversible airflow obstruction, poses a substantial economic burden on patients and caregivers alike. Moreover, the heterogeneous nature of the disease and the presence of various phenotypes make the treatment of asthma challenging and nuanced. Despite the availability of several approved pharmacological treatments, approximately half of patients with asthma in the United States experienced exacerbations in 2016, highlighting the need for effective add-on treatments. Furthermore, asthma control remains suboptimal due to low adherence to medications, poor inhaler technique, and several patient-related factors. Importantly, the primary care setting, in which pharmacists play an integral role, represents a critical environment for providing long-term follow-up care for the effective management of chronic diseases, such as asthma. Pharmacists are uniquely positioned to ensure optimal clinical outcomes in patients with asthma since they have the clinical expertise to educate patients on their disease state and the role of asthma medications, provide training on inhalation technique, address patients’ concerns about potential side effects of medications, and improve adherence to therapy. Therefore, in this review article, we discuss the overall role of pharmacists in effective asthma care and management.
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Affiliation(s)
- Mary B Bridgeman
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, 5751Rutgers, The State University of New Jersey, NJ, USA
| | - Lori A Wilken
- Pharmacy Practice, 14681University of Illinois at Chicago College of Pharmacy, IL, USA
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Karle E, Patel TP, Zweig J, Krvavac A. Understanding the Knowledge Gap and Assessing Comfort Level among Healthcare Professionals Who Provide Inhaler Education. COPD 2020; 17:197-204. [PMID: 32237908 DOI: 10.1080/15412555.2020.1746251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Inhaled medications play a pivotal role in the management of COPD and asthma. Provider knowledge and ability to teach various devices is paramount as poor inhaler technique directly correlates with worse disease control. The goal of our survey was to assess the knowledge and comfort level with various inhaled devices among providers involved in patient inhaler education. We constructed a 20-question survey consisting of a five-question Likert scale-based comfort assessment and a 15-question multiple-choice inhaler knowledge test that was distributed both internally and nationwide. Groups surveyed included internal medicine residents, family medicine residents, pulmonary fellows, respiratory therapists, nursing staff, and pharmacists. A total of 557 providers responded to the survey. The overall correct response rate among all respondents was only 47%. There was no significant difference between correct response rates among prescribers (internal medicine residents, family medicine residents, and pulmonary fellows) and non-prescribers (respiratory therapists, nursing staff, and pharmacists), 47% and 47%, respectively (p = 0.6919). However, respiratory therapists had the overall highest correct response rate of 85%. Over 72% of respondents indicated that they educate patients on inhaler technique as part of their clinical duties. Furthermore, the correct response rates for various inhaler devices varied with 55% among metered dose inhalers, 52% among dry powder inhalers, and 34% among soft-mist inhalers. Our study reveals that there is a continued need for education on the subject of inhaler devices among providers given their overall poor knowledge, particularly in an era of fast-changing inhaler devices. We continue without knowing what we teach.
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Affiliation(s)
- Ethan Karle
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Tarang P Patel
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Jason Zweig
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Armin Krvavac
- Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Medicine, University of Missouri, Columbia, Missouri, USA
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Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
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Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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Slevin P, Kessie T, Cullen J, Butler MW, Donnelly SC, Caulfield B. Exploring the barriers and facilitators for the use of digital health technologies for the management of COPD: a qualitative study of clinician perceptions. QJM 2020; 113:163-172. [PMID: 31545374 DOI: 10.1093/qjmed/hcz241] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/23/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Digital health technology (DHT) promises to support patients and healthcare professionals (HCPs) to optimize the management of chronic obstructive pulmonary disease (COPD). However, there is a lack of evidence demonstrating the effectiveness of DHT for the management of COPD. One reason for this is the lack of user-involvement in the development of DHT interventions in COPD meaning their needs and preferences are rarely accounted for in the design phase. Although HCP adoption issues have been identified in relation to DHT, little is known about the challenges perceived by HCPs providing care to COPD patients. Therefore, this study aims to qualitatively explore the barriers and facilitators HCPs perceive for the use of DHT in the management of COPD. METHODS Participants (n = 32) were recruited using snowball sampling from two university hospitals and several general practitioner clinics. A semi-structured interview was conducted with each participant. NVivo 12 software was used to complete thematic analysis on the data. RESULTS Themes identified include: data quality; evidence-based care; resource constraints; and digital literacy presented as barriers; and facilitators include the following themes: digital health training and education; improving HCP digital literacy; and Personalized prescribing. Patient-centered approaches, such as pulmonary rehabilitation and shared decision-making were suggested as implementation strategies to ease the adoption of digital health for the management of COPD. CONCLUSION These findings contribute new insights about the needs and preferences of HCPs working in COPD regarding DHT. The findings can be used to help mitigate user-experience issues by informing the design of person-centered implementation and adoption strategies for future digital health interventions in COPD.
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Affiliation(s)
- P Slevin
- From the The Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland
| | - T Kessie
- From the The Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland
| | - J Cullen
- Tallaght University Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
| | - M W Butler
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
| | - S C Donnelly
- Tallaght University Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
| | - B Caulfield
- From the The Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland
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Panigone S, Sandri F, Ferri R, Volpato A, Nudo E, Nicolini G. Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment. BMJ Open Respir Res 2020; 7:e000571. [PMID: 32238349 PMCID: PMC7173981 DOI: 10.1136/bmjresp-2020-000571] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 01/19/2023] Open
Abstract
Patients with asthma and Chronic Obstructive Respiratory Disease (COPD) rely on three main device classes for inhalation therapy: metered-dose inhalers (MDIs), dry powder inhalers (DPIs) and soft-mist inhalers (SMIs). The carbon footprint (CF) of these inhalers differs with MDIs having a higher impact than DPIs and SMIs due to the propellant in MDIs. However, the certified CF of specific MDI products may differ significantly. MDIs still represent an essential option for many patients. Consequently, novel approaches shall be considered to balance environmental goals with patient health and well-being while maintaining a diverse range of choices for patients and physicians.
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Affiliation(s)
- Sara Panigone
- Corporate Marketing, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Rossella Ferri
- Corporate Health Safety & Environment, Chiesi Farmaceutici SpA, Parma, Italy
| | - Andrea Volpato
- Corporate Health Safety & Environment, Chiesi Farmaceutici SpA, Parma, Italy
| | - Elena Nudo
- Global Medical Affairs, Chiesi Farmaceutici SpA, Parma, Italy
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Kaplan A, Price D. Treatment Adherence in Adolescents with Asthma. J Asthma Allergy 2020; 13:39-49. [PMID: 32021311 PMCID: PMC6969681 DOI: 10.2147/jaa.s233268] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
The burden of asthma is particularly notable in adolescents, and is associated with higher rates of prevalence and mortality compared with younger children. One factor contributing to inadequate asthma control in adolescents is poor treatment adherence, with many pediatric studies reporting mean adherence rates of 50% or lower. Identifying the reasons for poor disease control and adherence is essential in order to help improve patient quality of life. In this review, we explore the driving factors behind non-adherence in adolescents with asthma, consider their consequences and suggest possible solutions to ensure better disease control. We examine the impact of appropriate inhaler choice and good inhaler technique on adherence, as well as discuss the importance of selecting the right medication, including the possible role of as-needed inhaled corticosteroids/long-acting β2-agonists vs short-acting β2-agonists, for improving outcomes in patients with mild asthma and poor adherence. Effective patient/healthcare practitioner communication also has a significant role to engage and motivate adolescents to take their medication regularly.
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Affiliation(s)
- Alan Kaplan
- University of Toronto Department of Family and Community Medicine, Toronto, ON, Canada.,Family Physician Airways Group of Canada, Edmonton, AB, Canada.,Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Donohue JF, Mahler DA, Sethi S. Revefenacin: A Once-Daily, Long-Acting Bronchodilator For Nebulized Treatment Of COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:2947-2958. [PMID: 31908443 PMCID: PMC6927563 DOI: 10.2147/copd.s157654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/23/2019] [Indexed: 01/17/2023] Open
Abstract
Bronchodilation with muscarinic antagonists, β2-agonists, and inhaled corticosteroids remains the foundation of pharmaceutical treatment for patients with stable COPD. These drugs are delivered from a variety of devices, including dry powder inhalers, pressurized metered-dose inhalers, soft-mist inhalers, or nebulizers. Nebulized delivery is often preferable in patients who are elderly, are cognitively impaired, are unable to generate sufficient inspiratory force to use their inhaler, have difficulty coordinating hand-breath activity, are too dyspneic to hold their breath for a sufficient time, and/or may be acutely ill. Revefenacin, a once-daily long-acting muscarinic antagonist for nebulization recently approved by the US FDA for the treatment of patients with COPD, was discovered and developed using "duration and lung selectivity-by-design." This strategy selected a molecule with a high lung-selective index to maximize bronchodilation and limit systemic anti-muscarinic side effects. In early-phase clinical studies, revefenacin for nebulization led to a rapid onset of bronchodilation that was sustained for 24 hrs in patients with moderate to severe COPD. Revefenacin also demonstrated minimal systemic exposure and good tolerability in these studies. Statistically and clinically significant improvements in lung function (ie, peak and/or trough FEV1) relative to placebo were observed with revefenacin in Phase III clinical trials of up to 3 months in patients with moderate to very severe COPD. Revefenacin was well tolerated in Phase III clinical trials with a low incidence of systemic antimuscarinic adverse events, which is consistent with its lung-selective design. There was no evidence of an increased risk of major cardiovascular events. Patient-reported outcome data from clinical trials indicated statistically significant improvements in several disease-specific measures. Revefenacin 175 μg for nebulization provides an effective once-daily treatment option for patients with moderate to very severe COPD who require or prefer nebulized therapy.
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Affiliation(s)
- James F Donohue
- Pulmonary Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Director of Respiratory Services, Valley Regional Hospital, Claremont, NH, USA
| | - Sanjay Sethi
- University at Buffalo, State University of New York, Buffalo, NY, USA
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Navaie M, Celli BR, Xu Z, Cho-Reyes S, Dembek C, Gilmer TP. Exacerbations, Health Resource Utilization, and Costs Among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease Treated with Nebulized Arformoterol Following a Respiratory Event. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2019; 6:297-307. [PMID: 31483988 PMCID: PMC7006702 DOI: 10.15326/jcopdf.6.4.2019.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Long-acting beta2-agonists (LABAs), with or without inhaled corticosteroids (ICSs), delivered by handheld inhalers or nebulizers are recommended as maintenance therapy in chronic obstructive pulmonary disease (COPD). This study evaluated exacerbations, health resource utilization (HRU), and costs among Medicare beneficiaries with COPD on handheld ICS+LABA who switched to nebulized arformoterol (ARF) or continued ICS+LABA following a respiratory event. METHODS Using Medicare claims, we identified beneficiaries with COPD (international classification of disease, 9th revision, clinical modification [ICD-9-CM] 490-492.xx, 494.xx, 496.xx) between 2010-2014 who had ≥ 1 year of continuous enrollment in Parts A, B, and D; ≥ 2 COPD-related outpatient visits ≥ 30 days apart or ≥ 1 hospitalization(s); ICS+LABA use 90-days before ARF initiation; and a respiratory event (COPD-related hospitalization or emergency department [ED] visit < 30 days before ARF initiation). Using propensity scores, 423 beneficiaries who switched to ARF were matched to 423 beneficiaries who continued on handheld ICS+LABA (controls). Difference-in-difference regression models examined outcomes at 180-days follow-up. RESULTS Beneficiaries who switched to ARF had 1.5 fewer exacerbations (p=0.015) but no difference in hospitalizations and ED visits compared to controls. Durable medical equipment (DME) costs were higher among ARF users than controls ($1590), yet total health care costs were similar due to cost offsets by ARF in pharmacy (-$794), inpatient (-$524), and outpatient care (-$65). ARF accounted for 55% ($886.63) of DME costs, with the remaining costs attributed to oxygen therapy ($428.10) and nebulized corticosteroids ($590.85). CONCLUSIONS Switching from handheld ICS+LABA to nebulized ARF resulted in fewer COPD exacerbations among Medicare beneficiaries. Nebulized LABAs may improve outcomes in selected patients with COPD.
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Affiliation(s)
- Maryam Navaie
- Advance Health Solutions, New York, New York
- School of Professional Studies, Columbia University, New York, New York
| | - Bartolome R. Celli
- Harvard Medical School and Chronic Obstructive Pulmonary Disease Center, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Zhun Xu
- Department of Family Medicine and Public Health, Division of Health Policy, University of California San Diego, La Jolla
| | | | - Carole Dembek
- Sunovion Pharmaceuticals Inc., Marlborough, Massachusetts
| | - Todd P. Gilmer
- Department of Family Medicine and Public Health, Division of Health Policy, University of California San Diego, La Jolla
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Tohid H, Ng SD, Azmi A, Nur Hamidi NFA, Samsuri S, Kamarudin AH, Omar K. Quality of asthma care at a university-based primary care clinic in Malaysia. JOURNAL OF HEALTH RESEARCH 2019. [DOI: 10.1108/jhr-11-2018-0148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose
The quality of asthma care may be affected if asthma management is overlooked, thus needing frequent clinical audits to identify areas for improvement. The purpose of this paper is to evaluate the quality of the process (e.g. documentation of asthma-specific information), the structure (e.g. availability of resources) and the outcome (e.g. proportion of patients prescribed with asthma medications) at a university-based primary care clinic. The associated clinical factors for non-documentation of asthma control at the last visit were also examined.
Design/methodology/approach
This retrospective study involved auditing medical records and the pharmacy data system of 433 adult patients with asthma to evaluate 18 quality indicators. The standard target for the indicators of process and structure was 80 percent and the standard target for the indicators of outcome was 100 percent.
Findings
All the indicators failed to reach the standard targets. Documentation of asthma-specific information and availability of resources were deficient. The non-documentation of asthma control was significantly associated with presence of acute complaint(s) unrelated to asthma, presence of other issues and number of the documented parameters for asthma control. Although the prescription rates of inhaled reliever and preventer were substandard, they were reasonably high compared to the targets.
Research limitations/implications
In this study, evaluation of the quality of care was limited by absence of asthma register, use of paper-based medical records and restricted practice capacity. Besides, the asthma-specific assessments and management were only audited at one particular time. Furthermore, the findings of this study could not be generalised to other settings that used other methods of record keeping such as patient-held cards and electronic medical records. Future studies should sample asthma patients from a register, evaluate more reliable quality indicators (e.g. over-prescription of short-acting β-2 agonist and underuse of inhaled corticosteroid) and assess asthma management over a duration of time.
Practical implications
This study provides quality information on all aspects of asthma care (process, structure and outcome) which can be a basis for clinical improvement. It is hoped that the study could assist the stakeholders to plan strategies for improvement of the asthma care. A more strategic and reliable system of documentation is needed, such as the use of a simple template or structured form, which should not jeopardise the provision of personalised and comprehensive care. With complete documentation, thorough investigational audits can be continuously performed to determine the quality of asthma care.
Social implications
This study could provide useful findings to guide healthcare providers in developing a more strategic model of asthma care that can ensure asthma patients to receive a personalised, comprehensive, holistic and continuous care. Through this approach, their physical and psychosocial well-being can be optimised.
Originality/value
Even though our healthcare has advanced, the quality of asthma care is still suboptimal which requires further improvement. However, it could be considered assuring due to high outcome levels of asthma care despite having limited resources and practice capacity.
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Zhang D, Hop CECA, Patilea-Vrana G, Gampa G, Seneviratne HK, Unadkat JD, Kenny JR, Nagapudi K, Di L, Zhou L, Zak M, Wright MR, Bumpus NN, Zang R, Liu X, Lai Y, Khojasteh SC. Drug Concentration Asymmetry in Tissues and Plasma for Small Molecule-Related Therapeutic Modalities. Drug Metab Dispos 2019; 47:1122-1135. [PMID: 31266753 DOI: 10.1124/dmd.119.086744] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
The well accepted "free drug hypothesis" for small-molecule drugs assumes that only the free (unbound) drug concentration at the therapeutic target can elicit a pharmacologic effect. Unbound (free) drug concentrations in plasma are readily measurable and are often used as surrogates for the drug concentrations at the site of pharmacologic action in pharmacokinetic-pharmacodynamic analysis and clinical dose projection in drug discovery. Furthermore, for permeable compounds at pharmacokinetic steady state, the free drug concentration in tissue is likely a close approximation of that in plasma; however, several factors can create and maintain disequilibrium between the free drug concentration in plasma and tissue, leading to free drug concentration asymmetry. These factors include drug uptake and extrusion mechanisms involving the uptake and efflux drug transporters, intracellular biotransformation of prodrugs, membrane receptor-mediated uptake of antibody-drug conjugates, pH gradients, unique distribution properties (covalent binders, nanoparticles), and local drug delivery (e.g., inhalation). The impact of these factors on the free drug concentrations in tissues can be represented by K p,uu, the ratio of free drug concentration between tissue and plasma at steady state. This review focuses on situations in which free drug concentrations in tissues may differ from those in plasma (e.g., K p,uu > or <1) and discusses the limitations of the surrogate approach of using plasma-free drug concentration to predict free drug concentrations in tissue. This is an important consideration for novel therapeutic modalities since systemic exposure as a driver of pharmacologic effects may provide limited value in guiding compound optimization, selection, and advancement. Ultimately, a deeper understanding of the relationship between free drug concentrations in plasma and tissues is needed.
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Affiliation(s)
- Donglu Zhang
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Cornelis E C A Hop
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Gabriela Patilea-Vrana
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Gautham Gampa
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Herana Kamal Seneviratne
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Jashvant D Unadkat
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Jane R Kenny
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Karthik Nagapudi
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Li Di
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Lian Zhou
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Mark Zak
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Matthew R Wright
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Namandjé N Bumpus
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Richard Zang
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Xingrong Liu
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - Yurong Lai
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
| | - S Cyrus Khojasteh
- Genentech, South San Francisco, California (D.Z., C.E.C.A.H., J.R.K., K.N., M.Z., M.R.W., R.Z., S.C.K.); Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (H.K.S., N.N.B.); Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota (G.G.); Department of Pharmaceutics, University of Washington, Seattle, Washington (G.P.-V., J.D.U.); Biogen, Cambridge, Massachusetts (X.L.); Pharmacokinetics, Dynamics and Metabolism, Pfizer Inc., Eastern Point Road, Groton, Connecticut (L.D.); Drug Disposition, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana (L.Z.); and Drug Metabolism, Gilead Sciences, Foster City, California (Y.L.)
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Cheung MMY, Saini B, Smith L. 'It's a powerful message': a qualitative study of Australian healthcare professionals' perceptions of asthma through the medium of drawings. BMJ Open 2019; 9:e027699. [PMID: 31028044 PMCID: PMC6501968 DOI: 10.1136/bmjopen-2018-027699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES This study aimed to explore healthcare professionals' (HCPs') perspectives of asthma through their drawings, and their responses when viewing patients' drawings of their experiences of asthma. DESIGN A qualitative exploratory study with a purposive, convenience sample of participants. Participants were asked to first express their perspectives of asthma in a drawing, which was followed by a review of drawings made by patients with asthma. SETTING Primary and tertiary HCPs from Sydney, Australia. PARTICIPANTS Twenty-three HCPs from a range of health professions. RESULTS The HCPs illustrated their perspective of asthma through drawings which were largely biomedically framed, depicting physiological and clinical aspects of asthma. In contrast, their discussion around the patients' drawings centred on the person more than the condition. The patients' drawings triggered the HCPs to revisit their personal expectations of their patients' illness experience; prompted differing degrees of acknowledgement and empathy regarding the patient experience; and encouraged clinical reflexivity. CONCLUSIONS Our findings provide support for the educational application of patients' drawings in bringing HCPs closer to the patient lived experience. The drawings fostered deeper insight into patient perspectives of asthma and stimulated critical reflection on current healthcare practices.
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Affiliation(s)
- Melissa Mei Yin Cheung
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Bandana Saini
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Lorraine Smith
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
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Wittbrodt ET, Millette LA, Evans KA, Bonafede M, Tkacz J, Ferguson GT. Differences in health care outcomes between postdischarge COPD patients treated with inhaled corticosteroid/long-acting β 2-agonist via dry-powder inhalers and pressurized metered-dose inhalers. Int J Chron Obstruct Pulmon Dis 2019; 14:101-114. [PMID: 30613140 PMCID: PMC6307496 DOI: 10.2147/copd.s177213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose The aim of this study was to examine real-world differences in health care resource use (HRU) and costs among COPD patients in the USA treated with a dry powder inhaler (DPI) or pressurized metered-dose inhaler (pMDI) following a COPD-related hospitalization. Methods This retrospective analysis used the Truven MarketScan® databases. Eligibility criteria included 1) age ≥40 years, 2) COPD diagnosis, 3) inpatient admission with a diagnosis of COPD exacerbation, 4) inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) prescription within 10 days of hospital discharge (index date), and 5) continuous enrollment for 12 months preindex and 90 days postindex. Outcomes included pre- and postindex HRU and costs. DPI and pMDI groups were compared on postindex outcomes via multivariate models controlling for demographic and baseline characteristics. Results The sample included 1,960 DPI and 1,086 pMDI ICS/LABA patients. During the preindex period, pMDI patients were significantly more likely to be prescribed a short-acting β-agonist, experienced more COPD exacerbation-related hospital days, and had a greater number of pulmonologist visits compared to DPI patients (P<0.05), all suggestive of greater disease severity. However, multivariate models revealed that pMDI patients incurred 10% lower all-cause postindex costs (predicted mean costs [2016 US dollars]: $2,673 vs $2,956) and 19% lower COPD-related costs (predicted mean costs: $138 vs $169; P<0.05). Additionally, pMDI patients were 28% less likely to experience a COPD exacerbation-related hospital readmission within 60 days postdischarge compared to the DPI patients (OR: 0.72, 95% CI: 0.52–0.99, P<0.05). Conclusion Despite greater COPD-related HRU and costs preceding index hospitalization, US patients using a pMDI after hospital discharge incurred significantly lower all-cause and COPD-related health care costs compared with those using a DPI, in addition to a decreased likelihood of a COPD exacerbation-related hospital readmission. Results suggest that inhaler device type may influence COPD outcomes and that COPD patients may derive greater clinical benefit from treatment delivered via pMDI vs DPI.
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Affiliation(s)
| | | | - Kristin A Evans
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Machaon Bonafede
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Joseph Tkacz
- Life Sciences, Value-Based Care, IBM Watson Health, Cambridge, MA, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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Khurana AK, Dubey K, Goyal A, Pawar KS, Phulwaria C, Pakhare A. Correcting inhaler technique decreases severity of obstruction and improves quality of life among patients with obstructive airway disease. J Family Med Prim Care 2019; 8:246-250. [PMID: 30911514 PMCID: PMC6396621 DOI: 10.4103/jfmpc.jfmpc_259_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Asthma and chronic obstructive lung disease (COPD) together constitute a huge burden on healthcare all around the world. Treatment of these patients is largely dependent on the way the inhalation devices are used. This study aimed at measuring the impact of rectification of inhalation technique on quality of life and severity of obstruction in patients with asthma and COPD. Materials and Methods A total of 45 asthma (partly controlled) and 38 patients with COPD (categories B and C) were enrolled after applying optimal exclusion criteria. These patients underwent Asthma Control Test (ACT)/COPD Assessment Test (CAT) questionnaire as a measure of quality of life and forced expiratory volume in one second (FEV1) as a measure of severity of obstruction at 0 and 4 weeks, respectively. Results In asthmatics, the mean FEV1 improved from 2.0 to 2.15 L after 4 weeks of technique correction (P < 0.001). In addition, the mean ACT scores improved from 18.0 to 20.75 (P < 0.001). In patients with COPD, the mean FEV1 improved slightly from 1.54 to 1.56 L after 4 weeks of technique correction (P = 0.28). In addition, the mean CAT scores improved from 21.86 to 19.83 (P < 0.001). Conclusion Demonstration of correct inhalation technique should be an indispensible part of the treatment prescription of patients with obstructive airway disease. This simple and important task can be undertaken at the level of primary care physicians in a community-based setting to improve patient compliance.
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Affiliation(s)
| | - Kapil Dubey
- MBBS Student, AIIMS, Bhopal, Madhya Pradesh, India
| | - Abhishek Goyal
- Department of Pulmonary Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Kamendra Singh Pawar
- Department of Pulmonary Medicine, Index Medical College, Indore, Madhya Pradesh, India
| | | | - Abhijit Pakhare
- Department of Community and Family Medicine, AIIMS, Bhopal, Madhya Pradesh, India
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George M, Bender B. New insights to improve treatment adherence in asthma and COPD. Patient Prefer Adherence 2019; 13:1325-1334. [PMID: 31534319 PMCID: PMC6681064 DOI: 10.2147/ppa.s209532] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/14/2019] [Indexed: 12/12/2022] Open
Abstract
Chronic respiratory diseases such as asthma and COPD are typically managed by daily inhaled medication. However, the efficacy of an inhaled medication depends upon a patient's adherence to therapy, which refers to whether the medication is actually taken as prescribed. In patients with these diseases, higher adherence has been associated with better health outcomes, such as improved disease control and a reduction in severe and potentially costly exacerbations. Adherence is a multifaceted concept that includes medication-related, intentional, and unintentional reasons that patients may or may not take their medication as directed. The purpose of this integrative review is to present the individual patient factors that contribute to suboptimal adherence to inhaled therapies and the associated effects on health outcomes, while also highlighting evidence-based strategies for health care providers to improve adherence to such therapies in patients with asthma or COPD. Working closely with patients to establish a model of shared decision-making, which takes patient beliefs and preferences into account when choosing treatment options, has the potential to improve adherence and overall patient outcomes in the management of asthma and COPD.
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Affiliation(s)
- Maureen George
- School of Nursing, Columbia University, New York, NY, USA
| | - Bruce Bender
- Division of Pediatric Behavioral Health, National Jewish Health, Denver, CO, USA
- Correspondence: Bruce BenderDivision of Pediatric Behavioral Health, National Jewish Health, 1400 Jackson Street, Denver, CO80206, USATel +1 303 398 1697Fax +1 303 270 2141Email
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Cho-Reyes S, Celli BR, Dembek C, Yeh K, Navaie M. Inhalation Technique Errors with Metered-Dose Inhalers Among Patients with Obstructive Lung Diseases: A Systematic Review and Meta-Analysis of U.S. Studies. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2019; 6:267-280. [PMID: 31342732 DOI: 10.15326/jcopdf.6.3.2018.0168] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Metered dose inhalers (MDIs) are commonly prescribed for inhalation therapy, but correct use is critical to promoting effective medication delivery. This systematic literature review and meta-analysis evaluates the overall and step-by-step prevalence of errors among adults with obstructive lung diseases in the United States who used MDIs. Methods Electronic and manual searches conducted between 1979-2018 using PubMed, EMBASE, PsycINFO, Cochrane, and Google identified 10 articles that met the following inclusion criteria: (a) English language, (b) U.S. adults diagnosed with chronic obstructive pulmonary disease, and (c) MDI use error rates. Meta-analytic techniques using random-effects models were applied to calculate effect sizes, weighted proportions, and 95% confidence intervals (CIs). Heterogeneity was assessed by the I2 statistic. Results Aggregate findings revealed that 86.7% of patients (n=390, 95% CI 77.5-96.0) made at least 1 inhalation technique error, and 76.9% (n=885, 95% CI 65.8-87.9) incorrectly performed ≥ 20% of device use steps. The most prevalent step-by-step errors across the studies (n=1105) were failure to: (a) exhale fully and away from the inhaler before inhalation (65.5% [95% CI 52.0, 78.9]); (b) hold breath for 5-10 seconds (41.9% [95% CI 29.8, 53.9]); (c) inhale slowly and deeply (39.4% [95% CI 26.2, 52.5]); (d) exhale after inhalation (35.9% [95% CI 17.0, 54.8]); and (e) shake the inhaler before use (34.2% [95% CI 30.6, 37.7]). Conclusions Across the studies used in this meta-analysis more than three-fourths of U.S. adults with obstructive lung diseases used MDIs incorrectly. Our findings suggest the need for ongoing patient education and consideration of alternative devices to mitigate errors.
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Affiliation(s)
| | - Bartolome R Celli
- Harvard Medical School, Boston, Massachusetts and Chronic Obstructive Pulmonary Disease Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carole Dembek
- Global Health Economics and Outcomes Research, Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts
| | - Karen Yeh
- Advance Health Solutions, LLC, New York, New York
| | - Maryam Navaie
- Advance Health Solutions, LLC, New York, New York.,Columbia University, School of Professional Studies, New York, New York
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