Improving Symptom Control in Patients with Chronic ... · gress in Anaheim, California in December...

Supported by an unrestricted educational grant from

Proceedings from a special symposium on

Improving Symptom Control in Patientswith Chronic Respiratory Disease

Presented at the 54th International Respiratory Congress of the

American Association for Respiratory CareDecember 2008 • Anaheim, California

1 ForewordTimothy R Myers RRT-NPSAARC President

3 Why Patients Stop Taking Their Controller MedicationsPatrick J Dunne MEd RRT FAARCSymposium Chair

9 The Impact of Non-adherence with RespiratoryController MedicationsRussell A Acevedo MD FAARC

15 Engaging Patients through a Collaborative CareModelKent L Christopher MD RRT FAARC

21 Promoting Sustained Adherence: Tricks of theTradeChristine M Garvey FNP MSN MPA FAACVPR

25 Instructions and Questions to Earn ContinuingRespiratory Care Education (CRCE) Credits


Improving Symptom Control in Patientswith Chronic Respiratory Disease

Presented at the 54th International Respiratory Congress of theAmerican Association for Respiratory Care

December 2008 • Anaheim, California

American Association for Respiratory Care

9425 N. MacArthur BlvdIrving, TX 75063-4706

AARC.org

Ray Masferrer RRT FAARCEditor

Kelly PiotrowskiProduction

Copyright © 2009 by theAmerican Association for Respiratory Care

Continuing RespiratoryCare Education (CRCE).

Approved for 4.0 contact hours.See page 25 for instructions.

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From that small group of Dr. Edwin Levine’s studentsand other interested doctors, nurses, and oxygen or-derlies that met at the University of Chicago Hospital toform the Inhalation Therapy Association (ITA) in theSummer of 1946, the American Association for Respi-ratory Care (AARC) has grown immensely since its in-ception. The AARC in its 6th iteration has had a proudand distinguished history over the past 60 years andnow stands strong at over 49,000 members.

In addition to offering a full range of services, pro-grams, products, and money-saving opportunities tomeet the respiratory care communities’ needs, theAARC’s major emphasis has been and will always re-main the same—helping the respiratory therapist growand develop through a multitude of educational pro-grams and projects.

Since 1947, the AARC has been committed to en-hancing the respiratory therapist’s professionalism,improving performance on the job, and helpingbroaden the scope of knowledge essential to theprofession’s success. Education is the raison d’êtrefor the existence of the AARC, and has been sinceits organizational inception in 1946. A key purposelisted in the Articles of Incorporation of the newlychartered ITA was “To advance the knowledge of In-halation Therapy through institutes, lectures, andother means.“ Contemporary amplification of thatpurpose is codified in Article II, Section 1 of theAARC Bylaws that reads, in part, “The Association isformed to: Encourage, develop, and provide educa-tional programs for those persons interested in res-

piratory therapy and diagnostics hereinafter referredto as Respiratory Care.”

Chronic respiratory diseases are generally consideredto be chronic diseases of the airways and other struc-tures of the lungs. The most common respiratory con-ditions are typically asthma, chronic obstructivepulmonary disease (COPD), respiratory allergies and oc-cupational lung diseases. Chronic respiratory diseasesare those conditions that are present for months toyears, and are treatable but generally not curable.

Chronic respiratory diseases are not only widelyprevalent, but come with considerable costs in theirdaily morbidity and high potential for mortality. Cancerwill kill an estimated 160,000 in 2009 while COPD isthe fourth leading cause of death in the United States(behind heart diseases, cancer, and stroke) and now killsabout 140,000 Americans annually. While respiratorydisease mortality catches everyone’s attention, the dailyfunctional morbidity of COPD and asthma go largelyunmentioned. Experts estimate that about 30 millionAmericans have COPD (only 50% have been evaluatedand diagnosed), while asthma prevalence is estimatedto run at approximately 22 million. The total economicimpact of COPD in the country is estimated to be about$31.9 billion annually.

While the medications to treat and manage these dis-eases are generally quite effective, there are innumer-able issues in them being accessible to patients and thenbeing administered and used to their maximum effi-ciency. A breakfast symposium titled Improving Symp-tom Control in Patients with Chronic RespiratoryDiseases from the 54th International Respiratory Con-gress in Anaheim, California in December 2008 providesfour articles that all deal with various issues of compli-ance and non-adherence and potential educational in-terventions.

Through unrestricted educational grants from theAARC’s Corporate Partner community, the AARC has

Foreword

Improving Symptom Control in Patients with Chronic Respiratory Disease

Timothy R Myers RRT-NPS AARC President

Disclosure: The author reports no conflict of interest related to the contentof this paper.

Timothy R Myers RRT-NPS, AARC PresidentUniversity Hospital’s Rainbow Babies & Children’s HospitalCase Western Reserve University School of MedicineCleveland OHEmail: [email protected]

the ability to bring contemporary educational topics andcontinuing education at no costs to its members. Thesetypes of educational projects and resulting products are atthe core of the AARC’s Mission and Vision for the respira-

tory care profession. We hope that you enjoy the four arti-cles from nationally recognized speakers and take advan-tage of the free CRCE by completing the post-test.

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Introduction

One of the major challenges clinicians face when pro-viding care to patients with a chronic respiratory diseaseis convincing the patient (or caregiver) to continue totake prescribed controller medications when symptomsassociated with an exacerbation have been resolved. Itseems that once the crises has passed and breathing re-turns to a relative degree of normalcy, there is no longerany urgency to take medications, or in some cases, tono longer even think about the chronic condition. Un-fortunately, as is very obvious to most respiratory ther-apists but less so to our patients, chronic respiratoryconditions are never completely cured. Instead, ourclinical objective is to control, to the degree possible,the signs and symptoms of a particular disease to min-imize the discomfort and disability for each patient.

To that end, patient or caregiver “buy-in” and activeparticipation in the sustained self-administration of pre-scribed controller medications is essential. However, re-cent data clearly shows that this is not the case, andalarmingly, is probably more the exception as opposedto the rule. Simply stated, patients are not inclined tocontinue to take controller medications once the ur-gency, discomfort or fear associated with symptomflare-ups has passed. There is a substantial amount ofrecently published material addressing the issue of“non-compliance” with prescribed medications, not to

mention similar concerns over certain home respiratorydevices such as long-term oxygen therapy equipmentor positive airway pressure machines. The clinical andeconomic impact of non-compliance is staggering andis addressed elsewhere in this monograph.

Is it compliance or adherence?

Traditionally, the word compliance has been used todescribe a patient’s behavior with respect to the degreethat they actually take a controller medication or use arespiratory device according to the schedule and dosesprescribed by their provider. On the other hand, non-compliance describes the opposite - - disregard for theprovider’s intended self-care. Non-compliance can beeither complete (in which case nothing is taken or used)or partial (in which meds are taken or equipment is usederratically). In either case, effective symptom control iscompromised.

In an attempt to try and address why sustained com-pliance remains such a problem, there has been a re-cent flurry of articles suggesting that the wordcompliance itself might be part of the problem. Oneof the best was authored by Joseph Rau and publishedin RESPIRATORY CARE in October 2005.1 In his article, Dr.Rau provided a nice review of how the word compli-ance has been described in the medical literature. Forexample, Haynes and colleagues authored a completetextbook on the subject, defining compliance as “theextent to which a person’s behavior, in terms of takingmedications, following diets or executing lifestylechanges, coincides with medical or health advice”.2 In1995, Tashkin writing in Chest, described complianceas “. . . nothing more than simply following the in-structions of a health care provider”3. Citing several

Why Patients Stop Taking Their Controller Medications

Patrick J Dunne MEd RRT FAARC


Patrick J Dunne MEd RRT FAARCHealthCare Productions, Inc.Fullerton CAEmail: [email protected]

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other similar descriptors, Rau concluded that the wordcompliance “. . . has the connotation of a person giv-ing into a request or demand”, arguing that the termimplies a passive, disinterested, and at times, stubborn,participant simply following orders.

As a contrast, Rau describes the work of Rand andWise, who, in 1994 advanced the notion of using theword adherence, describing it as “. . . the degree towhich patient behaviors coincide with the clinical rec-ommendations of health-care providers”.4 Supportingthe adoption of this softer, gentler word, in 2001 Lewisand Fink suggested that adherence “…describes an ac-tive patient who is an empowered partner in his or herown care”.5 Further, in 2003, an international teamwriting under the auspices of the World Health Organ-ization to address poor disease control in both devel-oping and developed countries, stated the following“The idea of compliance is associated too closely withblame, be it of providers or patients, and the concept ofadherence is a better way of capturing the dynamic andcomplex changes required of many players over longperiods to maintain optimal health in people withchronic diseases”.6 This led Rau to conclude that theword adherence “. . . describes the degree of agree-ment between prescription and practice”. Others haveconcurred and we now see a definitive movement to-ward the use of the word adherence to describe the de-gree to which patients with a chronic respiratorycondition take their prescribed medications or use theirrespiratory devices as intended by their respectivehealth care provider. In this context, adherence impliesan activated patient who willingly accepts their role andresponsibility for providing self care on a daily and sus-tained basis.

Engendering sustained patient adherence is also cen-tral to the basic tenants of chronic disease state man-agement. Disease management is a medical carestrategy increasingly being recognized as an importantway to reduce rampant recidivism - - frequent re-ad-missions due to exacerbations that are not only costlybut at times, may be life-threatening. It is now com-monly accepted that a majority of such re-admissionsare often avoidable, especially when prescribed con-troller medications and/or home respiratory devices areused properly on a sustained basis.

This of course begs the question as to why respiratorytherapists should be concerned about patient adher-ence with prescribed respiratory medication or deviceregimens. Well, aside from the obvious clinical advan-tages to our patients, there are economic imperatives aswell. For example, writing in Chest in 2000, Cochranenoted that “. . . with any chronic disease, patient ad-herence is an important determinant of therapeutic suc-

cess”.7 In 2004, Bender and Rand noted that “. . . pa-tient non-adherence to treatments for chronic illnesscompromises treatment success and patient quality oflife while increasing health care costs”.8 This led Rau tostate unequivocally that “. . . patient non-adherencewith prescribed inhaled therapy is directly related to in-creased morbidity, mortality and costs”1. One wouldhope that these points aptly underscore why respira-tory therapist, regardless of practice venue, shouldnever pass on an opportunity to discuss with their pa-tients and/or caregivers the importance of appropriateand sustained use of prescribed controller medicationand/or respiratory devices. As the incidence of chronicrespiratory diseases continues its alarming increase inthis country, this imperative becomes all the more im-portant, especially as the US health care delivery sys-tem is now poised to undergo, what some are calling,a radical transformation. As this undertaking material-izes, there is no doubt that significant attention will befocused on the huge economic burden associated withchronic medical conditions and the sub-par manner inwhich they are treated and managed.

Most Common Respiratory Controller Medications

In terms of chronic respiratory diseases, the list ofcontroller medications is relatively short, and the vari-ous medications are often disease specific. It shouldalso be noted that the role of prescribed controller med-ications is now clearly established in evidence basedpractice guidelines, as is seen in the latest iterations(2007) of the National Asthma Education and Preven-tion Program (NAEPP) as well as in the 2008 GOLDGuidelines for COPD.9-10 For example, with chronicasthma, the most important controller medication re-mains low-to-moderate doses of inhaled corticos-teroids. On the other hand, for COPD, the controllermedications of choice are long-acting bronchodilators(both beta agonists and anticholinergics), and for thosepatients with advanced, very severe COPD, long termsupplemental oxygen therapy. However, when a singlecontroller medication fails to provide effective symp-tom control, physicians often decide to use combina-tion therapy, such as an inhaled corticosteroid and along acting beta agonist. Fortunately, for our patients,there are now pharmaceutical formulations containingboth medications in a single dose, making adherenceinherently easier since only one administration isneeded instead of two or three. Nonetheless, whetherit be mono or combination therapy, controller medica-tions are only effective if patients and/or caregiverscontinue to remain adherent, especially when symp-toms are no longer in evidence.

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Types of Non-adherence

When attempting to describe non-adherence in orderto establish an effective remedy, it is helpful to considerit as a range of behaviors, from incomplete to totalnonuse. It is likewise useful to also recognize that thereare two broad categories of non-adherence – inten-tional and unintentional.11 Intentional non-adherenceoccurs when a patient or caregiver understands thepurpose and importance of prescribed controller med-ications, but for a variety of reasons to be discussedbelow, intentionally decides to stop taking their med-ications, or in the case of a positive airway pressure ma-chine, to stop using the device during sleep. Factorsthat contribute to intentional non-adherence include:forgetfulness (especially so with the elderly population),stress - resulting from a busy family and/or work sched-ule or financial uncertainty, overly complex or de-manding aerosol regimens, and even psychologicalfactors such as depression.

Unintentional adherence, on the other hand, occurswhen patients or caregivers do not have a clear under-standing and/or appreciation of the role of a controllermedication, or what is probably more common, how tocorrectly use the medication delivery device, such as ametered dose or dry powder inhaler. Factors con-tributing to unintentional non-adherence include: lan-guage or cultural barriers, improper prescribing,misunderstanding of the prescribed regimen or incor-rect or incomplete teaching by the health care provider.

Unfortunately, these two types of non-adherence arenot necessarily mutually exclusive, adding yet anotherchallenge to those clinicians grappling with the negativeconsequences of non-adherence. Fortunately, as is dis-cussed elsewhere in this monograph, we now have amuch better handle on addressing unintentional non-adherence, leaving us to address here the reasons whypatients/caregivers intentionally decide to stop takingtheir prescribed controller medications or from usingtheir prescribed positive airway pressure machines.

Causes of Intentional Non-adherence

Table one lists the most common reasons that pa-tients willfully decide to stop taking their controllermedications. Although not necessarily exhaustive, itdoes provide a rather comprehensive listing of the rea-sons (or, as some might argue, excuses) patients offerwhen confronted with non-adherence. Regardless ofwhether or not one agrees or disagrees with the variousreasons, central to this issue is that patient/caregiverbeliefs, no matter how far-fetched they may seem tothe health care provider, must not be discounted.

To set the stage for subsequent articles in this mono-graph that will provide more specific recommendationsand “tricks of the trade” on engendering sustained ad-herence, at this point we will merely discuss each rea-son and provide a commentary as to the validity ofeach.

Concern over Adverse Effects

Concerns about adverse effects are well-founded, es-pecially with parents of children with chronic asthma.The term “steroid-phobia” nicely captures the concernparents have when long-term use of inhaled steroids isprescribed for their children. To underscore the perva-siveness of this concern, it has been reported that 65%of new prescriptions for inhaled corticosteroids are notrefilled, clearly demonstrating that this particular con-troller medication, in spite of overwhelming evidenceof its relative safety and effectiveness, is woefully un-derutilized in the management of chronic asthma. Inmost instances, parents equate the adverse effects re-ported with the indiscriminate (not to mention illegal)use of oral or parenteral steroids, especially by certainathletes seeking an unfair competitive advantage.What is unfortunate is that we now know that the in-halational route of steroid administration, when prop-erly prescribed, does not necessarily equate to HPA axissuppression (i.e., growth retardation), bone density is-sues or exogenous Cushing’s syndrome. Respiratorytherapists are indeed the best qualified to addresssteroid-phobia by stressing the safety of the inhaledroute and the long-term advantages associated withkeeping asthma inflammation under control.

Medications are too Expensive

Unfortunately, the number of Americans lacking ef-fective health care coverage for their medications – ei-ther non-insured or under-insured – is staggering.When patients, parents or caregivers are forced tochoose between food and shelter or controller medica-tions, for obvious reasons, food and shelter will alwayswin. Few will deny that the existing US health care sys-tem is in trouble and access to affordable prescription

Table 1

Reasons for Intentional Non-adherence• Concerns about adverse effects• Medications are too expensive• Not really that sick• Not wanting to get “hooked”• Medications no longer work • To gain attention

medications will be only one of the myriad issues fac-ing the Obama Administration as they attempt to over-haul what many now believe is a dysfunctional andout-of-control industry. In the meantime, we areobliged to work within the existing system and to do allthat we can to help our patients have access to theseimportant medications. One source of potential assis-tance could be working with medical social workerswho may have insight into alternate funding sources.Moreover, since many pharmaceutical firms offer re-bates or special pricing for low income patients, thismay be a path worth exploring to help counter this veryreal concern.

Not Really that Sick

When patients are initially diagnosed with anychronic medical condition, let alone a chronic respira-tory disease, one of the first reactions is denial. This isan all-too-human response, especially in a society thatis constantly being bombarded with video and digitalimages of youth, vigor and vitality. Few, if any of us,welcome the news that we have a chronic medical con-dition, but the reality is that many Americans are in-deed afflicted with one or more chronic conditions.This is especially so as the elderly portion of the popu-lation continues to expand, but younger Americans arevulnerable as well. Of major concern to respiratorytherapists is chronic asthma, where denial can lead todeath. The problem is that when asthma symptoms ofbronchospasm and inflammation are under control, theindividual may literally be asymptomatic and experi-ences little discomfort. This is where denial rears itsugly head, or as the old adage goes “out of sight – outof mind”. It is therefore important for respiratory ther-apists to have frank and candid discussions with theirpatients afflicted with asthma, COPD, or even OSA.The focus of the conversation should be on the starkdifference between effective long-term symptom con-trol and a 100% cure. The former is attainable,whereas the latter is not.

Not wanting to get “Hooked”

It is probably safe to assume that the great majorityof human beings do not readily welcome the possibil-ity of dependence or addiction to a chemical prepara-tion. Such aversion is reinforced with daily and oftensobering accounts of the horrendous effects of illegaldrug addiction and the human toll extracted by thisblight on society. However, even with safe and prop-erly prescribed medications, dependency is disruptive

and often imparts a major impact on daily living. In aword, it is something else to worry about in an alreadyfull and increasingly complex life. Couple this fact withthe perception described above that “I’m not really thatsick”, it is easy to see why patients offer this reason fordeciding to stop taking their medications. Again, res-piratory therapists have a unique opportunity to discussthe differences between dependency and the success-ful long-term control of symptoms, stressing the harm(not to mention danger) of off-again on-again regi-mens. An effective counter to this very real yet spe-cious patient perception would be to stress that theeventual goal is to achieve an improved overall qualityof life.

Medications no Longer Work

One of the most common explanations for this rea-son is that patients often confuse the difference theyexperience when taking a dose of the newer long-act-ing beta agonists instead of a short-acting, rescue betaagonist. This is especially so if a short acting beta ag-onist had been used on a scheduled daily regimen forsymptom control, as was often the case before thelonger-acting versions became widely available. Specif-ically, the tremulous and/or tachycardia experiencedwith the inhalation of a short-acting beta agonist isoften perceived, and becomes synonymous, with thefact that the drug is working. In another example,when a regimen of inhaled corticosteroids is successful,subsequent doses may not be perceived as having anyimpact, as their role is now more preventative.

It should be noted that even today, there are stillmany prescribers who continue to prescribe, albeit indirect contravention to evidence-based guidelines, adaily regimen of short acting beta agonists, when in re-ality, this class of drugs are now only to be used on anas needed basis when there is an acute onset of bron-choconstriction. Consequently, whenever a patient isbeing converted to one of the newer, long-acting betaagonists, it is essential that the respiratory therapist an-ticipate this patient response and instruct the patientaccordingly.

To Gain Attention

This rather subtle yet real problem is typically seenwith young children and adolescents, who, for one rea-son or another, decide (intentionally or unintentionally)to use their disease as a way to try and control parentalbehavior. This patient population learns very quicklyand at a relatively young age that a medical condition

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can be used for manipulation purposes. It may be as sim-ple as having an excuse to not go to school or church, notwanting to play sports or be involved in outdoor activities.Or, it could be something much more complex such as deeprooted psychological issues or ill-founded feelings of aban-donment or estrangement. In either case, it is importantthat parents realize, especially with asthma, the possibilitythe a recurrence of symptoms may indeed be the direct re-sult of the child willfully deciding, in spite of the risks, of nottaking their medications as directed. Parental supervision istherefore an important part of ensuring sustained adher-ence.

Summary

Patient/caregiver non-adherence with prescribed medica-tions to control respiratory symptoms is an increasinglyproblematic challenge, made all the more critical becauseof the adverse clinical and economic impact. Non-adher-ence leads to poor disease control and an increase utilizationof re-current and costly emergency care. On the otherhand, effective symptom control, achieved through willfuland sustained adherence, offers our patients an improvedquality of life in spite of their chronic respiratory condition.Respiratory therapists possess all of the skills, attributes andtalents needed to help foster sustained adherence, andthere is no shortage of opportunities to do so. While pro-viding patient education (and motivation) may not providethe adrenalin rush as working in a hi-tech pulmonary criti-cal care setting, it is as every bit as important to the lives of

those patients who continue to struggle with daily bouts ofdyspnea and wheezing. It is a patient population that weshould embrace and work with in every practice venue. Theend results could indeed be remarkable in a very short pe-riod of time.

References

1. Rau JL. Determinants of patient adherence to an aerosol regimen.Respir Care 2008; 50(10).

2. Haynes RB, Taylor DW, Sackett DL, eds. Compliance is health care.Baltimore, MD: Johns Hopkins University Press, 1979.

3. Tashkin DP. Multiple dose regimens:impact on compliance. Chest1995; 107(5) :176S-182S.

4. Rand CS, Wise RA. Measuring adherence to asthma medication reg-imens. Am J Respir Crit Care Med 1994; 149:S69-S76.

5. Lewis RM, Fink JB. Promoting adherence to inhaled therapy: buildingpartnerships through patient education. Respir Care Clin N Am 2001;7(2); 227-301.

6. Sabate E, editor. Adherence to long-term therapies: evidence for ac-tion. Geneva 2003: World Health Organization. www.who.int/en/accessed January 15, 2009.

7. Cochrane GM, Bala MV, Downs KE, Mauskopf J, Ben-Joseph RH. In-haled corticosteroids for asthma therapy: patient compliance, devicesand inhalation technique. Chest 2000; 117(2): 542-550.

8. Bender BG, Rand C. Medication non-adherence and asthma treat-ment cost. Curr Opin Allergy Clin Immunol 2004; 4:191-195.

9. National Asthma Education and Prevention Program.http://www.nhlbi.nih.gov/guidelines/asthma/ accessed January 23,2009.

10. Global Initiative for Chronic Obstructive Lung Disease.http://www.goldcopd.com accessed January 23, 2009.

11. Cochrane GM, Horne R, Chanez P. Compliance in asthma. RespirMed 1999;93(11):763-769.

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Introduction

The medical profession has known for some time thatnon-adherence with prescribed controller medicationsis a major problem leading to poorer clinical outcomes,increase costs and worsening of the quality of life. Thegeneral public is now also learning about non-adher-ence and its implications. On October 22, 2008, TheNew York Times ran an article on the dramatic drop inthe number of prescriptions filled in 2008 (fig. 1). Nodoubt, this drop coincided with the major financialdownturn of 2008.1

In a related article, the Kaiser Health Tracking Polllooked at the way patients were consuming healthcarebefore and after the onset of the financial crisis. Theyfound that in October 2007, as compared with April of2008, 7% more patients deferred seeking healthcare orskipped needed treatment. Three to four percent morepatients either did not fill or finish their prescribed med-ications. Overall, non-adherence increased from 42%to 47% (fig. 2). When the October group was polled,20% reported that their condition got worse. In an ear-lier Kaiser survey conducted in 2006, one in four fami-lies reported problems in paying for healthcare. In2008, that number increased to one in three in 2008.2

Non-adherence is a worldwide problem. Accordingto the World Health Organization (WHO), 50% of pa-tients with chronic diseases are non-adherent with theirmedications. For example, in a study conducted in Aus-tralia, 57% of patients were non-adherent with anyasthma medications, and 72% were non-adherent withprescribed controller medications. Their overall asthmanon-adherence rates were estimated at 30-70%, with

The Impact of Non-adherence with Respiratory Controller Medications

Russell A Acevedo MD FAARC


Russell A Acevedo MD FAARCCrouse HospitalUpstate Medical UniversitySyracuse NYEmail: [email protected]

Figure 1

Drug prescriptions dispensed year-to-year.

Figure 2

Non-adherence rates: October 2007 v. April 2008

Put off or postponed gettinghealth care you need

Skipped recommendedmedical test or treatment

Didn’t fill a prescription

Cut pills or skippeddoses of medicine

Had problems gettingmental health care

Did any of the above

36%29%

31%24%

27%23%

22%19%

12%8%

47%42%

October 2008

April 2008

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the rates for adolescents as high as 70%.3

Not surprisingly, adherence rates in the US are simi-larly low. In one early asthma study, researchers de-fined primary non-adherence as the failure to fillprescriptions. 4 They found this rate to be a wide rangeof 6 - 44%. Secondary non-adherence was defined asthe failure to take medications appropriately. To assessthis rate, the researchers followed 19 patients for 12weeks on their prescribed anti-inflammatory steroids.Patients were instructed to record their daily medica-tion use in a journal but were unaware that dose coun-ters were also being used. Overall, they were found tobe 53% non-adherent by medication counters eventhough they over reported their medication use in theirjournals.

Adherence Reporting

In recent pediatric study, Bender and Rand looked atthe different ways of reporting adherence and hypoth-esized that an impersonal computer reporting methodwould remove the potential embarrassment. This, inturn they thought, would lead to greater accuracy thanface-to-face questioning. 5 Both the patients and theirparents were randomized to reporting the patient’sasthma anti-inflammatory medication use by computer,pencil questionnaire, or face-to-face interview. Sub-jects were blinded to the fact that dose counters in eachof the delivery devices tracked actual adherence rates.All three reporting groups showed poor correlation be-tween the reported and actual adherence. Moreover,adherence reporting was just as poor for medicationstaken the day before the data collection began as theweek before (fig. 3 and 4).

Non-adherence Rates

Patients with COPD adhere to their medications aspoorly as any other group studied. Overall, adherencerates for COPD patients are estimated to be around50%. In a recent study by Bourbeau and Bartlett, whenCOPD patients were asked why they chose not to taketheir maintenance treatments, 31% stated it was be-cause they were “feeling good” 6. However, duringexacerbations, COPD patients tended to overuse theirrescue medications. A 10-year retrospective studylooked at refill rates of inhaled corticosteroids, combi-nation beta agonists and steroids, and anticholinergicsin older asthma and COPD patients. 7 The results re-vealed that medications were underused by 59% ofthose studied and overused by 12%. Only 28% ofprescriptions for repeat inhaled corticosteroids werefilled appropriately.

In another example, prescription claims data fromOntario Drug Benefit Program were followed for oneyear to assess adherence in a population of 31,368asthma and COPD patients. Refill rates for inhaledbeta agonist, anticholinergics and steroids were stud-ied. Tiotropium had the best adherence rate of all themedications and that rate was only 53% (fig.5).8

Figure 3

Self-report discrepancy frequencies for past-week questions: ACASI

(left), clinical (middle), and questionnaire (right).

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Figure 4

Self-report discrepancy frequencies for yesterday questions: ACASI

(left), clinical (middle), and questionnaire (right).

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Figure 5

Adherence rates for COPD controller medications

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Non-adherence Outcomes

There is no question that non-adherence is associatedwith poor clinical outcomes. The aforementionedWHO report found that, in patients with moderate tosevere asthma and poor adherence, physician visits in-crease by 5% and hospitalizations increase by 20%.3

In a similar vein, Balkrishnan conducted a retrospec-tive 2-year study that looked at prescription refill ratesfor inhaled corticosteroids in 1,595 patients, aged 65and older, having a diagnosis of asthma or moderate tosevere COPD. 9 Prescription refill rates were used todefine degree of adherence. 60% of the group wasfound to have poor adherence and 10% had good ad-herence. These two cohorts were then compared onclinical outcomes. Those patients with poor adherencehad more hospitalizations, longer length of stay, moredoctor visits, less effective use of rescue medicationsand higher cost of care (table 1).

In a study of elderly patients admitted through anemergency department (ED), 8% of the ED visits werefelt to be due to medication non-adherence. 10 Ofthese, 63% of the non-adherence was determined tobe intentional. The major reasons reported included:cost, forgetfulness, adverse effects and switching to un-conventional forms of treatment. The authors notedthat not all non-adherence necessarily leads to bad out-comes. They define “intelligent non-adherence” as pa-tients altering the dose or frequency of theirmedications to avoid side effects. Many times, theysurmised, this is due to over prescription of the dose orfrequency by the clinician. Some patients learn thatthey can achieve the same therapeutic result with fewerside effects at lower dosages.

In another hospitalization study in the elderly, the per-centage of admissions found to be drug related was28%.11 Non-adherence accounted for 11.4% of theseadmissions. For the 36 patients admitted due to non-adherence the total hospital cost was $77,289, approx-imately $2,100 per patient. Three of the top 9medications associated with hospitalization due to non-adherence were theophylline, albuterol, and prednisone.

The EFRAM study, from a group in Barcelona, was aprospective case-control study in severe COPD patientslooking at risk factor for re-hospitalization. 12 In thisgroup, the average FEV1 was 39% of predicted. Al-though medication non-adherence trended with hos-pital admissions, there was not a significant correlation.However, the findings did suggest that under-prescrib-ing of long-term oxygen therapy, a history of prior ad-missions and lower FEV1 values were independentlyassociated with a higher risk of admission for a COPDexacerbation.

Non-adherence and Healthcare Costs

In 2002, the total healthcare expenditures in the USexceeded $1.6 trillion or 14.9% of the gross domesticproduct (GDP). On a more personal level, this trans-lated to an average of $5,440 in healthcare costs perperson. There was an average of 3.1 physician officevisits per person, which equates to over 880 millionphysician office visits a year. With an estimated over188 million (or more!) medical visits resulting in non-adherence, the waste and excess cost due to non-ad-herence has been estimated to be as high as $300billion/year.13

From another perspective, when a prescribed courseof medication is not completed, this leads to wastedmedications. For example, a recent study in a 65-yearor older population that employed a medicationcounter, found that the waste from uncompleted pre-scriptions accounted for approximately 2.3% of totalmedication costs, averaging about $30.47 per person.13

The estimated annual cost for wasted medications - -well over $1 billion per year!

Asthma disease management has been shown to im-prove clinical outcomes and decrease cost. Totalasthma cost is approximately 1- 2% of all healthcarespending. ED and hospital cost are disproportionatelyhigher compared to other care locations. Poor asthmacontrol, with non-adherence as a contributing factor, isa major cost driver. Each preventable ED visit saves aminimum of $500 and each preventable hospitalizationsaves $2,000 or more. This excess cost for urgent care,ED and hospitalization is nearly $2 billion annually. Withoptimal control, it is estimated that as much as 45% oftotal asthma cost could be saved.3

The medical care costs for families with asthmaticchildren ranges from 5.5% to 14.5 % of total familyincome. When money gets tight, prescription controllermedications are frequently the first omitted as a costsaving measure. While the economic reality cannot bedenied, in the long run this is a misguided strategy,since not spending the money upfront for controller

Table 1

Clinical outcomes from non-adherence.

OUTCOME POOR GOODADHERENCE ADHERENCE

Hospitalizations per year 0.5 0.3Physician visits per year 9.0 8.4Hospital days per year 1.9 1.2Number of SABA 5.0 5.5Health care charges $10,399 $8,412

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medications often results later in increased family andoverall costs. And, this is in addition to an increase inthe number of lost school days as well as lost work dayssince a parent often must also remain home with a sickchild.3

Quality of Life

In an attempt to gauge the impact of non-adherenceon the quality of life, researchers provided COPD pa-tients with nebulizers equipped with counters to meas-ure treatment adherence. 14 As in prior studies, thesubjects were unaware of the counters. After a 4-weekperiod, the patients completed the St. George’s Respi-ratory Questionnaire. When adherence rates werecompared with the quality of life scores from the ques-tionnaire, they found a strong correlation between lowadherence rates and lower quality of life scores.

Another study looked at patients who were on longterm home nebulizer therapy. 15 Patients with poor ad-herence scored significantly worse on the family andhome life sections on the Recent Life Changes Ques-tionnaire (RLCQ) reflecting greater disruption in homeand family life.

Self Management & Adherence Programs

Much can be learned about the impact and cost ofnon-adherence from the benefits of successful adher-ence programs. One example is the Harvard PediatricAsthma Outreach Program that utilizes an asthma casemanagement nurse who spends approximately 8 hoursa week to ensure adherence.16 Over a two-year pe-riod, fifty-seven asthmatic patients aged 1 to 15 yearswere randomized into 2 intervention groups. Whileboth groups received a single intensive asthma educa-tion presentation, the outreach group received addi-tional follow-up from the asthma educator throughoutthe intervention period. Data revealed that ED visitsdecreased by 73% and hospital admissions decreasedby 84% respectively for those in the interventiongroup. In terms of cost-benefit, it was estimated thatfor every dollar spent on the case manager nurse’ssalary, savings to the health plan ranged from $7.69 to$11.67. The key message, again reiterating what haspreviously discussed, is that non-adherence results inmore ED visits, more hospitalizations, and greater over-all costs of care.

Another example is the Wee Wheezers program isaimed at children ages 4-6 year olds who are taught tomanage asthma attacks and communicate with healthproviders.18 The cost is $26 per child. The patients had

0.9 fewer sick days per month, 5.8 more symptom-freedays per month, and for the parents, 4.4 more unin-terrupted nights sleep per month. The key message inthis case is that sustained adherence results in fewersick days for children and fewer sleepless nights forboth children and parents.

Summary

To summarize, non-adherence with prescribed con-troller medications results in poor clinical outcomes andincreased costs. Below is a list summarizing the majorimpacts of non-adherence that is provided to re-em-phasize that there is a clinical and economic imperativeto address this major impediment to optimum man-agement of chronic respiratory diseases.

In the words of Brian Haynes, a prolific and highlyrespected author/researcher on the subject of non-ad-herence, “increasing the effectiveness of adherence in-terventions might have a far greater impact on thehealth of the population than any improvement in spe-cific medical treatments”.18 Thus, promoting improvedadherence with properly prescribed controller medica-tions represents a very timely and important challengefor respiratory therapists. Moreover, the potential pos-itive impact of improved disease and symptom control,increased quality of life and reduced healthcare costswould bode well, not only for our patients, but for thehealthcare delivery system in general.

References

1. New York Times October 22, 20082. Kaiser Health Tracking Poll; Oct 20083. Sabate E, editor. Adherence to long-term therapies: evidence

for action. Geneva 2003; World Health Organization Press.4. Spector SL, et al. Compliance of patient with asthma with an

experimental aerosolized medication: Implications for con-trolled clinical trials. J All Clin Imm 1986;77:65

Table 2

Major impact of non-adherence

• Poor symptom control• More frequent exacerbations• Increased ED visits and hospitalizations• Unnecessary stepping up of medications and

diagnostic testing• Education interruptions• Greater family disruption• Diminished quality of life• Increased healthcare cost – in the $billions!

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5. Bender BG, Rand CR. Impact of interview mode on accuracy of childand parent report of adherence with asthma-controller medication.PED 2007; 120, (3): 471

6. Bourbeau J, Bartlett SJ. Patient adherence in COPD. Thorax2008;63:831- 838

7. Krigsman K. Refill adherence by the elderly for asthma ⁄ chronic ob-structive pulmonary disease drugs dispensed over a 10-year period.J Clin Pharm Ther 2007;32, 603

8. Cramer JA. Treatment persistence and compliance with medicationsfor chronic obstructive pulmonary disease. Can Resp J 2007;14:25

9. Balkrishnan R. Inhaled corticosteroid use and associated outcomes inelderly patients with moderate to severe chronic pulmonary disease.Clin Ther 2000; 22 (4): 452

10. Hughes CM. Medication non-adherence in the elderly. Drugs Aging2004;21(12):793

11. Col N. The role of medication noncompliance and adverse drug re-actions in hospitalization of the elderly. Arch Intern Med1990;150:841

12. Garcia-Aymerich J, Farrero E, Felez MA, et al. Risk factors for hospi-talization for a chronic obstructive pulmonary disease exacerbation -EFRAM study. Am J Respir Crit Care Med 2001;164:1002-1007.

13. Bender BG, Rand CR. Medication non-adherence and asthma treat-ment cost. Curr Opin Allergy Clin Immunol 4:191

14. Corden ZM. Home nebulized therapy for patients with COPD. Chest1997;112:1278

15. Turner J. Predictors of patient adherence to long-term home nebulizertherapy for COPD. Chest 1995; 108:394-400

16. Greineder DK, Loane KC, Parks P. A randomized controlled trial of apediatric asthma outreach program. JACI 1999; 103:436-440.

17. Wilson, SR, Latini D, Starr NJ, Fish L, et al. Education of parents of in-fants and very young children with asthma: a developmental evalu-ation of the Wee Wheezers program. J Asthma 1996; 33:239-254.

18. Haynes RB et al. Interventions for helping patients follow prescrip-tions for medications. Cochrane Database of Systematic Reviews,2001

Introduction

I have been asked to discuss my clinical experience inengaging patients with chronic respiratory disease incollaborative self-care. My views and philisophic ap-proach regarding this aspect of patient care are basedupon my past experience as a respiratory therapistworking with physicians and as a pulmonary physicianworking with respiratory therapists. Additionally, it hasbeen requested that I present our experience with anoutpatient collaborative care model for patients withchronic respiratory disease. This concept offers a newhorizon for respiratory therapists (RTs) to work hand-in-hand with physicians in an outpatient setting to em-power patients to actively participate in optimalself-care to control symptoms and to maintain pro-longed periods of wellness.

Collaboration: the Clinician-Patient Relationship

A message that is carried throughout this monographis that we all want better outcomes for our patients, andthat this can best be achieved by sustained adherencewith prescribed controller medications. Simply handinga patient a prescription for an inhaled medication is notenough. Similarly, initiation of long-term oxygen ther-apy (LTOT) that is limited to a phone call to the localdurable medical equipment (DME) provider is doomed

for failure. Even the best writtren protocols, patient careplans, procedures and payor authorization for paymentall fall short without the caring hand of the clinician.That said, even the most caring clinicians must ade-quately address patients’ questions, fears and concerns.If we do not meet the needs of our patients, we cannotexpect optimal self-care.

The clinician-patient relationship with patients strug-gling with chronic respiratory disease spans far beyondexplaining the peak flow or FEV1. During a patient en-counter, how we use information is oftentimes as im-portant as how much we know. Furthermore, what wedo know is inadequate without understanding theneeds of each of our patients.

Unfortunately, patient encounters typically have thesame set pattern: 1) Clinicians ask very specific ques-tions that are not open ended, 2) Patient responses aretypically very limited, 3) Next, an assessment is made,and 4) Recommendations and plans are made or revisedas the case may be. Interactive discussion is minimal tonone. The patient’s needs are not likely to be fulfilled astheir questions, fears and concerns were not addressed.In short, collaboration cannot occur without interactivediscussion.

In my experience there are two types of clinicians;those who are are “healthcare professionals” and thosewho are also “caring health professionals”. Clinicianshortage, ever-increasing workloads and expectations,as well as high levels of stress, tend to distract us fromthe reason we entered the healthcare profession. Thefast pace of clinical practice pushes us to focus more ontask completion which may not be balanced with com-passionate interactions with our patients.

The checklist in Table 1 presents six questions youmay wish to consider following encounters with yourpatients.

Engaging Patients through a Collaborative Care Model

Kent L Christopher MD RRT FAARC


Kent L Christopher MD RRT FAARCUniversity of Colorado Health Sciences CenterDenver COEmail: [email protected]

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Whether or not you actually “connected” with the apatient is largely intuitive. However, there are some im-portant signals patients often send. First and foremostis the quality of your verbal interaction. Other cues arethe patient’s affect, attention span and body languageand whether or not there was direct eye contact. Pa-tients with chronic respiratory diseases, especially whenan exacerbation is experienced, often experience sad-ness and despair. Everyone needs hope, reassuranceand the feeling that someone cares about them. Expe-rienced RTs become adept in balancing their knowledgeof the medical condition of the patient with an under-standing of the individual’s emotional and psychologicalneeds.

It is often relatively straightforward as to when an RT isqualified to give reassurance regarding a patient’s medicalconcern or condition and when one is not. Effectiveness inlifting the patient’s spirits frequently has nothing to do withdiscussion of their medical problems. A few simple gesturessuch as a warm greeting, and a big smile, as well as inquiriesabout family and friends can make a huge difference.Spending a few extra minutes sitting in a chair at eye leveloften brightens our patient’s day (and their trust in us) muchmore than standing over them and giving the impressionthat you are eager to gallop out of the hospital or examroom or even the home. Asking open-ended questions andencouraging patient questions is paramount to establish-ing quality interaction and understanding patient needs. Asdiscussed elsewhere in this monograph, Chris M. GarveyFNP MSN MPA, describes the basic skills in asking open-ended questions that will encourage patient questions (andinteraction). These skills help foster the attainment of sus-tained adherence.

Obviously, when a patient question falls outside theboundary of the RT‘s scope of practice, the proper recourseis to defer to the physician. Sometimes, perhaps even moreoften than we may realize, this means more than simplytelling the patient to discuss the issue with their doctor dur-ing their next visit. Depending on the circumstances, it maybe appropriate for the RT to directly contact the physicianregarding a patient’s major issue or concern. Of utmost im-

portance is the fact that every encounter an RT has with apatient brings an opportunity for a “teachable moment”.Even though this is clearly not the “high-tech” RTs havebeen trained for, we now recognize that such “high-touch”is every bit as important. Such interactive “high touch” al-lows RTs to bring forth their extensive knowledge, skills andexperience. This in turn gives patients a better under-standing of their chronic respiratory disease, the optimummanagement plan and the importance of sustained self-care in maximizing health and quality of life.

Collaboration: The RT-Physician Relationship

Over the years I have been amazed by the close pro-fessional relationship between the RT and physician com-munities in general and, in particular, the clinical teampartnership between individual RTs and physicians. Thereare many attending physicians that have a high level oftrust and respect for individual RT professionals. Fur-thermore, there are numerous medical directors that, whoin addition to being excellent clinicians, are also strongleaders who actively participate and support their RT de-partments. Similarly, RT educational institutions count ontheir medical directors, in addition to program directorsand other RT educators, for high educational standardsand accreditation. Numerous physicians, in collaborationwith RTs, have aggressively supported the expanding vol-ume of research in respiratory care. It goes without say-ing that there has been staunch physician involvement inAARC annual meetings, various RT programs and med-ical publications, including the scientific journal RESPIRA-TORY CARE. There is also direct physician support of theprofession through the AARC Board of Medical Advisors(BOMA), the National Board for Respiratory Care (NBRC)and the Commission on Accreditation for RespiratoryCare (CoARC). Finally, there are numerous physician or-ganizations that support the RT profession, particularlywith regards to legislative and regulatory issues.

Table 2 lists questions you may wish to ask regarding

Table 1

RT Post Encounter Checklist• Were you able to “connect” with the patient?• Did you make appropriate attempts to lift his/her

spirits?• Did you ask open-ended questions and encourage

patient questions?• Were you able to engage in interactive discussion?• Did you effectively defer to the physician when you

could not answer?• Were you able to use your knowledge and skills in

a “teachable moment”?

Table 2

Collaboration Regarding Self-Care: Your Physician-RT Relationship

• Is care collaborative with interactive discussionbetween professionals?

• Do you have a “team approach” or are you “is-lands”?

• Do physicians allow you to participate in patientself-care education?

• Is there an RT-physician “game plan” regardingself-care education?

• Is there organized and objective feedback to knowif your plan is working?

• Is your collaborative self-care education updatedwith new scientific information?

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your physician-RT relationship.Unfortunately, many RTs may not have the luxury of

a collaborative and interactive professional relationshipwith their medical director or even attending physicians.You may be on the receiving end of written orders withlittle opportunity for your valuable input. It is under-standably an uncomfortable position being an oarsmanwith no ability to change the course of the ship.Though this issue is of paramount concern to the RTprofession, it is beyond the scope of this monograph toaddress this problem. On the bright side however,many of those physicians still rely upon RTs to admin-ister self-care education in the use of prescribed inhaledmedications. This expectation also spills over to respi-ratory equipment such as continuous positive airwaypressure devices (CPAP), mechanical ventilators (inva-sive as well as non-invasive) or LTOT. Take every op-portunity to make a significant impact upon thatindividual’s health and quality-of-life.

Now, if the prescribing physician is supportive of yourparticipation in self-care education, you might ask your-self - do you in turn have your own game plan to closethe loop? Are you effectively communicating impor-tant and relevant information back to the physician? Ifnot, implementation of an organized and effectivefeedback system is essential, not only to determinewhether or not your actions and outcomes are effica-cious, but if these actions and outcomes are consistentwith what the physician intended. Such evaluation andanalysis in needed to assure success both collectively inyour patient population and on a case-by-case basis.As with any medical intervention, the care we provideneeds to be periodically reassessed based upon insightfrom new scientific information.

The RT in Outpatient Pulmonary Medicine: A Collaborative Self-Care Model

The incidence, prevalence and healthcare costs in theUS directly (and indirectly) associated with chronic res-piratory diseases such as COPD, asthma and obstruc-tive sleep apnea are overwhelming. In fact, they areoverwhelming the healthcare system. Although hospi-tal care has made significant strides in technology andpharmacologic interventions, it is still limping along asan inefficient delivery system. Sadly, high hospital uti-lization is often a result of inadequate outpatient care,especially with regards to individuals with the chronicrespiratory diseases noted previously. The recurrentneed for frequent re-hospitalization is analogous toclosing the barn door after the horse has left.

The premise of this monograph is that collaborationamong and between RTs, physicians and chronic respi-

ratory disease patients can result in improved self-care,particularly with respect to sustained adherence. Makeno mistake - RTs have made significant contributions inboth the acute care and home respiratory care settings.However, it is unfortunate that reimbursement con-straints continue to make utilization of the RT in thehome (through DME providers) more and more pro-hibitive. Absent any drastic reductions in Medicarecoverage for the RT in the home setting, RT serviceswould be anticipated to improve the quality of homehealthcare delivery. However, if the healthcare systemis to work for the benefit of the expansive growingpopulation of millions of patients with chronic respira-tory disease, the vast majority of care will need to bedelivered through the outpatient clinic or medical of-fice setting. The outpatient environment has the great-est potential for effectively and efficiently becoming thecatalyst for self-care with sustained adherence. Thereis obviously a role for the RT in this setting, yet outpa-tient care is greatly underutilized with regards to onsiteRT clinical expertise. When the famous outlaw WillieSutton was asked why he robbed banks, he replied“because that’s where the money is.” Perhaps it is timefor an accelerated entry of RTs into the outpatientarena, since that is where most healthcare policy mak-ers tell us the majority of future patients will be.

The passage of the Medicare Improvements for Pa-tients and Providers Act of 2008 (MIPPA), represents amajor opportunity in that regard. One component ofthe MIPPA legislation mandates that the Centers forMedicare and Medicaid Services (CMS) promulgate, nolater than January 1, 2010, a standardized nationalMedicare eligibility and coverage policy for pulmonaryrehabilitation. At present such eligibility and coveragedeterminations are made at the local level by con-tracted Medicare fiscal intermediaries, and astonish-ingly, many such contractors do not cover thisimportant and evidence-based intervention, arguingthat the evidence does not support its effectiveness.However, beginning in 2010, RT Departments nation-wide will finally be able to offer their chronic respira-tory patients access to a proven and cost-effectiveintervention, that intervention that RTs themselves willbe able to provide under a national reimbursementstructure in an outpatient setting.

In light of the fact that for years Medicare coveragefor pulmonary rehabilitation has been anything but ro-bust, and frustrated that many of my patients were notgetting the extended care they needed to prevent anexacerbation leading to hospitalization, I decided totake matters into my own hands. Nearly 19 years ago,I approached Stephanie Diehl, a practicing RRT in theDenver area, to see if she would be interested in the

creation of a novel physician-RT collaborative outpa-tient pulmonary medicine model. In addition to the po-tential for improved care for my chronic respiratorydisease patients, Stephanie readily appreciated the ad-vantages that this new environment presented RTs whowere exploring alternatives to critical care within acutecare hospitals. Over the years, the advantages of ournovel professional relationship have expanded well be-yond our initial plans and are listed in Table 3.

While the onsite utilization of RTs in the outpatientenvironment is certainly not yet as commonplace as itshould be, it is no longer considered a totally novel orunique concept. The roles and responsibilities of theRT vary among outpatient settings across the spectrum- from the university clinic to both large and small pri-vate practice groups. Participation of RTs will be influ-enced by the involvement of other clinical staff, suchas RNs and LPNs, nurse practitioners and even medicaltechnologists. Duties may often be driven by the tech-nical services offered in a particular outpatient environ-ment (e.g. pulmonary function testing, exercise testing,and endoscopy). However, the scope of non-techni-cal, direct patient care responsibilities will likely be afunction of the individual RT-physician professional re-lationship.

Stephanie and I believe that the model that we haverefined over the years has proven very effective andprofessionally gratifying. The following discussion is asummary of her roles and responsibilities that evolvedin the management of chronic respiratory disease pa-tients in our particular outpatient medical office setting.

There are certain procedural skills that one would ex-pect the RT to bring to the outpatient environment.Even though the procedures could be delivered througha separate hospital facility, delivery onsite in the officeor clinic can be scheduled quickly and done more effi-

ciently with rapid turnaround of results. Again, thosetasks will depend upon the scope of the outpatientservices. Examples of our substantial experience withRT procedures performed in the medical office are iden-tified in Table 4.

With Stephanie’s full-time presence in the office prac-tice, she is able to lend her clinical insight to coordina-tion of a number of care tasks. Consequently, we nolonger had a need for a medical technologist and therewere reduced time demands placed upon receptionistpersonnel. These savings in operating costs were eas-ily shifted to support part of the salary of the RT. Table5 shows the important tasks performed by the RT thatfacilitated coordination of care and kept the ball frombeing dropped.

A theme that threads throughout this monograph isthat patient education is key to their ”buy in” for sus-tained adherence. This outpatient care model hasdemonstrated that RTs can play a critical role in sup-porting the physician in patient education, especially

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Table 3

Outpatient Pulmonary Medicine Environment: Advantages for the RT

• Dayshift with weekends and holidays off• Alternative to the critical care environment and

related high intensity and stress• Opportunity for a new frontier and professional

growth• Opportunity to play a significant team role• Active participation in continuity of care • Education and monitoring of patient self-care with

fostering of sustained adherence• Satisfaction of long-term professional relationships

with patientsTable 4

Outpatient Role of the RT in Procedures• Clinical testing

– Spirometry pre and post bronchodilator– Rest and exercise pulse oximetry (including

O2 titration)– Arterial blood gas draw

• Medical procedures– Assist in transtracheal catheter insertion – Perform transtracheal catheter cleaning

(removal over wire guide)– Assist in fiberoptic rhinolaryngoscopy

• Technical care– Nebulized bronchodilator administration– Assessment of appropriate stationary &

portable O2 delivery system – Patient evaluation on intermittent flow O2

delivery devices

Table 5

Outpatient Role of the RT in Care Coordination• Schedule outside testing • Obtain outside test results• Schedule return visits• Facilitate referrals• Obtain referral reports and hospital records• Document coordination with primary care • Facilitate completion of Certificates of Medical

Necessity for LTOT

with regards to the patient’s and their understanding ofhow any why benefits can accrue from self management.Table 6 list the educational contributions in our model.

In this outpatient care model, the role of the RT was ex-panded to involve a greater participation in patient evalua-

tion and management as a result of demonstrated expertise.This experience (shown in Table 7) fostered RT professionalgrowth with utilization of expanding knowledge to engagein higher levels of assessment and decision making.

The RT roles and responsibilities illustrated in Tables 6 and7 also obviated the need for a nurse in this particular officepractice setting. Again, control of operating costs allowedfunds to be available to offset RT salary. As noted in Table8, it became clear through implementation of this modelthat collaboration of the physician with the RT resulted innumerous physician benefits as well.

Though there were benefits to the physician and RT, thetrue goal of this model was to facilitate improved patienthealth and quality of life through a collaborative experiencewith the caregivers. It is our conclusion that the patient ben-

efits noted in Table 9 can promote sustained adherence.

Summary

There is definitely a role for the RT in the outpatient man-agement of patients with chronic respiratory disease, al-though this aspect of professional practice is not yet widelyin place. This outpatient model suggests that self-care isbest served by an RT-physician team relationship that isboth collaborative and patient-centric. A major obstacle toovercome is the lack of a reimbursement structure for out-patient services delivered by an RT working under the su-pervision of a physician, (or, in Medicare lingo ”incident tothe physician”). The AARC is presently pursuing legisla-tion that would allow billing of RT services under physicianoversight, similar to that of a physician assistant. Strongsupport of this pursuit by the RT and physician communitiescould will help lay the groundwork for exciting new careeropportunities that promote the health and quality of life forour growing population of patients with chronic respiratorydisease.

Additional Reading

Health Care at the Crossroads: Guiding Principles for the Developmentof the Future Hospital. The Joint Commission 2008. Available atwww.jointcommission.org. Accessed January 30, 2009

Halvorson, GC. Health Care Reform Now: A Prescription for Change.Jossey-Bass 2007: Hoboken, NJ.

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Outpatient Role of the RT in Patient Education• Understanding chronic respiratory diseases

– Asthma– COPD– Interstitial lung disease– Other pulmonary diseases– Obstructive sleep apnea

• Importance of test results and follow-up studies– Spirometry, oximetry, sleep studies

• Benefits of sustained adherence with medications• Proper technique with inhaled medications• Benefits of other devices (CPAP, home ventilation,

LTOT, TTO)• Proper use and sustained adherence regarding other

devices (CPAP, home ventilation, LTOT, TTO)• Reinforcement of the self-care plan

Table 6

Outpatient Role of the RT in Patient Evaluation and Management

• Check patients into the examination room• Obtain interim history• Perform preliminary HEENT-chest examination• Update medication & treatment flow sheet• Assist in self-care plan design & revision• Facilitate prescription writing• Dispense samples• Triage patient phone calls

Table 7

RT in Outpatient Care: Physician Benefits• Improved patient education and care• Trusted interface between patient & physician• Reliable triage clinician in office while physician in

hospital setting• Reduced workload burden with improved efficiency• Opportunity for innovation• Opportunity for clinical research• Opportunity for intellectual growth

Table 8

The Collaborative Experience: Patient Benefits• Feeling of Trust • Compassionate care • Appropriate reassurance • Access to care• Coordinated care• High quality education • Management through integrated knowledge• Reliable self-care plan

Table 9

Introduction

Optimizing sustained adherence to medications trans-lates effective clinical skills into meaningful outcomesfor patients with chronic lung disease. Important com-ponents include: evaluating adherence and related bar-riers, providing effective patient-centered strategiessuch as motivational interviewing and use of optimaldelivery devices that are appropriate for the patient’sage, physical capacity and cognitive function.

Methods for evaluating adherence include self-report,patient interview, dose counting and electronic moni-tors. Self-report and patient interview are simple andinexpensive but may lack accuracy. Dose counting anduse of electronic monitor devices attached to the inhalerimprove accuracy but are costly and cumbersome. In-forming the patient that medication use will be moni-tored may enhance adherence to treatment.

Perceptual barriers such as concerns about medica-tions and their effects may impact adherence. Concernsabout medications may include: lack of information,harmfulness, dependence, long term effects and beliefof diminished effectiveness when used regularly.

Up to forty-five percent of inhaled corticosteroid (ICS)users report ten or more moderate to severe side effectsrelated to the medication and concerns are moststrongly related to higher doses of ICS.1

Using a framework for medications that ‘makessense’ to the patient is important to promote treatment

acceptance and ongoing use. Health threats such aslung disease may trigger development of a ‘mentalmap’ based on a patient’s understanding and beliefsabout the disorder and symptom experience that guidea patient’s actions. A patient may process clinical advicein light of their personal understanding and beliefsabout the illness which may conflict with medical prac-tice and recommendations.2 When a patient is symp-tom free, he or she may believe their lung disease iscontrolled and long term medications are not needed.A rationale for daily maintenance medication should notat odds with the patient’s understanding of the diseaseand its management. Adherence improves when a pa-tient has a ‘medical view’ of the lung disorder. Clini-cians should help patients to view disorders such asasthma or COPD as chronic diseases with acute featuresand be knowledgeable about why treatment should re-flect this. A key message is that persistence is necessaryeven when respiratory symptoms are not present. 2

Factors that influence adherence include: the patient’sacceptance of the disease process and recommendedtreatment, understanding and faith in the treatment, ef-fective patient - clinician interaction and incorporatingthe medication into their daily routine.3 Other factorsthat improve adherence include: a clinician’s willingnessto listen, spend time with the patient, be supportive andempathetic and a patient’s trust in their clinician.4

Greater perceived disease severity and longer diseaseduration have also been associated with improved ad-herence as have greater MDI instruction, fewer med-ications, fewer doses and / or inhalations.5,6,7 Factorsthat negatively impact adherence include: languagebarriers, suboptimal selection of delivery device, med-ication cost, side effects, complex medication regimensand psychosocial co-morbidities including depression.4,5

Promoting Sustained Adherence: Tricks of the Trade

Christine M Garvey FNP MSN MPA FAACVPR


Christine M Garvey FNP MSN MPA FAACVPRSeton Medical CenterDaley City CAUniversity of CaliforniaSan Francisco CAEmail: [email protected]

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Patients may not understand that certain symptomssuggest poorly controlled lung disease such as activitylimitation, interrupted sleep or intermittent exacerba-tions and that these findings point to the need for on-going medication. Patient education includes relevantinformation about the patient’s lung disorder, medica-tions, reassurance about side effects and the need fordaily use in the absence of symptoms. The medicationschedule should be tailored to patient’s lifestyle. A non-judgmental manner is important to elicit and addressconcerns about medication use and perceived side ef-fects. Practical support includes ongoing training andreturn demonstration of proper inhaler technique andevaluation for side effects such as oral candidiasis and/ or dysphonia. A treatment change or an alternativeprofile may be needed for unresolved or intolerable sideeffects.2 A written action plan should be collaborativelydeveloped and regularly updated that includes medica-tion schedule in the patient’s preferred language. Med-ication labels should also be in the patient’s preferredlanguage and / or use pictograms. Suboptimal adher-ence or faulty inhaler technique should be suspectedfollowing an exacerbation or flare. Educational supportand monitoring of adherence can be supported with re-ferral to Asthma clinic or camp, Better Breathers club orPulmonary Rehabilitation program.

Inhaled medications have several advantages overoral medications, including greater concentration andeffectiveness with fewer side effects. Use of combina-tion inhalers may improve adherence and reduceasthma severity.8 Suboptimal control has been foundto improve with the addition of long acting beta ago-nists or LABAs to ICS as well as improvement in lungfunction, quality of life and exacerbations compared toconcurrent inhalers.3,9 Use of a combination inhaleralso simplifies the regimen and may lower medicationcosts or co-pays.

Collaborative patient self management is associatedwith improved adherence and fewer ER visits.10,11 Keyfeatures include identification of barriers to adherence,ongoing self-monitoring of medications, goal settingand problem solving.12 Patient-centered approachesrecognize that patient motivation is necessary for ac-ceptance and adherence to treatment. ‘MotivationalInterviewing’ focuses on two key strategies: buildingthe patient’s built-in motivation to use recommenda-tions and resolving ambivalence toward the change inbehavior.12 Important areas of focus include relatingchange to the patient’s values and goals, e.g., the useof controller medication may improve participation insports, quality of sleep at night, etc. Begin by setting anagenda and offering a menu of options to increase pa-tient participation in decision-making. Explore the pa-

tients concerns and beliefs about the options. Encour-age active involvement and elicit shared goals. Ask thepatient to describe a typical day and where medicationsfit in to assess adherence in a nonjudgmental frame-work. Use ‘I’ statements to support patient autonomyand empathy and evocative questions to elicit positivestatements about change in a comfortable, non-coer-cive atmosphere. Open-ended questions offer a frame-work for the patient to ‘tell their story’ about beliefsand concerns. Affirmations or statements of apprecia-tion support positive patient statements and actions.Reflective listening helps the patient to hear the clini-cian’s interpretation of the discussion.

Finally, summary statements pull together the dis-cussion. Emphasize that the risk for uncontrolled res-piratory disorders is greater than the side effects ofmedications. Consider the following dialogue: ‘As yourrespiratory therapist, I believe that the most importantthing for your asthma is to use your controller inhalerdaily. The decision is up to you. I know these deci-sions can be difficult. What would make this work foryou?

Age-appropriate interventions should be consideredwhen working with teens and children. Maximize ef-fective communication and self-esteem by meetingwith teens without parents present. Involve parents atend of the meeting to review the discussion and dis-cuss ways parents can support the teen’s efforts. In-volve teens in setting goals and development of anaction plan, keeping the plan simple. Consider use ofa “contract” of expectations, benefits and conse-quences. Stress that controller medications can betaken before school and that daily use will mean fewerflares and less need for rescue inhaler. Teens often re-late to idols such as celebrities and athletes. Remindthe patient that many elite Olympic and professionalathletes have asthma. Consider referral to an asthmasupport group to facilitate support through peer inter-action.

Advise parents that use of ICS prevents asthma symp-toms and has no role as a rescue medication. Promotea child’s acceptance of medication use by making theprocess enjoyable with a game, toys, reading, singing,DVD or video. Reinforce use by rewarding children witha book, healthy treat or stickers. Encourage the parentto keep treatment times consistent. Children ten yearsor older should be directly involved in setting goals, de-velopment of the action plan and the review process.Encourage the child to take the action plan to schooland camp. Resources include http://www.peakperformanceusa.info/ and http://www.asthma.org.uk/using_your.html

23

Cultural barriers may lead to distrust of the health-care system and doubts about usefulness of anti-in-flammatory medications. Address the diverse needs ofpatients with culturally competent care to improve out-comes and patient satisfaction. When language, liter-acy or learning barriers are suspected, ask the patient torepeat or restate medication instructions and offer helpif the patient has trouble reading. Use caution not tooverwhelm the patient with information at each visitand schedule regular follow-up visits to reinforce edu-cation. Resources for diverse learning levels include theAmerican Medical Association health literacy informa-tion and toolkits at www.ama-assn.org/ama/pub/cat-egory/8115.html

Unintentional non-adherence can be due to incorrectdevice use including failure to prime MDIs and im-proper doses tracking. One study found that seventy-two percent of MDI users continued to use the MDIuntil the inhaler made no sound when actuated.14 Var-ious devices may promote regular medication use anddose tracking. Inhaler dose counters include the Doser(800.863.9633 or www.doser.com) and the MD Turbo(www.mdturbo.com) . Various valved holding chamberoptions are available including the LiteAire dual-valvecollapsible spacer (800.250.3330 or www.thayermed-ical.com). Portable spacer and nebulizer options in-clude the MicroChamber and MicroSpacer(978.97.1947 www.rdusa.com) and AeronebGo Mi-cropump Nebulizer (www.aerogen.com).

Selection of the optimal delivery device requires con-sideration of age, ability to use device correctly, con-venience, dose frequency, cost, insurance coverage andpatient preference. A small volume nebulizer (SVN) isappropriate for all ages and inhalation velocities. Co-ordination is not required and doses can be adjusted.Combining nebulized medications may be an optionbut requires assurance of drug compatibility.

An MDI is complex device which presents challengesfor proper use including coordinating deep inhalationwith actuation. HFA formulations need to be primedbefore use and if not used for seven or more days or ifdropped. Use of a spacer/valve holding chamber sim-plifies MDI technique, prevention of deposition oflarger particles in the oropharnyx and allow for pro-longed inhalation. There is limited data on use of HFAMDIs with holding chambers. Use of an electrostaticresistant holding chamber (www.mongahnmed.com)or pre-washing with liquid detergent and thorough airdrying is recommended.

Inspiratory flow drives activation of dry powder in-halers to carry medication to the lungs. Devices are notdependent on propellants and minimal coordination isneeded. Limitations include difference across the spec-

trum of device designs and poor efficacy for patientswith severe impairment in inhalation velocity. Regularclinical evaluation and follow-up should be used to pro-mote ongoing education and adherence.

Some products may offer advantages such as ci-clesonide (www.alvesco.com), a new inhlaed corticos-teroid that is classified as a pro-drug that is activated inthe lungs and not in the oral cavity. It is associated withless than 1% of dysphonia and oral candidiasis as wellas 52% pulmonary deposition when used without aholding chamber.13 Various manufacturers have web-sites that support adherence including:• Symbicort – www.mysymbicort.com - Includes re-

minders for medication, refills, physician appoint-ments and monthly savings coupons.

• AstraZeneca – www.everydaykidz.com - Asthmakid program offers a quarterly brochure and sup-plies.

Medication costs vary as do coverage by insurancecompanies. Most pharmaceutical companies haveplans for low cost medications for persons meeting lowincome levels. Various controller inhaler options and ap-proximate costs are listed in table 1.

Prices from http//www.rxusa.com

The clinician plays a critical role in optimizing med-ication adherence through focus on clinician – patientcommunication and advice regarding long term use andrationale. Effective treatment requires combination of

MEDICATION COSTSmallest approved dose,30 day supply

Advair Discus: $167.82, (fluticasone / salmeterol) HFA: $1673.44AeroBid (flunisolide) $87.86Alvesco (ciclesonide) $148.20Asmanex (mometasone) $109.10Azmacort (triamcinalone) $145.02Brovana (arformoterol $341.46solution)Flovent (fluticasone) Discus: $90.98,

HFA: $95.60 Foradil Aerolizer $148.07(formoterol)Pulmicort (budesonide) Flexihaler: $136.62,

Respules: $216.34Serevent (salmeterol) $146.15Spiriva (tiotropium) $171.97 Symbicort (budesonide/ $120.66formoterol)QVAR (beclomethasone) $71.58

medication and behavioral approaches beginning withassessing patient understanding of medication scheduleand use, ongoing education and follow-up, review ofdevice technique and a written medication scheduleand information. Effective clinician-patient communi-cation is a key feature in promoting a patient’s motiva-tion to use medications. Interventions should addressage, cultural and learning needs. Uses of respiratorycare protocols offer a collaboratively developed struc-ture to support effective clinical care, patient educationand optimal outcomes.

References

1. Foster JM, Aucott L, van der Werf R, et al. Many patients per-ceive numerous side effects of inhaled corticosteroids. PrimaryCare Respir J 2003;12:68-69.

2. Horne R. Compliance, adherence and concordance: implicationfor asthma treatment. Chest 2006; 130:65-72.

3. George J, Kong D, Thoman R, Stewart K. Factors associatedwith medication non-adherence in patients with COPD. Chest2005;128: 3198-3204.

4. Jin J, Sklar G, Min Sen Oh V, Chuen Li S. Factors affecting ther-apeutic compliance: a review from the patient’s perspective.Ther Clin Risk Manag 2008; 4(1): 269–286.

5. De Smet B, Erickson S, Kirking D. Self-reported adherence in pa-tients with asthma. Ann Pharmacother 2006;40: 414-420.

6. Coutts J, Gibson N, Paton J. Measuring compliance with inhaledmedication in asthma. Arch Dis Child 1992;67: 332-333.

7. Chapman K, Walker L, Cluley, Fabbri L. Improving patient com-pliance with asthma therapy. Respir Med 2000;94: 2-9.

8. Marceau C, Lemiere C, Berbiche D, et al. Persistence, adher-ence and effectiveness of combination therapy amount adultpatients with asthma. J Allergy Clin Immunol 2006;118:574-581.

9. Campbell DA, Robinson DS. Cost advantages of combinationasthma therapy. Treat Respir Med 2004;3:113-117.

10. Smith J, Mildenhall S. Noble M, et al. The Coping with AsthmaStudy: a randomized controlled trial of a home based, nurse ledpsycho-educational intervention for adults at risk for adverseasthma outcomes. Thorax 2005;60: 1003-1011.

11. Walders N, Kercsmar C, Schluchter M, et al. An interdisciplinaryintervention for undertreated pediatric asthma. Chest 2006;129:292-299.

12. Borrelli B, Riekert K, Weinstein A. et al. Brief motivational inter-viewing as a clinical strategy to promote asthma medication ad-herence. J Allergy Clin Immunol 2007;120:1023-1030.

13. Dahl, R. Ciclesonide for the treatment of asthma. Ther Clin RiskManag. 2006;2: 25-38.

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25

CRCE

Continuing Respiratory Care Education (CRCE)

As part of your membership benefits with the American Association forRespiratory Care (AARC), the association

• provides you with the continuing education opportunities;• keeps track of all the CRCE hours you earn from CRCE-approved

programs; and• allows you to print an online transcript of your CRCE records.

These services are available to you 24 hours a day, 7 days a week atthe AARC website (www.AARC.org)

The proceedings from the symposium contained in this book are ap-proved for 4.0 CRCE contact hours, and as an AARC member there isno charge to you. To earn these CRCE hours please visit the followingwebsite

http://www.AARC.org/education/improving_symptom_control/

The questions on pages 26-29 will be available for you to answer on-line (you may want to use this book as a worksheet before you log in).The website will also include:

• registration for the examination;• instructions for obtaining access to the examination itself; and• the option to update your contact information so that the exami-

nation results can be emailed to you

AM

ER

ICAN ASSOCIATIO

N

FO

R

RESPIRATORY

CA

RE

★★

Why Patients Stop Taking Their Controller MedicationsPatrick J Dunne MEd RRT FAARC

Objectives:

• Describe why the word adherence is preferred over compliance• List four reasons why patients stop taking prescribed controller medications• State the importance of sustained adherence in controlling symptoms• Describe why respiratory therapists should promote sustained adherence

Questions:

1. In the context of taking prescribed controlled medications, the word adherenceimplies:

A. A patient who merely follows the doctor’s ordersB. An activated patient who willingly accepts responsibilityC. A patient who reluctantly give into a demandD. None of the above

2. Non-adherence with prescribed controller medications contributes to:

A. Sustained symptom controlB. Increased morbidity and mortalityC. Increased health care costsD. B & C only

3. The most important controller medication for asthma is:

A. Twice weekly short-acting beta agonistB. Low-to-moderate doses of inhaled corticosteroidC. Twice daily long-acting beta agonistD. Once daily anti-cholinergic

4. Which of the following would contribute to non-adherence?

A. Concerns over adverse eventsB. Concerns over the expense of medicationsC. Medications are thought to no longer workD. All of the above

26

CRCE

The Impact of Non-Adherence With Respiratory Controller Medications

Russell A Acevedo MD FAARC

Objectives:

• Describe the economic impact of non-adherence with respiratory controller medications

• List three positive outcomes associated with sustained adherence with prescribed respiratory controller medications

• Discuss why self-report of medication administration alone is not always effective in determining sustained adherence

• Describe ways that non-adherence can lead to symptom flare-ups

Questions:

1. Which of the following is an effective way for patients to report adherence?

A. Electronic reportingB. Pencil/paper daily logsC. Weekly face-to-face interviewsD. None of the above

2. In the study by Balkrisnan evaluating prescription refill rates for inhaled corticosteroids, which of the following is true?

A. Poor adherence resulted in fewer hospitalizationsB. Good adherence resulted in fewer doctor visitsC. Good adherence resulted in greater use of short-acting beta agonistsD. Poor adherence resulted in lower health care costs

3. Which of the following statements is true regarding improved adherence with prescribed nebulizer treatments in COPD patients?

A. Higher adherence resulted in lower medication useB. Lower adherence resulted in higher medication useC. Lower adherence resulted in lower quality of lifeD. Higher adherence resulted in higher quality of life

4. Non-adherence can also contribute to:

A. Reduced frequency of symptom flare-upsB. Increased periods of wellnessC. Decreased costs for medicationsD. Increase in wasted medications

27

CRCE

Engaging Patients Through a Collaborative Care Model

Kent L Christopher MD RRT FAARC

Objectives:

• Describe the best type of questions to ask when conducting a patient interview• State how a respiratory therapist should evaluate the success of a patient encounter• Discuss the essential components of a successful collaborative self care model• Describe the potential impact of the Medicare Improvements for Providers and

Patients Act of 2008 for COPD patients

Questions:

1. For optimum clinician-patient interviews, which of the following is a true state-ment?

A. It is best to have a patient complete a written questionnaireB. It is best to ask open-ended questionsC. It is best to try and keep patient responses to a few wordsD. It is best to only ask specific questions

2. To determine if a patient encounter was successful, which of the following should a respiratory therapist consider?

A. Was the encounter/discussion interactive?B. Did the patient feel engaged?C. Were teachable moments fully utilized?D. All of the above

3. In order to be successful, a collaborative self-care model for a chronicrespiratory disease state management program would be:

A. Physician-therapistB. Therapist-patientC. Physician-patientD. Physician-therapist-patient

4. The Medicare Improvements for Providers and Patients Act of 2008 mandates the Centers for Medicare and Medicaid Services to:

A. Increase the payment rate for long-term oxygen therapyB. Authorize reimbursement for RRTs for home care servicesC. Establish a national coverage Medicare policy for pulmonary rehabilitationD. None of the above

28

CRCE

Promoting Sustained Adherence: Tricks of the TradeChris M Garvey FNP MSN MPA FAACVPR

Objectives:

• List three factors that improve patient adherence with prescribed controller medica-tions• Describe the essential elements of motivational interviewing• Identify common barriers to adherence related to inhalers• Discuss why age-appropriate interventions improve adherence

Questions:

1. Which of the following is an important factor in having a patient remain adherentwith prescribed mediations?

A. The intensity of the physician’s adviceB. The reputation of the physician in the communityC. The instruction provided by the pharmacistD. The degree to which the patient accepts their disease process and

recommended treatment

2. Motivational interviewing is intended to:

A. Focus on the consequences of untreated disease symptomsB. Keep patients engaged by having them track when they take the

medicationsC. Help patients resolve their ambivalence toward their diseaseD. Get patient’s family members to provide oversight on adherence

3. Inhalers are preferred devices for improving adherence because

A. They are more convenient to use than nebulizersB. They are usually covered by insuranceC. They deliver more aerosol drug than a nebulizerD. They last longer than a nebulizer

4. Age-appropriate interventions improve adherence because

A. Older patients do not require as much time to learn about their diseaseB. Older patients prefer interacting with older cliniciansC. Children and teens tend to respond better when instruction is provided

without their parents in attendance D. Children are more inclined to do what their parents tell them to do

29

CRCE

AARC members may earn 4.0 contact hours of Continuing Respiratory Care Education (CRCE)

free of charge (see page 25).


Improving Symptom Control in Patientswtih Chronic Respiratory Disease

American Association for Respiratory Care

9425 N MacArthur BlvD

Irving, TX 75063-4706

NON-PROFIT

U.S. POSTAGE

PAIDGreenfield, OH

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