Good morning everyone. Welcome. I think we're going to go ahead and get started. This is a slide because we're going to have a few of the talks that will be using the audience response system. So you can go ahead and I'll give you a second if you want to pull out your phones. Scan this code and this will allow you to participate. I believe there are options later to scan but I'm not 100% sure. And it's not a big deal. It's really just to try and make things a little more interactive and keep things flowing. I see a few more. I'm just going to wait until I see the phones go down. Great. Welcome. So I'm going to be introducing the session. I'm really pleased to be here today with my colleagues. I'm Valerie Press. I am at the University of Chicago where I'm an internal medicine and pediatrics physician and researcher. I focus mostly on obstructive lung disease and how to improve the quality of care for our patients. So the objectives for the session today are to understand the current evidence base for why we still need to talk about teaching our patients how to use inhalers. This we would hope would have been a done deal many years ago but it's still really a salient topic today. Then we're going to be thinking about this topic of inhaler education and self-management and how to deliver that care in our more current telemedicine world since the pandemic has really galvanized that and really thinking about how to ensure that if we are going to move to technology based solutions that it happens in an equitable way and doesn't further create disparities for some of our patients. And so in that in that regard we want to think about some of the barriers for our patients. This is the outline for the whole session today. We're going to have several great speakers here so I'll be talking and just setting up the stage at the beginning and then Dr. Riley will be talking about barriers to medication adherence. Dr. Schwack will be talking about a specific inhaler education approach and we'll be doing some demonstration with that. Dr. Phan will be talking about how to deliver this education for primarily for rural patients using telemedicine. Dr. Gray is going to be talking about a hybrid approach of some aspect of in-person and some aspect of telemedicine. And then if we have time at the end we're happy to take questions and answers afterwards or else we can stay around for a few minutes and talk with you after the session. So moving into the first topic today I'm just going to be setting the stage for this why. Why do we even need to be talking about this and what do we need to be thinking about in the setting of using technology. Again this is just my background and my only disclosure is I do provide some consultation for Humana on patient education. This is a slide that I'm probably speaking to the choir here but this is just a reminder to all of us that there are lots of different types of inhalers. They all have different mechanisms and different types of steps and different numbers of steps and we don't necessarily get trained depending on our backgrounds on these specific devices and actually our patients don't always get this information as well. So for those of you that did scan that QR code and it is in the bottom again so there is another option if you're just coming in and you want to participate in the polling questions feel free to answer this question. I'm just keeping an eye on the bottom. We've got eight, nine, almost a dozen. Give it a few more minutes or seconds I should say. All right. Sorry if you haven't had a chance, but I'm going to move on. So the question was, how many patients misuse rescue inhalers? And that's a bit vague, I guess, but I'm really thinking primarily about those meter dose inhaler pump inhaler types. And so you'll see a nice spread here. In general, I would say the audience is close. It's a lot. So for those of you choosing 60% or greater than 80%, you're correct. The literature is varied, but it's really up to over 80% of patients actually really don't get effective technique from using their rescue inhalers. One more question, then we'll get to some more answers. So this is the second question. Now how many patients misuse their controller inhalers? All right, that's about as many as we had last time, so I'll move on to the answer. So again, yes, that same kind of most. Again, depending on which article you read and which study, it's really a lot. So that's generally the correct answer. In our studies, again, we found actually over 70%, even though a lot of controller devices are considered easier to use than the pump inhalers. So this is one of the many studies out there that myself and other members of our team have looked at. And this was a study now over a decade ago where we enrolled hospitalized patients with asthma or COPD. These were adults. And we looked to see, we actually observed their technique and said, do they know how to use their rescue inhalers? And we found 86% of these individuals could not use a pump inhaler and 71% could not use their discus device. So I'm just going to lay the ground for just general concepts around education. And as I already noted earlier, some of the other speakers will go more into depth on these topics. But just so we have some definition and language. Standard education varies. Often standard education, unfortunately, is just you pick up your inhaler and there's that tiny little type with the package insert. And that's where patients go to look if they even do. Some patients take the initiative to look online or look up videos. Sometimes there's education where you actually get like a pamphlet or a handout. So then the typeset is a little bigger. Maybe there's some pictures. This is something that we study called brief instruction inhaler education. And we take a patient handout and we actually read it to patients. So that gets past some barriers like vision problems or literacy problems. But that's it. We just read it to them. And then there's this concept, teach to goal, which you will hear a lot about today. And again, I'm just defining it now. So in order to use this teach to goal concept where you're really trying to work with a patient to develop a skill and you assess and teach them in the same session, you need to be able to know if they're using their inhalers correctly. So this is a standardized checklist. And you start by actually seeing what the patient can do before you even start teaching. This is a great concept in general for education is sort of getting on the same page. So a lot of times we just jump in and start telling our patients, you know, oh, here's X, Y, Z information. But we don't actually know if they already know that and they actually need to know more or if they even are at a space to absorb that. So you start by watching them. Then that's when you can start to provide that kind of in the moment tailored education where you can kind of watch what they did, maybe what missteps they took and kind of adjust in the moment. And then you see this completes a cycle because now you can actually have them teach back or show back. And you can say, okay, you know, let me see how well I did teaching you. Show me what you can do now. And this cycle can be repeated. This teach to goal concept is not unique to inhaler education. This is a skill-based or knowledge-based process that is helpful for patients across different levels of health literacy. When it comes to inhaler technique, there are different ways you can measure it and kind of say, well, how well did they do? So obviously there's perfect technique. Did they get literally every step correct or not? In the real world, what we care about is whether the medicine made it into their lungs. And so there's probably a little wiggle room with some of the steps. But when you look at all of the different steps together, it's hard to think they're getting the medicine into their lungs effectively if they miss more than about a quarter of the steps, 20 to 25% of the steps. So that's that misuse cutoff. That's what we call misuse. And just a note for why teach to goal is helpful in general, and this is part of why we're using audience response. Adult learning theory says that you actually map information that you're learning differently if you're tested during the learning process than if you just listen to information and then walk out. It helps you map that information differently. And so teach to goal in that back and forth can help with that. So just very quickly, a proof of concept of this health literacy concept is at baseline in this study where blue shows patients with adequate health literacy and red is less than adequate health literacy. At baseline, this was the same 100 patients I showed you earlier. This is a small subset, 42 of them that used two devices. This is for meter dose inhaler. At baseline, nobody had perfect technique. And again, that's not necessarily what we expect. But after round one, many more patients had perfect technique than those with low health literacy, as you can see here. But what was interesting is by having a built-in system of rounds of education, it really was able to accommodate those with lower health literacy and allowed them to catch up. And then just very briefly, this is just comparing that brief instruction I showed you. And so I like to show this because one main message is just we need to teach our patients. We need to do a better job teaching and not just assume they can figure it out. But this takes it to the next level and says there are better ways to do it, more effective ways to do it. So the red line is just the all-comers. But if you look at the light blue line compared to the black line, this compares the reading out loud instructions, or BI, compared to the teach-to-goal. And you can see that at baseline, both groups started at that above 80%. Again, this is for meter dose inhaler. And while both did improve within their groups, you can see the much more improvement with teach-to-goal. So that's that second message. First message, we need to teach. Second message is some strategies work better than others. And then this is the depressing but not surprising piece of this. If you do one teaching session, they use it, it works. It works long enough to have some impact. But if you don't do repeated education dosing, so to speak, they're at high risk of losing those skills. And that's common with any skill-based technique. We don't learn how to drive in one session, right? We need repeated educational sessions. So very briefly, just moving into this concept of health literacy I've mentioned. I think many people know this concept. But it's basically patient's capacity to take in information and use that information to help them make good health decisions and act on it. This is just a national survey that shows that less than about 9 in 10 adults lack the potential for being able to do those skills, get information and then use them adequately. So very high risk. The yellow zone is about half of the population. And this is because health literacy is actually dynamic. So sometimes it would be okay and sometimes it wouldn't. One more concept that's really important for the rest of this session is this concept of e-health literacy or mHealth. And this is basically this concept that there's added skills needed when you're obtaining and using information using technology. So one more quick question and then I'm almost done and we'll move on to the next speaker. So do patients with low health literacy necessarily have low e-health literacy or vice versa? Are these one and the same? So feel free to, if you're coming late, yep, you can scan that QR code. Still time to participate. Great. So we're right around, I always stop right around 20 because that's our usual group number. So thank you. All right. So in this case, it's about half and half from the audience. So they're actually not correlated. And this was very surprising to us. We were collecting using an e-health literacy tool called eHeals and we were already collecting data on health literacy using a brief health literacy screen. And we actually could not find a correlation between the two, meaning someone could have high health literacy but not be tech savvy and potentially vice versa. So this is just a note on the digital divide. I think when I was first coming into this space, the digital divide over a decade ago really thought about access to devices and software and the things you needed to use technology. And that has diminished, but I will note it has not gone away. A lot of us now think, oh, everyone has a phone in their pocket, so they're good. But not everyone has a smartphone and not everyone has equitable access to data to use that smartphone as much as they want or in any way they want. And not everyone has equitable access to fast broadband or even reliable Wi-Fi. So it's much better, but not perfect. And then there's also now more and more use in the medical world of technology. And we just need to think about not just access, but ability and willingness to use. So I'm just going to go quickly through this because I want to get to our next speaker. But basically, low e-health literacy is associated with things you would expect. Lower searching for health information, lower interest in telehealth, right? I mean, you're not going to be interested in if it's something you don't use or can't use. And then telehealth video usage, very salient for this talk, also increased unequally during the pandemic. So just some things to keep in mind as we move forward with the rest of our talks. And so this is just a summary slide, but basically you'll hear a lot more on this summary with our speakers moving forward. We're going to be mostly taking questions at the end. I'll leave it up to our speakers and their discretion if they feel like they have a few minutes with their talks. But I think I went a little over. So I'm going to save my questions for the end. So thank you. And there'll be an opportunity to evaluate at the end. So thank you. Hello, everyone. So today, I will talk about barriers to asthma medication adherence and associated health disparities. And I'm actually going to take more of a global approach to this and not just focus on the U.S. So again, I have a few titles as Professor at Duke, I'm also Vice Chief of Diversity, Equity, and Inclusion within our Division of Pulmonary Allergy and Critical Care. So first, I'm really going to talk about trends in asthma and inhaler use, again, globally across the age continuum. And then really talk about the conceptualization of social determinants of health as a barrier to adherence. And lastly, I'll talk about the effects of socioeconomic and political context on barriers to adherence. Again, taking more of that global approach. So here is the use of asthma inhalers according to asthma severity in the past year by age. And this is really data from the Global Asthma Network. So what you see here is that the SABA use definitely increases as patients have more symptoms. And we see that there's frequent SABA use across the age continuum. However, when you look at the ICS use across the age continuum, it's low overall, right? Everyone is about less than 50%. Definitely the ICS use increases with severity, but again, it's overall kind of low. Okay. So now, this is more of a, this is the WHO Social Determinants of Health Framework, which was adapted for asthma. But I'm actually using it to kind of show how various social determinants of health can affect your adherence or a patient's adherence. So in the first column, you have the socioeconomic and political context in which a person exists. For example, in the U.S., you know, those that live in red states versus blue states, there is a differential increase in the Medicaid expansion. And we know that with increased Medicaid expansion, we have improved outcomes, including improved asthma outcomes, right? So that's how your macroeconomic policies can affect your adherence, right? So if your state didn't expand Medicaid, there may be populations that don't have access to health insurance and kind of downstream effects can affect their adherence to inhalers or the affordability of their inhalers. Other things that are important is to really understand the socioeconomic position of the different populations you're treating. And so we know that in regards to social determinants of health, your social class, gender, sexual orientation, race, racism, and all those things that represent your kind of caste system, quote, unquote, really affects your access to education, occupation, and income. And the way that these things affect your adherence is that, you know, based on where you live or different race and ethnicities, that correlates to your type of quality education, your quality of education affects your occupation. And we know certain occupations actually have access to health insurance, which allows them to get access to affordable inhalers. There's also some may not have paid sick time. And so if you don't have paid sick time in certain occupations or certain income levels, then you may not have the ability to go to your provider's office. I know that if patients don't see me every 12 months, then, you know, I have to ask them to come in before I kind of refill their medications for, like, another 12 months. And so if you don't have that paid sick time, then there could be gaps in your inhaler use because you can't even come in for your inhalers. I know some of our patients at our federally qualified health center, they actually have to come into the FQHC to get their inhalers. They can't do mail-in or anything of that nature. So again, all those things, those social, economic composition can really affect your ability to adhere to your medicines. Here in this last column, you have the intermediary determinants. And so here, you know, health system access and utilization. Some health systems are more kind of in tune to low SES populations and their needs. So maybe they'll have late hours or weekend hours. But at Duke, we don't have that. And so, you know, right? So that can, again, we kind of talked about not everyone really being able to make their appointments. And so when I have childcare to come to some appointments, like during the COVID pandemic, I worked in the VA, and there, people couldn't bring their kids like during the height of the pandemic. And so if you didn't have childcare, you had young children, you couldn't come in to see me, right? And so people would like sneak their kids in and things like that. And I was fine with it. But then if security caught you, right? So all these different policies in the health system, things like high stress or high psychological stress can affect your adherence and things of that nature. So I really included these slides so that one can really understand the complete picture when you're looking at adherence. And it's not just cost, it's not just access to care, things like that. There are just so many factors that are more upstream that can affect someone's ability to adhere to their inhalers. So next, I'm really going to give you an example of how the socioeconomic and political context can affect your barriers to adherence. And so I previously published an article called the International Barriers to Asthma Medication Adherence. And it was a scoping literature review that kind of identified patient-reported barriers to adherence. And so this was a systematic review that was conducted a while back. And one limitation was that I only used English language literature. And I really only wanted articles that were qualitative. So I really wanted what patients reported were their barriers to adherence, not just what the provider said was their barriers. So I had two investigators independently collect data, and then they mapped the barriers to the theoretical domains framework. The theoretical domains framework is a behavior change theory that really kind of comprehensively identifies all the reasons why someone doesn't do a behavior and has 14 domains. And so then I also categorized the data by where the participants lived, their country of residence, the gross national income of the country, and if that country had universal health care. We reviewed close to 3,000 articles, and we identified 47 studies. And these 47 studies represented 12 countries. And these studies was about 2,600 subjects. Most of the participants were females, and the age range ranged from 19 to 70. And most of the people used interviews and not really focus groups as much. So in regards to the countries, 45 of the studies were conducted in high income countries to middle income. Most of the, about 27 had universal health care, and 20 actually did not have universal health care. One thing to notice that of those without universal health care, 20 were actually, I think 17 of the 20 were in the U.S. The most common barriers, if you look globally, were belief about consequences. So patients really not thinking that they needed their ICS or their asthma medication to control their asthma, knowledge deficits, and then environmental context. So environmental context and resources, a broad category, includes anything from costs or access to a pharmacy or transportation issues. And so here are just some quotes. Let me look at the time, yeah, okay. So there's some quotes here in regards to belief about consequences. So I frequently do not take my inhaler because when I do not, because I don't have symptoms. Or I tell myself that I don't need it. So again, people not really realizing that their inhalers are used for prevention of symptoms or knowledge issues. The important thing is to ensure our understanding, or like, I do not take my medication without asking questions. So this is really showing that it wasn't just a knowledge deficit, but that they wanted to know more information about their inhalers from their providers. Environmental context, again, I cannot afford my steroid inhaler, or I knew I was going to have a gap in insurance coverage, so I stockpiled my medication for me and my kids. So you know, if you have to stockpile, that means you're not using it properly, right, at the right dosing. So you're trying to save it, maybe taking it once a day instead of twice a day because they're planning to get laid off or something like that. The least common reported barriers to adherence were goals, so stating that asthma was not a priority, reinforcement, asthma was not valued, or emotion. So this is globally, like the fear of side effects or like stress. So here now I'm going to show you how the barriers differentiated based off of the income of the country and the presence of universal health care. So here we have in high-income countries, in those with universal health care, the first barrier, the primary barrier to adherence here was belief about consequences, again, not really believing that you need your inhaler to control your asthma. Second was knowledge, last was social influence. So social influence has really kind of made me focus on gender roles. So some women are really prioritized with taking care of their family, so they're not really thinking about their asthma inhaler. So again, that's high income with universal health care. However, if you look at those countries that have universal health care, this column over here, the primary barrier is environmental context and resources, right? And that's something you would expect. Cost becomes a barrier now when you don't have universal health care. The other two are still the same, belief about consequences, and then drops down to number two, and then knowledge is number three. When you look at middle-income countries, remember there were only two here, Brazil and India, again, these have equal weight. So two studies reported these barriers, so environmental context, memory, attention, and decision, and emulsion. So again, we're having different ones when you're looking at these middle-income countries starting to pair the memory, attention, decision, and emulsion. So here, so some people are just too busy to really kind of focus on their inhaler. They have a lot of other tasks. Emulsion, again, fear of becoming addicted. We hear that all the time in clinic, right? Fear of the side effects, long-term side effects, and things like that, or they may get immune. And so in conclusion, the social determinants of health have a direct and indirect effect on medication adherence, so more proximal and kind of upstream effects. Barriers may vary based on a country's socioeconomic and political policies, and future medication adherence interventions should really be tailored to the barriers you meet to a target population. That's it. Thank you. All right, my section is called A Proposed Solution, Teach-to-Goal Education. I'm Jennifer Schwock. I'm a clinical pharmacist at Johns Hopkins Hospital, and I have nothing to disclose for this presentation. And I'm here to teach about Teach-to-Goal, which we've heard briefly about already. Teach-to-Goal is a method of repeated rounds of assessment and education, so again, focusing on that patient with the goal of mastering inhaler technique. So as we heard, lots of patients misuse their inhalers. It's very common. And this method of teaching, we really want to make sure that patients understand how to use their inhaler and get the most out of that inhaler that they're using. Teach-to-Goal has been demonstrated to have lower rates of inhaler misuse than verbal instruction. So to go back through that approach, it starts with a baseline assessment of inhaler technique, watching the patient use the inhaler that they will be using for their rescue and maintenance therapy. The trainer then will demonstrate correct inhaler use, actually showing the patient how to use it instead of just telling them. Words can mean a lot of different things to different people, so showing can be really impactful in having the patient understand the words in the same way that you mean for them to understand them. We then reassess the patient's technique and offer on-the-spot feedback. This cycle can then be repeated for up to two additional rounds until the patient demonstrates mastery. So it gives the patient additional times to further enhance their understanding and use of their inhalers. So we're actually going to have a demonstration now, so a little interactive. If we can have a volunteer come up to be a patient. So we're expecting a patient to use their inhalers, so we don't need to do perfect technique. If someone wants to come up, and while someone's deciding to come up, I will pull up our standardized checklist for everyone to look through. Am I going to have to call on a volunteer? Okay. Thank you so much. We'll get your very own spacer as a prize. So if people want to look through this while I come down and give her hers. You don't have to. Perfect. We're going to have our patient. You won't hear me. Sorry. Yeah. Okay. So the next part will be providing feedback. So I'm going to have you all look through our checklist. For those of you that can't see this far away, I know it's far away, there is a QR code if you'd rather scan it and look at it on your phone. But I'll have you take a minute to go through those steps and identify some things that our patient here can work on. Okay. So does anyone want to throw out one or two steps that were done inappropriately? How about one more? I know I did a lot wrong. I did it like my patients do it in my clinic. Right, didn't breathe slowly. I didn't shake. Didn't exhale, didn't shake. I saw someone motioning. Great. You all found a lot of the mistakes. You did a very good job as patients. This is often what we see. So I will take the inhaler back. So as the teacher, I'll take that in. I will take account for what she's done wrong. Then I'm going to show her myself. A lot of times I'll give some verbal feedback as well. So thank you so much for showing me. I have a few tips I think will help you make your inhalers work a little bit better for you. If you would like to watch me, I'll show you how to do it and then I'm going to have you repeat it back to me. Between talks we're going to wait about 30 seconds to a minute to make sure that your lungs are ready for that second breath. So we'll say it's been 30 seconds. Okay, so that's how I use my emailers when I use them. Would you show me just to make sure that I've taught you the right things? 30 seconds elapses. Great. Thank you so much. What do you all think? I'm good. You don't want to take any extra stuff back? Thank you so much. So that was great. She did all of our steps correctly. Had she not done a step correctly, I would have, again, given her her feedback, and then we could have gone through the process again. When we have a patient, I often will give them feedback and say, you did a great job that time. Did you feel like you got the medication deeper into your lungs when you exhaled out before taking your breath in? Really feel like your lungs are filling. If someone has the same step they've missed more than once, again, repeating that, it's important, but making sure that they watch what you're doing. I think that's one of the big things. You can see a lot of patients watching you do it really makes it click in their head what you mean. When we tell patients to take a big, slow breath, for them that can look very different. A lot of times when I'm teaching students to teach patients, a lot of our COPD patients, especially those that are in the hospital, their big, slow breath looks a lot different than our big, slow breath just looked here, right? So also being aware that that's going to be different for every patient, but it still helps them to see what that big, slow breath can be. So that was our demonstration section. Thank you so much, and we'll move on to the next speaker. Thank you. Good morning. My name is Vincent Phan. I'm at the University of Washington and at the VA Puget Sound in Seattle. I have no disclosures today. I'll be using the audience response system for one question. So if you haven't scanned the QR code, you can look at it here. So today what I'd like to cover is provide a brief overview of rural-urban disparities for patients with COPD, and then describe the acceptability and impact of a video inhaler training for rural patients, and I'll end with describing a different approach, an asynchronous app-based approach to provide inhaler training. Oh, here we go. Yeah, so the question here is, rural patients are at risk. Do I have to go back? Go back one slide. Yeah, and try again. Oh, just, yeah, and then go forward again. Can I go forward? Yeah, perfect. Oh. And then leave it here for just a minute. Good. All right, sorry, it didn't look that way on my screen. Yeah. So this is, the question is, are rural patients are at risk for which of the following adverse COPD outcomes? One, increased COPD prevalence, increased hospitalizations for COPD, or increased COPD mortality, or all of the above? So I'll give everyone a chance to answer. Okay, we have 22 votes. So I think everyone said all of the above, which is actually the correct answer. And I guess it's, you know, it's a little bit surprising to me why these disparities exist. This is data from Croft and colleagues. They actually looked at increased risk of adverse outcomes for rural COPD patients in the United States. They defined rurality based on the National Center for Health Statistics, and you can see that 23% of people live in large central metropolitan areas, and 9% live in rural areas. And if you compare the prevalence of these outcomes between these two groups, in terms of prevalence, 4.7% of people in large metropolitan areas have COPD, whereas it's over 8% in rural areas. And Medicare hospitalizations for COPD specifically are elevated in rural areas at 13.8 per 1,000 versus 11.4 per 1,000. And impressively, the COPD-related deaths are quite a bit higher in rural areas at 55 per 100,000 versus 32 per 100,000 in more urban areas. So given the burden of COPD in rural areas, Croft and colleagues also looked at what is the access to pulmonary care? And this is every county in the United States, and they looked at who has access to a pulmonologist within 50 miles of their home. And you can see that the people with the highest access are in dark blue, and those correspond to the more urban areas. So if you live in a dark blue area county, there's one pulmonologist for every 200 to 1,600 patients. But if you live in one of these light blue counties, more rural areas, there's one pulmonologist for almost 7,000 COPD patients. And then there's a whole group of counties where there's white, where there's no pulmonologist within 50 miles. So given this decreased access to care for rural patients, how can we adapt COPD self-management programs to reach those people? Self-management programs, you know, have been studied in a number of clinical trials, and they've been associated with improved quality of life, reduced hospitalizations, and they really focus on a number of behaviors. Today we're primarily talking about medication adherence, which is a key behavior for COPD and for asthma. But they also, these programs also address self-monitoring for exacerbations, avoiding triggers, smoking cessation, exercise, physical activity, breathing techniques, and how to manage stress and anxiety. And again, most of the clinical trials have been done with training delivered face-to-face. So you're in the room with someone who's delivering that training, either a nurse or respiratory therapist. But telemedicine may be able to allow us to reach rural patients to provide this education. So in terms of video internet conference, so video conferencing for inhaler training specifically, there's been a number of studies using, where pharmacists have been able to provide training for patients with HIV, anticoagulation, and asthma medication management, which suggests that this could be an approach used for COPD. This is actually not COPD. This is asthma, but this was an initial study done over 20 years ago in a rural setting in southeastern Arkansas. There's a pharmacist who was communicating with patients who were at a clinic, a rural clinic, and did two 15-minute telepharmacy sessions. They used an MDI checklist, I guess similar to the Teach to Go, but probably not as sophisticated. And then they rechecked it two to four weeks later. It was a very small study, 24 people in the intervention group and 25 in the control, but they found that there was improvement in several of the steps, including correctly holding the medication, inhaling deeply and slowly, and waiting a full minute between puffs. And this is on this graph. You can see just the total score, you know, eight being the highest score, and the people in the intervention group with the telephysicists improved. Although this was not statistically significant, it did suggest that this approach could be helpful. So we used a similar approach for rural COPD patients who were getting care at the VA hospital in Seattle. This was funded by the VA Office of Rural Health. We used kind of an older technology that was available at the VA at the time. Which was Cisco Jabber video. And we provided inhaler training. There was, I think, three pharmacists that used Teach to Go that we just heard about, but delivered it using video as opposed to doing it in person. And we repeated it every month for three to four months. We ended up enrolling 74 rural veterans with either COPD or asthma. The average age was 69, 100% male, a VA population, and 93% had COPD. And the mean number of inhalers was almost three, which at the time was due to kind of the medications we were using in our formulary. And these are the results we had. We actually showed similar improvements in inhaler technique from the first to the first month, and then the second month. Because they had a total of three training visits. These are the medications that we trained people on. So albuterol, butadiene formotorol, formotorol dry powder inhaler. The ipitropium albuterol, respimat, the memetazone dry powder, and the teotrobium dry powder. And you can see the range of scores for each of those inhalers and the number of people who use them. But for all the inhalers, we showed, or we found, I should say, an improvement in inhaler technique between baseline and month two. And then we asked people at the end whether they were satisfied with the program, and satisfaction was very high. Ninety-eight percent said they had a good relationship with the pharmacist. Ninety-two percent would recommend training to other patients. And interestingly, 96% preferred the video approach to going to the facility. And this was pre-pandemic, not surprisingly due to the convenience and saving time and travel. We did have some technical issues. Forty-three percent of the patients and 60% of the pharmacists had technical issues. A lot of that was due to the technology we were using at the time, which required that patients have a separate password every time they logged in, and that they had to cut and paste. And that turned out to be a pretty big barrier for a lot of our older patients. Hopefully, we're just better with kind of the newer generation of technology. We repeated the same study with urban patients. And this was 35% of patients that turned out didn't have a computer, so couldn't participate. We enrolled 48 people. Seven withdrew due to technical difficulties. And similar to the rural patients, 93% were male. The average age was 68. Fifteen percent had inadequate health literacy. And the average number of inhalers was 2.3. And this time, we were able to look at, so inhaler technique improved. But we were able to look at quality of life as an outcome. And we found that quality of life measured with this chronic respiratory disease questionnaire. All four domains improved after training. Now, this was not a randomized trial. This was just a pre-post study. But we found that dyspnea, fatigue, emotional function, and mastery all improved after they got this virtual, or video, sorry, video inhaler training. So this suggested that this approach with pharmacy-based video training could improve technique and quality of life. However, one barrier that we ran into, at least at our hospital, is that the hospital, we have a limited number of pharmacists. And, you know, we have a lot of patients with COPD. I think at our facilities, we're over 8,000 who have COPD. And so we just, it was not possible to deliver this intervention to every COPD patient. So this is another approach that I think is promising. This is by Dr. Press, who's here today. And her group, this is a study looking at a tablet app called Virtual Teach-to-Go. And this is a randomized non-inferiority trial. They looked at hospitalized patients with either asthma or COPD who were using an MDI. And the intervention was comparing this virtual Teach-to-Go program, which was delivered on a tablet, with the same cycles of video demonstration and self-assessment that could be repeated, and compared that to in-person Teach-to-Go, which we just saw demonstrated a few minutes ago. And they looked at follow-up at 30 days. They were able to randomize 121 patients. And the outcome was the improvement in the proportion of patients who had correct inhaler technique, defined as a score of 10 or more. And this is the findings from the study. They had similar improvement in the proportion of people who had correct technique, so 67% of the intervention patients. Sixty-six percent of the control patients improved. And then they looked at the proportion of people who had correct technique at hospital discharge. So that's the third line down. After adjustment for baseline, their baseline score, 82% of people who had the in-person had good technique or correct technique, and 71% of the virtual group had correct technique. So with a difference of 10%, that was within their kind of the range of non-inferiority. So these look like they're similar in terms of their effectiveness. And then looked again at 30 days, and 61% of people in the in-person group had correct technique, and 55% of the people in the virtual group had correct technique, again, within the margins of non-inferiority. So this suggests that, you know, maybe a virtual approach, which is potentially more broadly applicable in our health system, could help reach a lot of the patients that we can't reach due to the limitations of the pharmacy service. So in summary, rural COPD patients are at increased risk for adverse outcomes, but have less access to specialty care and programs like inhaler training and self-management. Telemedicine approaches may provide access to self-management training, and inhaler training is an example of a program that can be delivered by pharmacists using televideo visits. And then there's this new approach using an app-based approach that may be more scalable to improve patient outcomes. Thank you. So while this is loading, I'm going to fly through our next group until we leave some time for questions at the end. So what I'll be talking about today is how we tried to pair some of the things that we heard about in the last couple sessions and talk about how we tried to really make this something that was practical and usable within a standard clinical practice. I think we've heard a lot about how patients aren't good at inhalers. We see that. We know that. It's difficult. It's time-consuming to do the teaching, and it needs to be repeated. And so we need to develop methods to make this something that flows in our clinic space and is something that's usable by both our clinic team and then also the patient as well. With the advent of everything, certainly all of us are experiencing a lot of staffing shortages, and so having enough pharmacists or even having enough medical assistants or having enough time as the clinician to do this teaching in clinic can become a really challenging part. At the same time, we've had a radical change in how we deliver our healthcare practice in that there was this huge surge in telehealth, and now we've seen that kind of back off a little bit too. And I think it's not unsurprising because we know, we feel it as people who work with the patients, and the patients see it as well, that it's not... There's so many things that we use to augment our clinic visits that are in person that are then not offered as a part of the telehealth platform. And so in a lot of ways, people feel they're not getting the same care that they would otherwise. And then we heard earlier that there is a big disparity as well in the people who have access and ability to use telehealth. So if you only offer it to certain groups, then other groups are certainly going to be disadvantaged. So how can we try to use this new technology and this knowledge that telehealth can work and video conferencing can work to deliver this inhaler education? We saw that that had great improvement in patients' outcomes, but in a way that's feasible to integrate with the clinic and integrate with our patients as well. And so that's why we developed our COPD VMed pilot, looking at medication reconciliation and inhaler education. And really our goal for this was twofold. So when we first were brainstorming this, it was at the time of COVID and there were a lot of virtual visits and our patients weren't getting inhaler education. And that was something that was really disparate for a lot of them and impacted a lot of care. As this came into fruition, we saw a big return to in-person practice, but still with staffing shortages and time restraints and things like that, inhaler education was not present at the same pre-pandemic levels that we had originally. So our goal with this was twofold. One, to develop something that, could we implement it? Could we implement virtual education as part of our standard clinic visit, whether it's an in-person visit, and I'll talk about this a little bit more, or a virtual visit? Can we incorporate this into our own clinical practice? And then again, something that's usable, something that the patients appreciate and they feel is helpful to them and worth their time, something that it's easy for the staff to set up and for our pharmacists or whoever you're having be your clinical educator work with in the clinic that is something that is beneficial, because we know that if the barriers are too high, people won't use something, whether it's on our side or on the patient side, they won't use it. And so what we did, and let me just see if I can, I can't really do a screen, but so when people came into the clinic, they had their originally scheduled, so this is people in our care transitions clinic, so this is a group of people who hospitalized, identified with COPD and trying to get them sooner follow-up, so maybe even a higher risk population for inhaler misuse potentially. Technically in our program, they're supposed to get inhaler education inpatient before they leave, but not everyone does. And so they come in, they have their clinical visit, and then afterwards say, okay, now it's time for inhaler teaching. So we brought in an iPad, had a pharmacist come in on a Zoom, and then give the inhaler education while the rest of clinic still kind of functioned. And the goal with that was we could do that if someone came in in person, but then also if it was already built out as a virtual visit, then the pharmacist could hop onto that virtual visit as well and deliver inhaler education in that modality. And so we did this across the board in the entire clinic. This wasn't a randomized thing, but what we did then is talk to patients and talk to the physicians afterwards to get their perspectives on how this worked. Was it useful? Were there barriers? Was it too much going on? And that's really what we were trying to look at is trying to make this something that could be used on a more wide scale basis. And then we also, like I said, it's not just our patients' perspectives, but is it something that the care team can use? And so we looked at care team perspectives as well, both people who were not affiliated with the study to try to understand what their use and practice and understanding with telehealth was and using augments, multidisciplinary care augments to telehealth. And then people who participated in the program, we also administered them a second survey afterwards to see if there were changes in their practice patterns or beliefs, or again, seeing if this is useful for everyone. And we really did see some interesting themes come out of this, and I'll go through them pretty quickly today. The first, we'll talk about patient perspectives first. So patients, not only we asked them about the actual program that we did, but we asked them about their general impressions with telehealth. And across the board, patients, they know there's benefits and there's drawbacks. People cite convenience of telehealth, but then the biggest thing is people felt they were missing out on a lot of the clinical aspects of care. They were missing out on that touch, the physical exam, the vital signs, things like that. And so they could see where there is utility in using it, and I think we've seen a lot more acceptance of telehealth in the last three or four years as well, but that there were a lot of drawbacks, and they felt they didn't offer it. With that, we did see a very strong preference for in-person clinical visits. So people wanted to come into the office. They wanted to have that face-to-face encounter. No one really liked phone visits, and I think that people will very much agree that phone visits don't compare and don't stack up to a regular clinic visit and all the things that we offer there. There was a little bit more variance in the video visits. People felt at least that someone could see them, see how they're breathing, see what's going on, and have that a little bit better connection than just a telephone, but it still didn't quite stack up. And so with that, certainly there's concern. People don't like telehealth, and so what are we doing with this virtual program? Are people actually going to be receptive to it? And we were really surprised to find that despite the very strong preference for in-person clinical care, in-office care, the virtual program was very well received by this patient cohort. There were, you know, almost half of the patients said they had actually never gotten any inhaler education before this, despite this being a group that we specifically target. Some of them forgot, and I think we all forget, but they said they hadn't gotten education before this. And there was a really, an equipoise almost, and people felt that they were able to get all the instruction that they needed from this face-to-face videoconferencing format because they could see, you know, when the pharmacist said, this is how I do it, watch me, and the pharmacist could then see the person doing it and say, you know, you did great, but let's, you know, fix these couple things and do that repeated teach-to-go feedback. And people felt that that was valuable, a valuable use of their time, and there were people who had never used telehealth, were apprehensive about telehealth, and they really, even that group, responded very well. And people felt that this was good, a good use of their time, and they would recommend it to other patients as well. When we looked at, you know, again, we want to make sure this is effective, right? So we can do something, everyone loves it, but if it doesn't change the needle, it's not useful either. And we did. I think this is not surprising, knowing what we know about teach-to-go and the studies that you've heard about today, is that there was improvement in inhaler technique with telehealth, with this videoconferencing modality. And certainly there's a lot of questions about how often this needs to be repeated, but this one dose was effective at improving outcomes in their use technique. And then I wanted to just briefly talk about, you know, we're in an urban population, some people are very high adept at using telehealth, others are not, and so we wanted to look at this based on the people who responded positively, the people who would recommend it, the people who are considering using it more, was there a difference in the people who were more familiar with telehealth, or even videoconferencing? They FaceTimed their grandkids, things like that, versus people who had no interaction with any videoconferencing. And we look, and there's really no difference about people's acceptance and willingness to use this type of platform going forward, when we look at people who had never had any video encounters, whether it's personal or medical, and when we look at people who specifically interacted in the medical care system with telehealth technologies, and across the board, people responded really positively and were interested in additional visits. We did follow up a month later with people, just a phone call to say, hey, do you remember that? You know, what did you think of it? Are you still interested in doing more? Because certainly there's excitement in the time that you're getting it, but then the longevity of it, are people committed to kind of doing further education and sessions with this is something we wanted to ensure as well. And it did pan out that people still were interested in engaging in this platform and would be willing to use this again. And the one thing that I think was really interesting is, you know, while we know, no one wants to hear the same thing over and over again, because we feel we know it, even if we don't. And so we wanted other types of information with this type of platform as well. And I think that there's questions there about how you do that, because we know that they do need repeated inhaler education as well, but kind of using this on a more broad scale for patient education and disease self-management. Looking just briefly at our care team surveys, we'll talk about this, and then I think we're going to wrap up. But when we looked at people, so we looked at a couple of different groups. We looked at primary care group, we looked at POM, POM sub-specialties, people that focused on COPD. And not unsurprisingly, I think the primary care group had had less experience with multidisciplinary care in telehealth. I think we can think back to, you know, deep in COVID with our CF clinics and things like that, where you would pull in the pharmacist, the nutritionist, things like that, to try to get a greater complement of care for our patients. But people wanted to use it. It was more about the barrier to implementation than it was that they didn't think it was beneficial. And that if a system were in place, that they would want to use it. And so when they said, you know, benefits outweigh the cost, it really, the implementation was the biggest barrier there. But when we looked at our group afterwards, the people who participated in our program, they felt that it was really useful. And all of them wanted it to continue as something that they offered to the patients going forward. So we'll just briefly run through all of this. So we know that virtual teaching is an effective complement to clinical care. We've seen that in multiple studies, and that patients are willing to use this modality as well. And even though they may prefer in-person clinical visits, augmenting that visit with a virtual component, or even combining virtual into an already integrated virtual visit is something that they find useful in their time. And even in people who are not high telehealth users, this can be effective, which I think is really promising as far as when you think about our underserved patient population groups, we don't have to limit this access to them. And our VMed platform worked. And then people, clinicians, are interested in being able to provide this for their patients as well.

inhaler education

obstructive lung disease

patient education

proper inhaler technique

teach-to-goal education

barriers in inhaler education

telemedicine for inhaler education

telehealth platforms

patient outcomes