Introduction
Morbidity and mortality by chronic obstructive pulmonary disease (COPD) is increasing worldwide and Korean survey in 2008 detected 13.4% of COPD among subjects older than 40 years
1,2. Comprehensive care including inhalation therapy and disease education for self management is a cornerstone in the management of COPD
1,3,4. However, previous studies showed that COPD patients were not using inhalers as prescribed or correctly
5,6,7. Correct usage of inhalers is reported to be related to patients' knowledge about disease process, educational status, age, gender, formal training, etc.
5,6,8,9. It has been reported that inadequate inhalation technique and poor adherence to inhaled medication in COPD are associated with poor clinical outcomes such as increased hospitalization and high mortality
10,11. Even self-management interventions in patients with COPD are associated with improved health-related quality of life, a reduction in hospital admissions, and improvement in dyspnea
4.
Recently, comprehensive educational program of COPD management including smoking cessation, nutritional support, exercise, vaccination, co-morbidity evaluation, acute exacerbation, and inhaler training was developed by Korean Academy of Tuberculosis and Respiratory Disease
12. We implemented this program for COPD patients in a primary care setting and evaluated the efficacy of this comprehensive education program comparing clinical markers before and after this program.
Discussion
Our study demonstrated that a comprehensive education program including inhaler training and COPD management performed at primary care setting resulted in positive outcomes including correct inhaler usage, improvement of CAT score, and patients' better understanding of COPD management.
Therefore, authors are of the opinion that education program about the clinical course of COPD should be combined with inhaler training to overcome poor adherence and improve the outcomes of COPD.
Our study has some noteworthy findings.
First, inhaler training and organized education program on COPD management with pamphlet and educational video (specially designed by The Korean Academy of Tuberculosis and Respiratory Diseases) made significant improvements on many outcomes including inhaler usage, CAT score, and knowledge about COPD, in COPD patients treated by primary care physicians. Few studies have addressed the clinical outcomes of COPD assessed by clinicians and patients through comprehensive program with a visual education by video and pamphlet, including the education of patients on the management of COPD and inhaler training.
In inhaler items of our study, positive answers for enough breathing out before inhalation, holding their breath for 5 seconds after inhalation, and understanding the manner of inhalation were only 32.3%, 40.2%, and 44.9% respectively, before inhaler training. However, positive answers for all the items regarding inhaler usage increased after inhaler training.
Previous studies showed that correct usage of inhalers was 58.9% for dry powder inhaler (DPI) and 31.1% for pressurized metered dose inhaler (pMDI), and that proper training led to an improvement in correct usage of inhalers to 92.6% for DPI and to 45.2% for pMDI
5.
Misuse of inhaler devices due to inadequate training can lead to poor disease control and an increase in health care cost in COPD and asthma
16.
Analysis of Torch study over 3-year period showed that increased adherence independent of study treatment was associated with improved mortality and reduction in hospital admission in COPD, although direct comparison between Torch study and our findings is not possible because of different study design
10.
Another randomized controlled trial in COPD over 3-month period demonstrated that the intervention focusing on inhalation technique and adherence to maintenance therapy could reduce hospitalization rate
17.
Second, all the items of our study concerning the knowledge on COPD care showed a remarkable improvement after comprehensive disease education program. The effect of comprehensive disease education was further proven in findings that most items regarding the understanding of COPD being associated with improvement of MCID or more.
One limitation is that our study cannot prove whether the comprehensive education per se may have been a placebo effect due to the single arm design. Another limitation is that this study did not demonstrate how long the effect of comprehensive education will last and how often the education should be performed on a long-term basis. Further studies are required to instruct such points.
The improvement of MCID or more were achieved in 44.9% of enrolled patients, through this program. We defined MCID as 4 points or more of CAT score, in keeping with previous report using this cohort, although our definition is a conservative approach, compared to other studies
15.
Comprehensive management including smoking cessation, nutrition, exercise, vaccination, and co-morbidities is necessary in the care of COPD along with proper inhalation therapy, since COPD is deemed a syndrome with a high prevalence of comorbidities
18.
Despite advancement in medical treatment, poor adherence remains a major challenge in the management of COPD
10,11,19. Patients' perception about disease process and recommended treatment is critical in improving medication adherence in COPD patients
9,19.
Before disease education program, only 36.8% of total patients gave positive answers on coping with acute exacerbation of COPD, but remarkable positive change with positive answer rate of 82.4% occurred after this education program.
Acute exacerbation of COPD can lead to more severe lung function decline and worse quality of life in the clinical course of COPD patients
20,21,22. Previous studies reported a high incidence of unreported exacerbations which can have an impact on health status
23,24.
This study has several limitations.
First, this study did not include a control group because lack of inhaler training and no education on the management of COPD could be hazardous for control group. Accordingly, we investigated the effect of educational intervention in a design comparing clinical markers before and after comprehensive educational program.
Second, observation period was not long enough to assess the major outcomes of COPD such as acute exacerbation, hospitalization, and mortality.
Third, COPD was not diagnosed with traditional post-bronchodilator ratio of FEV
1 to forced vital capacity <0.7. However, the FEV
1/FEV
6 can substitute FEV
1/forced vital capacity as a valid alternative in diagnosing airflow obstruction, in primary care setting for screening COPD
13,14.
Fourth, the severity of COPD was not assessed because spirometry was not performed in primary care setting.
Fifth, other outcome measures such as exercise test and smoking cessation rate were not performed.
In conclusion, our study showed that in the primary care setting, a comprehensive education program including inhaler training and COPD management resulted in correct inhaler usage and improvement of CAT score, suggesting that such programs should be extended further in the primary care of COPD.