Chronic obstructive pulmonary disease (COPD) is common among Veterans, and inhaled medications can reduce the risk of COPD exacerbations. However, 1/3 of COPD patients never receive inhaler training, and up to 80% use their inhalers incorrectly, which may lead to worse symptoms and increased hospitalizations. If patients receive inhaler training, it is typically in-person by VA pharmacists. In 2016, after this study ended, VA YouTube training videos for some inhalers also became available. To improve access to inhaler training, we examined whether inhaler training using "Teaching-to-goal" (TTG) methodology, shown to decrease inhaler misuse among hospitalized patients, could be delivered using VHA's existing Clinical Video Telehealth (CVT)-to-Home program.
1) Determine the feasibility, acceptability, and safety of a CVT-to-Home patient education program to improve inhaler technique in COPD patients, and 2) Examine the effect of "Teach-to-Goal" inhaler training delivered via CVT-to-Home on inhaler technique, medication adherence and recognizing respiratory symptoms in COPD.
Eligibility criteria: A diagnosis of COPD, age > 40 years, 10 pack-year smoking, prescribed 1 inhaler used at least once a week, and access to a computer with high-speed internet.
Intervention: 3 monthly CVT-to-home tele-visits with a VA pharmacist for inhaler training using the TTG method which breaks down inhaler technique for each inhaler into a checklist of 12-17 separate steps. After observing the patient, the pharmacist explained correct inhaler technique, and the patient re-demonstrated inhaler use. The training was repeated until they missed 2 steps or after 3 TTG cycles.
Outcomes: Patients completed the following mailed questionnaires at baseline and at 8 weeks after finishing the 3 training sessions: 1) The 20-item chronic respiratory questionnaire (CRQ) measured 4 domains (dyspnea, fatigue, emotional function, and mastery) of quality of life (QOL) [range 1-7, higher score=better health]; 2) The 4-item Seattle Obstructive Lung Disease Questionnaire (SOLDQ) Coping Skills scale [range 0-100, higher score=better coping]; 3) The 4-item (yes/no) inhaler adherence questionnaire [range 0-4, higher score=worse adherence]; 4) A 1-item self-efficacy scale for each inhaler [score range 0-10, higher score=more confidence]. At the end of the study, we assessed global improvement in inhaler technique [1-item, score range -7 to +7, higher score=improvement] and satisfaction with the program.
Subjects were predominantly male (93%) and Caucasian (83%) with a mean age of 67.5 6.6 years and 20% were current smokers. The most commonly prescribed inhalers were albuterol, tiotropium, and Symbicort (reported by 25, 19, and 16 subjects, respectively).
Aim 1 (feasibility, acceptability/satisfaction, safety): Between November 2014 and June 2015, 428 Veterans were sent letters. Of 375 contacted, 101 (27%) expressed interest, of which 72% had access to a computer with high speed internet. After completing required enrollment documents, 48 had an appointment with a telehealth technician to set up their computer, although 4 never completed the test call due to technical difficulties or frustrations with the software.
Forty-one Veterans participated in 1 CVT-to-home session, and 38 (77.1%) completed all 3 visits. The pharmacist reported technical issues in 65% of visits lasting from 1 to 165 minutes, and necessitating 5 rescheduled visits. Technical issues included difficulty with the audio and video feed, and difficulty navigating through the log-in and steps necessary to log in to visits.
Satisfaction survey: 23% of participants reported technical issues in > 50% of the video visits. Despite technology-related issues, overall satisfaction was high: 91% agreed or strongly agreed that they were satisfied with the training, and 94% would recommend the training to other Veterans. Over half (54%) said that they would not have received any inhaler training without this intervention, and 86% would rather have the home video training instead of traveling to the VA facility to get it.
Aim 2 (inhaler technique): During the initial visit, TTG scores improved for all inhalers, with significant improvements (p<0.05) in albuterol, combivent, tiotropium and symbicort. Inhaler technique (TTG scores measured prior to any teaching) improved for most inhalers from baseline to 1 month and month 2. For example, albuterol TTG scores increased from 10.1 to 11.8 (p=0.003) at 1 month which was sustained at 2 months (10.0 to 12.1, p=0.0002). Similar results were seen for combivent (improvement from baseline to 2 months 9.8 to 11.6, p=0.03) and tiotropium (11.0 to 14.4, p<0.0001). The other inhalers showed improvement at 2 months except for mometasone, where patients already had very high baseline TTG scores. Several inhalers were only used by 1 or 2 patients (e.g. levalbuterol, formoterol, and albuterol with a spacer), limiting statistical analyses due to small sample size.
Self-reported confidence in using all inhalers improved following the training (p<0.05 for all except formoterol). For example, mean self-confidence for albuterol increased by 3 points (on 10-point scale) (p<0.0001), 2.4 points (p<0.0001) for tiotropium and 2.8 points (p<0.0004) for Spiriva. Overall COPD self-efficacy measured with the SOLDQ-coping skills scale increased from 74.5 to 84.4 (mean improvement 9.8 18.4, p=0.003).
Aim 2 (respiratory symptoms): QOL measured with the CRQ-dyspnea scale improved after the training from a mean of 4.9 to 5.2 (mean improvement 0.35 0.76, p=0.01). There were both statistical and clinically meaningful improvements in the other CRQ domains: fatigue (0.61 0.79, p=0.0001), emotional function (0.55 0.93, p=0.001) and mastery (0.74 0.96, p=0.0001)
Aim 2 (medication adherence): Self-reported inhaler adherence improved significantly after the intervention (higher scores indicate worse adherence: 2.2 to 1.2, p=0.045).
This pilot study suggests that home internet-based video inhaler training is a promising approach to improving inhaler technique for Veterans with COPD that can improve objective measures of inhaler technique, patient self-confidence in inhaler use, and QOL. Almost all participants (>90%) were satisfied with the training and would recommend it to other Veterans, and more than half would not have otherwise received inhaler training. Technical difficulties were experienced by 65% of participants delaying or lengthening visits, and requiring technical support, and will need to be addressed in future interventions. A future clinical trial would need to be performed to assess whether this CVT-to-Home approach would improve inhaler training compared to currently available inhaler training in VA.
- Locke ER, Thomas RM, Woo DM, Nguyen EHK, Tamanaha BK, Press VG, Reiber GE, Kaboli PJ, Fan VS. Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2019 Mar 1; 25(3):230-236.
- Thomas RM, Locke ER, Woo DM, Nguyen EHK, Press VG, Layouni TA, Trittschuh EH, Reiber GE, Fan VS. Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life. Respiratory Care. 2017 Nov 1; 62(11):1412-1422.