US Pharm. 2018;43(1):25-29.
Serious respiratory diseases such as chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema, are a leading cause of morbidity and death worldwide. Asthma, a chronic disease that involves inflammation of the airways, bronchoconstriction, and intermittent (usually reversible) airflow obstruction, also affects numerous individuals around the globe. Asthma, in fact, is one of the most prevalent noncommunicable chronic respiratory conditions occurring throughout the lifespan. More than 14% of children have been diagnosed with asthma.1
Both COPD and asthma are common obstructive lung disorders that affect over 49 million people in the United States.2 While the pathology of asthma and COPD are distinct, both diseases share some features. Asthma is often a childhood disease, but some patients manifest symptoms or develop the disease as adults. The inflammatory response in asthma, such as an increase of lymphocytes, eosinphils, and macrophages in the airways, is associated with an increase in airway responsiveness to specific allergens or exercise.3 In the case of severe or unremitting asthma, airway remodeling is routinely seen.4
COPD, however, is an adult disease; the leading cause is long-term cigarette smoking. Airway inflammation with lymphocytes, neutrophils, and macrophages is common in COPD, and remodeling of airways frequently occurs.3 While airway obstruction in asthma is usually reversible, there can be a fixed obstructive component, and in COPD, where there is usually a significant fixed obstructive component, there can be partial reversibility in airway obstruction.3 There are patients who present with an overlap syndrome with mixed features of COPD and asthma.3 COPD is also potentially preventable, if one avoids cigarette smoking, which is often the primary cause. The most commonly recognized forms of COPD are chronic bronchitis, seen as bouts of coughing and severe mucus production, and emphysema, characterized by damaged alveolar structures.5
Digital Solutions to Disease Management
There is no cure for COPD or asthma, and evidence-based clinical guidelines can be implemented to optimize control of symptoms. Patients who adhere to a physician-prescribed treatment plan can achieve clinical improvement. Enter the health information technologies. The healthcare arena is witnessing an onslaught of technologies helping to reshape the treatment for these disease states, assisting in anything from self-monitoring to decision-supporting best-practice care models, all facilitated by the use of digital and Web-based tools.6 Additionally, we are seeing online communities empowering patients, their families, and caregivers to assist in disease self-management. These technologies are also able to collect data and, in turn, aid researchers and pharmaceutical companies in identifying personalized treatments based on patient-specific profiles, such as with the use of electronic health records (EHRs). These technologies can easily assist in the integration of medication usage and symptom control—along with environmental cues—to better manage and even promote new therapies when all the data is reviewed and collated.
The most commonly used pharmacologic treatment options for asthma and COPD consist of inhaled bronchodilators and corticosteroid medications.5,7 The shorter-acting bronchodilators, including 2-agonists for asthma and COPD and anticholinergic agents for COPD, are used in emergency situations to provide immediate relief.7 Technologies will play an ever-increasing role in monitoring compliance with these agents and, more importantly, finding strategies to promote therapeutic successes for individual patients. Monitoring technologies can be invaluable in this instance, since patients do not always adhere to their prescribed asthma and COPD medication plans, with nonadherence estimates ranging between 30% and 70%.8 Because of this, it can be difficult to distinguish patients with severe, medication-insensitive disease from those who do not take medicines appropriately.
Improving the care coordination of these respiratory illnesses, therefore, is often an arduous challenge. Clinicians are realizing that successful care-delivery solutions must include prevention, early diagnosis, patient empowerment, and real-time data for clinician review in order to maintain the best possible assistance in managing chronic diseases. The technologies monitoring these respiratory illnesses are also using telemedicine techniques which, when coupled with patient-empowerment strategies, help individuals acquire the necessary skills to manage their health and maintain an active lifestyle.
Infusing Technology Into the Management Paradigm
Technology applications now exist for disease self-management and patient empowerment, potentially improving a person’s overall health. Coupling telehealth interventions with these apps enables improved compliance with medications, as well as shared decision-making by both patients and clinicians—core principles to support best practice models in managing these chronic respiratory disease states.9-11 For example, patient-generated data from mobile apps can be directly transmitted to a patient’s team of clinicians (for example, a medical home) where the data can be incorporated into EHRs and used to augment care for patients in real time.11 This functionality can be enhanced through the adoption of clinical decision support systems. By analyzing incoming patient data in real time, the decision-support software can automatically identify noncompliant patients.11
The software can also asses which patients are at risk for exacerbations and/or have poorly controlled disease.11 These patients, once identified by the decision-support system, can be offered early intervention and/or case management programs involving pharmacists to improve compliance and minimize adverse health consequences. In either scenario, the end result would be improved healthcare delivery and better outcomes.
The decision-making portion of the intervention is based on a patient’s symptoms, any and all environmental exposures, and their compliance with prescribed medicines. The pharmacist has the opportunity to assist patients in understanding how these variables influence their health and, when necessary, instructing them on how to take medications properly and seek care, empowering them to develop skills that can change their health behavior and fulfill health-related goals.10
Online Communities Enter the Scene
Patients are rapidly adopting Web-based and mobile healthcare technologies to assist in self-monitoring and decision-making. These technologies support a personalized care model in which patients are increasingly involved—along with their clinicians—in managing their chronic respiratory diseases via smartphone apps and other Web-based tools.11 While the number of chronic pulmonary disease technologies is increasing, caution must be taken to ensure that the technologies are clinically effective. They must be easy to use, practical, and designed with input from patients. The technologies are often coupled with online communities for asthma and COPD patients, which further motivate patients to improve their own self-care.11
In fact, Web-based communities and social media sites have helped engage and support patients more successfully than has been possible with traditional approaches. According to a 2010 estimate, 62% of U.S. adults afflicted with one or more chronic diseases pursue online resources, and this percentage is likely to increase.12 Social media sites are increasingly used to share medical information. An estimated 58% of all American adults use Facebook.13 Memberships in online communities are typically free. One example of a patient-focused online community is PatientsLikeMe, featuring over 400,000 members (www.patientslikeme.com). This Website enables patients to network and exchange disease-related information. It is estimated that as of February 1, 2016, the site supported 5,849 patients with asthma and 2,348 patients with COPD.11 The success of online communities relies on motivated patients who self-engage along with their caregivers and who are willing to participate with clinical investigators to better understand their disease and identify successful therapies.14
The AAFA (Asthma and Allergy Foundation of America, Landover, MD), a prominent asthma advocacy organization, has partnered with an online patient networking platform called Inspire (Princeton, NJ). The website (www.inspire.com/groups/asthma-and-allergy-foundation-of-america/) allows patients to communicate and share educational resources. Another online community focused on asthma is the Asthma Community Network (www.asthmacommunitynetwork.org), sponsored by the U.S. Environmental Protection Agency, the Allies Against Asthma program, and the Merck Childhood Asthma Network, Inc. The focus of this site is to provide educational resources for asthma care, asthma management plans, and discussion forums to disseminate educational materials. The COPD Foundation (www.copdfoundation.org) created a registry called COPD360 sponsored by AstraZeneca Pharmaceuticals, LP (Wilmington, DE). This registry features patient-centered research and identifies new COPD treatments.
Home Monitoring Apps Taking Hold
One example of a mobile health app that uses innovative technology to enhance chronic pulmonary disease self-management is the Wizdy Pets app (LifeGuard Games, Inc., Brighton, MA).11 This app is designed for children with asthma and helps them learn more about their disease by presenting a fire-breathing “pet” dragon that has asthma. By taking care of the pet, children learn concepts such as asthma triggers and why it is important to take medications regularly as prescribed. Care TRx (Gecko Health Innovations, Inc., Cambridge, MA) and Propeller Health (Propeller Health, Madison, WI) have also developed apps for monitoring medication utilization.11 These apps feature Bluetooth-enabled sensors that attach to inhalers and medication nebulizers and can transmit medication-usage data to a synchronized smartphone. The apps generate usage reports, including graphs, and provide asthma management self-help, including information about potential asthma triggers.
The healthcare technologies and mobile applications currently being infused into the respiratory disease space are attempting to create effective management with real-time data and care monitoring, which can assist in reducing the long-term consequences of respiratory diseases, including hospital readmissions.15 Another venue gaining ground in the treatment and monitoring of respiratory disease states is home telemonitoring, which appears to be a promising patient-management approach capable of producing accurate and reliable data. In addition, this technology empowers patients by influencing their behavior to adopt strategies that improve their health condition. The technology can be used to coach patients to comply with their regimens and prevent disease exacerbation and emergency room visits. Furthermore, by facilitating self-management practices and incorporating appropriate case management, home telemonitoring can reduce the use of emergency care and unplanned hospital admissions and readmissions.16
Mobile technologies are becoming commonplace, and they are the future transformative force in healthcare. Patients are becoming armed with devices that can empower, monitor, track, and even measure their disease progression—creating interventions when necessary to optimize the health and disease response time. New devices and tools deliver technology into a smartphone, for example, and have the potential to become an extension of a patient’s healthcare provider. These devices can allow public health officials to better monitor and screen for diseases in large populations and, ultimately, help improve preventive strategies and access to care for millions of Americans.
As pharmacists, we are aware that the management of COPD is a multipronged approach. Treatment focuses on monitoring changes and relieving symptoms, improving lung function and exercise tolerance, and ongoing vigilance. There exist, however, the protocols needed to assess and monitor the disease, reduce risk factors such as smoking and air pollution, stabilize care to prevent disease progression, and manage exacerbations and comorbid conditions. This could not be accomplished efficiently without the infusion of healthcare technologies.17 Pharmacists who adopt these technologies can become integral partners with patients in Web-based and home telemonitoring applications to improve medication adherence, intervene early to prevent disease exacerbation, and effectively improve care while reducing the use of costly resources such as emergency room and inpatient care.
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