Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial

Rachel Willard-Grace; Chris Chirinos; Jessica Wolf; Denise DeVore; Beatrice Huang; Danielle Hessler; Stephanie Tsao; George Su; David H. Thom

doi:10.1370/afm.2461

Article Figures & Data

Figures

Tables
Additional Files

Download figure
Open in new tab
Download powerpoint
Figure 1
Consolidated standards of reporting trials diagram.
COPD = chronic obstructive pulmonary disease.
^aReasons: 23 lost to follow-up; 1 no inhalers; 4 did not bring inhalers to demonstrate.
^bReasons: 13 lost to follow-up; 3 no inhalers; 1 did not answer question.
^cReasons: 8 lost to follow-up; 1 no inhalers; 3 did not bring inhalers to demonstrate.
^dReasons: 8 lost to follow-up; 1 no inhalers; 2 did not answer question.

View popup

Table 1

Participant Characteristics, by Study Arm (N = 192)

Characteristic	All (N = 192)	Arm
Characteristic	All (N = 192)	Health-Coaching Arm (n = 100)	Usual-Care Arm (n = 92)	P Value
Demographics
Age, mean (SD), y	61.3 (7.6)	60.7 (8.0)	61.9 (7.2)	NS
Male, % (No.)	65.5 (126)	67.0 (67)	64.1 (59)	NS
Works full/part-time outside the home, % (No.)	17.8 (34)	16.0 (16)	19.8 (18)	NS
Income <$10,000/y, % (No.)	45.7 (84)	45.8 (44)	45.5 (40)	NS
Black/African American race, % (No.)	56.8 (109)	53.0 (53)	60.9 (56)	NS
Hispanic/Latino ethnicity, % (No.)	16.7 (32)	13.0 (13)	20.7 (19)	NS
Preferred language is not English, % (No.)	12.6 (24)	7.0 (7)	18.7 (17)	.02
Education less than high school, % (No.)	31.9 (61)	27.0 (27)	37.4 (34)	NS
Had visit with pulmonary specialist in 12 months before enrollment, % (No.)	31.3 (60)	34.0 (34)	28.3 (26)	NS
Severity of COPD
GOLD classification, % (No.)^a				NS
Gold A (low symptoms, low risk)	4.2 (8)	5.1 (5)	3.3 (3)
Gold B (high symptoms, low risk)	46.3 (88)	46.5 (46)	46.2 (42)
Gold C (low symptoms, high risk)	3.2 (6)	4.0 (4)	2.2 (2)
Gold D (high symptoms, high risk)	46.3 (88)	44.4 (44)	48.4 (44)
FEV₁ % of predicted, mean (SD)	58 (20)	55 (19)	60 (20)	NS
High COPD symptom score: CAT ≥10, % (No.)	92.7 (177)	90.9 (90)	94.6 (87)	NS
Ever smoked, % (No.)	96.3 (184)	99.0 (99)	93.4 (85)	.04
Current smoker, % (No.)	53.8 (99)	54.6 (54)	52.9 (45)	NS
Asthma diagnosis, % (No.)	27.6 (53)	29.0 (29)	26.1 (24)	NS
Inhaled medications
Uses any inhaler (rescue or controller), % (No.)	92.7 (178)	95.0 (95)	90.2 (83)	NS
Uses controller inhaler, % (No.)	65.6 (126)	67.0 (67)	64.1 (59)	NS
Number of controller inhalers prescribed, mean (SD)	1.4 (0.9)	1.5 (0.9)	1.3 (0.9)	NS
Types of medications prescribed^b
Short-acting β agonist (SABA), % (No.)	88.5 (170)	90.0 (90)	87.0 (80)	NS
Short-acting anticholinergic, % (No.)	34.4 (66)	32.0 (32)	37.0 (34)	NS
Long-acting β agonist (LABA), % (No.)	56.8 (109)	57.0 (57)	56.5 (52)	NS
Long-acting muscarinic antagonist (LAMA), % (No.)	51.6 (99)	59.0 (59)	43.5 (40)	.03
Inhaled corticosteroid (ICS), % (No.)	76.0 (146)	76.0 (76)	76.1 (70)	NS
Correctly identified rescue inhaler, % (No.)	88.5 (161)	90.7 (88)	85.9 (73)	NS
Number of uses of rescue inhaler/day, mean (SD) Inhaler use	2.5 (1.9)	2.7 (2.0)	2.3 (1.8)	NS
Metered dose inhaler, % (No.)	91.8 (168)	90.7 (88)	93.0 (80)	NS
Closed-mouth technique	66.1 (111)	63.6 (56)	68.8 (55)	NS
Open-mouth technique	8.9 (15)	10.2 (9)	7.5 (6)	NS
Use with a spacer	25.0 (42)	26.1 (23)	23.8 (19)	NS
HandiHaler, % (No.)	40.2 (70)	42.9 (39)	37.4 (31)	NS
Diskus, % (No.)	19.4 (35)	13.7 (13)	25.9 (22)	.04
Respimat, % (No.)	12.0 (22)	14.4 (14)	9.3 (8)	NS
Number days (of last 7) patient reports having taken medications as prescribed, mean (SD)	5.6 (2.3)	5.7 (2.1)	5.4 (2.4)	NS
Perfect adherence, % (No.)^c	59.5 (75)	64.2 (43)	54.2 (32)	NS
Good adherence, % (No.)^d	77.0 (97)	77.6 (52)	76.3 (45)	NS
Inhaler use technique
Perfect use of all inhalers, % (No.)^e	2.8 (5)	4.2 (4)	1.2 (1)	NS
Adequate use of all inhalers, % (No.)^f	9.6 (17)	12.6 (12)	6.0 (5)	NS
Weighted inhaler technique score, mean (SD)^g	72.3 (16.2)	72.9 (16.3)	71.5 (16.1)	NS

COPD = chronic obstructive pulmonary disease; CAT = COPD Assessment Test; FEV1 = forced expiratory volume in 1 second; GOLD = Global Initiative for Chronic Obstructive Lung Disease; NS = not significant.
↵a According to the 2014 GOLD guidelines.58
↵b Either alone or in combination with another inhaled medication.
↵c Report of taking all medications as prescribed in the last 7 days.
↵d Report of taking all medications as prescribed for at least 5 of the last 7 days.
↵e Successful completion of every step of inhaler use for every inhaler for which use was demonstrated.
↵f Successful completion of every essential step required for medication delivery, for every inhaler for which use was demonstrated.
↵g On a scale of 0 to 100, where higher score indicates better technique.
Note: Data missing for some patients for some characteristics.

View popup

Table 2

Adherence to Controller Inhalers at Baseline and 9 Months, by Study Arm (N = 98)

Measure	Health-Coaching Arm (n = 50)		Usual-Care Arm (n = 48)		Difference, %	Adjusted Difference, % (95% CI)^a	P Value
Measure	Baseline	9 Months	Baseline	9 Months	Difference, %	Adjusted Difference, % (95% CI)^a	P Value
Number days (of the last 7) patient reported taking medications as prescribed, mean (SD)	5.9 (2.0)	6.4 (1.3)	5.6 (2.4)	5.5 (2.0)	0.84	0.75 (0.13 to 1.37)	.02
Perfect adherence, % (No.)	66.0 (33)	70.0 (35)	58.3 (28)	54.2 (26)	15.8	15.2 (–4.3 to 34.8)	.13
Good adherence, % (No.)	84.0 (42)	90.0 (45)	79.2 (38)	68.8 (33)	21.2	26.4 (6.9 to 49.9)	.008

↵a Adjusted for baseline value of measure and clustering by clinic site.
Note: Includes only patients with data for baseline and 9 months (ie, patients on controller inhalers at both time points). See Table 1 footnotes for definitions of adherence.

View popup

Table 3

Inhaler Technique for Controller and Rescue Medications at Baseline and 9 Months, by Study Arm (N = 138)

Measure	Health-Coaching Arm (n =67)		Usual-Care Arm (n = 71)		Difference, %	Adjusted Difference, % (95% CI)^a	P Value
Measure	Baseline	9 Months	Baseline	9 Months	Difference, %	Adjusted Difference, % (95% CI)^a	P Value
Perfect use of all inhalers, % (No.)	4.5 (3)	23.9 (16)	1.4 (1)	7.0 (5)	16.9	24.8 (4.2-42.6)	.01
Adequate use of all inhalers, % (No.)	9.0 (6)	40.3 (27)	5.6 (4)	11.3 (8)	29.0	40.0 (20.7-59.2)	<.001
Weighted inhaler technique score, mean (SD)	71.9 (15.7)	88.9 (10.2)	72.9 (15.3)	77.7 (13.2)	11.24	11.61 (8.18-15.04)	<.001

↵a Adjusted for baseline value of measure and clustering by clinic site.
Note: Includes only patients with data for baseline and 9 months (ie, patients on controller or rescue inhalers at both time points). See Table 1 footnotes for definitions of use and score details.

Additional Files

Figures
Tables

The Article in Brief

Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial

Rachel Willard-Grace , and colleagues

Background Over 14 million U.S. adults have chronic obstructive pulmonary disease, and many face barriers to using inhaled medications regularly and effectively. Although inhaled medications can improve daily life and long-term outcomes, only 25% to 43% of people with COPD use them regularly. In addition, inhalers can be complex to use--requiring users to master a series of six to eight steps that differ across devices. Physicians and health teams have not yet found a solution to bring COPD medication adherence to the level of other chronic diseases.

What This Study Found In a multi-site randomized controlled trial from the University of California, San Francisco, non-licensed, trained health coaches offered COPD patients one-on-one support in person and by phone, with contact at least every three weeks for nine months. Participants were primarily low-income, African American and Latino men in an urban area. Those who received health coaching showed significant improvement in adherence to controller inhalers and improved inhaler technique, with 40% of health-coached patients versus 11% of a control group able to demonstrate effective use of their inhalers after the intervention.

Implications

The study's lay health coaching approach is grounded in shared decision making principles, which aligns with recent calls to incorporate collaborative care to address and improve adherence to inhaled medication for COPD. Researchers conclude that "improved inhaler technique and adherence are one of multiple factors contributing to long-term COPD outcomes," but their research has confirmed one technique--use of lay health coaches--that may help patients get optimal benefit from their COPD medications.