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Chronic obstructive pulmonary disease in the long-term care setting

current practices, challenges, and unmet needs

Suarez-Barcelo, Manuela; Micca, Joseph L.b; Clackum, Sharonc; Ferguson, Gary T.d

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Current Opinion in Pulmonary Medicine: November 2017 - Volume 23 - Issue - p S1-S28
doi: 10.1097/MCP.0000000000000416
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The term long-term care (LTC) includes a wide variety of facilities/environments designed to care for patients who are no longer able to live independently. These include residential care facilities (RCFs; also referred to as assisted-living facilities/assisted-living residences), skilled nursing facilities (SNFs)/nursing facilities (also referred to as nursing homes or extended-care facilities), and personal-care homes. In addition, home health agencies (HHAs), hospices, and adult day service providers may assist in providing care in a variety of settings, including private residences. Each service provider cares for a differing population of patients; however, all are faced with the burden of caring for an aging population. Approximately 70% of people older than 65 years need some type of LTC during their lifetime, and more than 40% need care in a nursing home for some period [1]. It is currently estimated that more than 4 million Americans will be admitted to or will reside in nursing homes and SNFs each year [2]. In addition, nearly 1 million people reside in an assisted-living facility.

A disease common in LTC settings is chronic obstructive pulmonary disease (COPD), a heterogeneous disorder constituting persistent respiratory symptoms and airflow limitation, including emphysema and chronic bronchitis [3,4]. COPD develops slowly over years and most often occurs in people aged 40 years and older and those with a history of smoking, although genetic and environmental factors can also lead to disease [5]. COPD causes serious, long-term disability and is exponentially problematic in the LTC population, which consists of older and sicker residents who have increased cognitive impairments, physical impairments, and multimorbidities. This supplement focuses on three key aspects of caring for an aging American population with COPD: current practices in the diagnosis and treatment of COPD in patients transitioning to and already in the LTC setting, ways to improve these practices and address current challenges, and the role of nebulized medicine in the LTC setting.


Burden of living with chronic obstructive pulmonary disease

COPD is the third leading cause of death in the United States, causing roughly one death every 4 min [6]. Age-standardized death rates for COPD have declined 12.7% for men from 1999 to 2014, whereas the rates for women have mostly been consistent across time (Fig. 1) [7].

Chronic obstructive pulmonary disease (COPD) mortality rates in the United States, 1999–2014. COPD as the underlying cause of death was defined by the International Classification of Diseases, Tenth Revision codes J40–J44. Death rates are reported per 100 000 population and were age-standardized to the 2000 US projected population. Source: Reproduced from [7].

According to the 2010 National Survey of Residential Care Facilities, the prevalence of COPD was 12.4% in RCFs in the United States [8]. The prevalence in the overall fee-for-service Medicare/Medicaid population enrolled in 2008 was reportedly 18.9%, with a higher prevalence in enrollees aged at least 65 years (21.9%) than in those aged younger than 65 years (14.8%) [9]. In enrollees aged at least 65 years, COPD was most prevalent in those who had a part-year length of stay in an LTC facility (39.1%), followed by full-year LTC stay (25.6%), and no LTC stay (18.6%) [9]. In a study of United States nursing home residents, the overall prevalence of COPD was 21.5% [10]. Although these studies suggest COPD prevalence rates range from 12 to 22% in LTC residents, actual prevalence rates may be much higher because COPD is commonly underdiagnosed or misdiagnosed [11–14].

Patients residing in LTC facilities tend to be of advanced age and often have a number of significant comorbidities (commonly including cognitive and functional deficits). In addition, LTC patients often have multiple diagnoses that are overlooked or suboptimally managed [e.g., asthma, congestive heart failure (CHF)], complicating overall health, well being, and quality of life [9,15–20]. An analysis of a nationally representative sample of older adults (age ≥67 years) who participated in the Medicare Current Beneficiary Survey (1992–2002) identified that patients with COPD or asthma had generally worse health status than those without COPD or asthma, including more chronic comorbidities, lower self-reported health status, and greater limitations in activities of daily living [21]. The National Survey of Residential Care Facilities reported that less than 3% of RCF residents had no comorbidities, with rates of comorbid arthritis, depression, CHF, diabetes, coronary heart disease, and asthma significantly higher for patients with COPD than for those without COPD (P < 0.05) [8]. In the Health and Retirement Study, cognition scores of older adults (>50 years) with COPD, both severe and nonsevere, were significantly lower than those of adults without COPD (P < 0.001) [18]. In a retrospective analysis of nursing home residents, 68.0% of nursing home residents diagnosed with COPD had a concurrent diagnosis of hypertension, 50.1% had depression, 39.8% had diabetes mellitus, 37.5% had CHF, 37.2% had Alzheimer's or other dementia, 21.2% had pneumonia, and 8.6% had asthma [10]. In addition, 43.3% of nursing home residents with COPD had moderate or severe impairments in cognitive skills for daily decision making, and 16.2% rarely or only sometimes understood others. Cognitive impairments that LTC residents may present with include communication difficulties, perseveration, aggressive/impulsive behaviors, lack of motivation, memory problems, and wandering [22,23]; these impairments can have significant impacts on the diagnosis, treatment, and maintenance of COPD in older people residing in LTC facilities.


COPD is marked by exacerbations, which are defined as sudden acute worsening of COPD symptoms resulting in additional therapy, with symptoms including dyspnea, chronic cough, sputum production, wheezing, and chest tightness [3,24]. Comorbidities and disabilities of various origins, commonly seen in LTC patients with COPD, can contribute to a reduced recognition of a potential COPD diagnosis and may dominate the clinical scene, with severe exacerbations of COPD presenting atypically and often recognized late [15,25–27]. Advanced age and comorbidities of most LTC patients may make COPD exacerbations more frequent or severe [28–31] and may create challenges with respect to polypharmacy [25]. Whether the comorbidities cause COPD exacerbations, mimic COPD exacerbations, or represent increased COPD severity still needs to be formally investigated. Additionally, cognitive impairment is a common comorbidity in this population and negatively impacts the patient's ability to bring symptoms to the attention of caregivers. As COPD management is driven by symptomatic presentation, cognitive impairment places the burden of symptom recognition on the caregiver. Lastly, COPD is usually not the primary diagnosis driving hospitalizations in LTC residents, and thus would not be the primary focus of pharmacotherapy and patient monitoring in that setting [32].

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease guidelines [3,4], and reiterated in the American Medical Directors Association (AMDA) COPD Management in the Post-Acute and Long-Term Care Setting guidelines [24], COPD should be considered in any patient with the symptoms of dyspnea, chronic cough, or sputum production, and in any patient with a history of exposure to risk factors; however, guidelines specify that spirometry is required to establish a diagnosis, with postbronchodilator, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) less than 0.70 as confirmation of the presence of persistent airflow limitation and COPD. The established threshold is independent of reference values, such as age, height, sex, and race. In elderly patients with a diminished lung function (due to age, if nothing else), this threshold may not accurately identify the presence of COPD, and using the lower limit of normal may be more appropriate. The lower limit of normal threshold is based on population reference values and corresponds to the lowest 5% of the normal distribution [3]; however, there is a lack of formal studies evaluating the accuracy of using this method. GOLD guidelines list several key COPD indicators for patients aged older than 40 years that will increase the probability of a diagnosis, including dyspnea that is progressive over time, characteristically worse during exercise and/or persistent; chronic cough that is intermittent and may be unproductive and/or recurrent; any pattern of chronic sputum production; recurrent lower respiratory tract infections; a history of host factors (e.g., genetic factors), tobacco smoke, smoke from home cooking/heating fuels and/or occupational noxious stimuli; a family history of COPD; and/or childhood factors (e.g., low birth weight, childhood respiratory infections).

Both GOLD [3] and AMDA [24] guidelines indicate that spirometry is necessary for COPD diagnosis. Although of lesser importance, spirometry may also be of benefit in the assessment of prognosis as well as help with therapeutic decisions and the identification of patients with a rapid decline in lung function. Spirometry informs whether therapy should be pharmacological (e.g., discrepancy between symptomatic grading and spirometric grading) or nonpharmacological (e.g., interventional procedures), as well as if an alternative diagnosis is needed (i.e., symptoms are disproportionate to the degree of airflow limitation). In addition, GOLD guidelines recommend the Chronic Obstructive Pulmonary Disease Assessment Test (CAT) (Appendix A) and The COPD Control Questionnaire as suitable comprehensive assessments of COPD symptoms in clinical practice, whereas more comprehensive health status questionnaires (e.g., the Chronic Respiratory Questionnaire and the St. George's Respiratory Questionnaire) are too complex for routine practice. Furthermore, the CAT is currently used in the GOLD 2017 ABCD assessment tool for COPD grading and therapeutic recommendations. The modified ABCD groups are now derived exclusively from patient symptoms and exacerbation history, with spirometry separated for diagnosis, prognostication, and consideration of alternative therapeutic approaches (Fig. 2).

The refined ABCD assessment tool (2017). CAT, Chronic Obstructive Pulmonary Disease Assessment Test; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; mMRC Scale, modified Medical Research Council Dyspnea Scale. Source: Reproduced with permission from [4].

In summary, there are two grading structures in the updated ABCD assessment tool: spirometric grading for the assessment of airflow limitation (GOLD 1–4; Table 1) and symptomatic grading for the assessment of symptoms and risk of exacerbations (Groups A–D). The GOLD 2017 guidelines separate the assessment of symptoms and exacerbation risk from the assessment of FEV1 predicted, whereas the AMDA 2016 guidelines combine the spirometric and symptomatic gradings, stating that how COPD affects an individual patient is dependent on both objective spirometry assessment as well as functional capacity and subjective assessment of breathlessness (Table 2) [24]. GOLD guidelines mention that further evaluation and testing is needed when there is a pronounced discrepancy between the level of airflow limitation and the perceived symptoms to elucidate any issues with lung mechanics, lung structure, and/or comorbidities that might impact patient symptoms. The CAT [33] is the primary symptomatic measure recommended by the GOLD guidelines; however, because the mMRC Scale (modified Medical Research Council Dyspnea Scale [formerly, Questionnaire for Assessing the Severity of Breathlessness] [34]) (Appendix B) is so widespread, a cutoff point for this measure is still included in the ABCD algorithm.

Table 1
Table 1:
Stages of chronic obstructive pulmonary disease based on airflow limitation according to AMDA guidelines
Table 2
Table 2:
Combined chronic obstructive pulmonary disease assessment that includes symptoms, dyspnea, spirometry, and risk of exacerbations according to AMDA guidelines

Although the GOLD guidelines state: ‘Good quality spirometric measurement is possible in any healthcare setting and all healthcare workers who care for COPD patients should have access to spirometry’ [3], it is not uncommon for LTC physicians to make the clinical diagnosis of COPD at the bedside [24]. Various barriers exist in performing spirometry in LTC settings: spirometers need regular calibration and need to produce a hard copy or digital display of the expiratory curve (to identify an unsatisfactory test); spirometric assessments must be performed by a technician or healthcare provider trained in optimal technique and quality performance; maximal patient effort is needed; assessment duration must be long enough to reach a volume plateau (longer for more severe COPD) or at least 6 s; and results need to be compared with reference values based on age, height, sex, and race [3]. These conditions are not always feasible in LTC settings with older, more cognitively and physically impaired patients [25]. In a comprehensive review of COPD in the elderly [25], the reasons frequently accounting for poor spirometric testing quality in elderly patients are detailed (Table 3).

Table 3
Table 3:
The main conditions potentially affecting the quality of spirometry and, consequently, the achievement of a state-of-the-art chronic obstructive pulmonary disease diagnosis in the elderly

Additional investigations identified in the GOLD guidelines [3] to consider as part of COPD diagnosis and assessment, relevant to patients in LTC settings [24], include the following (in no particular order):

  1. Chest X-ray imaging (for excluding alternative diagnoses and establishing the presence of significant comorbidities)
  2. Body plethysmography (or, less accurately, helium dilution lung volume measurement; for characterizing COPD severity)
  3. Measurement of diffusing capacity for carbon monoxide (for characterizing the functional impact of emphysema in COPD)
  4. Pulse oximetry (for evaluating arterial oxygen saturation and need for supplemental oxygen therapy)
  5. BODE (body mass index, obstruction, dyspnea, and exercise) Index (for predicting survival).

These alternatives to spirometry will assist in providing a greater overview of the patient and their symptomatology; however, spirometry is still viewed as the gold standard for the diagnosis of patients with COPD [3,24]. Misdiagnosis of COPD could lead to a more rapidly progressing disease and leaves the patient with a lower quality of life, as well as increases the risk of inappropriate concomitant prescriptions that could lead to adverse drug–drug interactions. In addition, guidelines recommend influenza vaccinations for patients with suspected or confirmed COPD to prevent respiratory infections, which in turn reduces the number of exacerbations and may reduce hospitalizations [24].

Differential diagnosis of asthma versus chronic obstructive pulmonary disease

Although asthma and COPD are common obstructive lung diseases, despite sharing some key symptoms, both diseases are very distinct in terms of pathogenesis and management. Often, asthma can be diagnosed by history and a simple challenge with a short-acting bronchodilator (SABD). This then differentiates the patients with asthma from COPD, who generally have a different history in addition to persistent airflow obstruction on bronchodilators, as evidenced by spirometry with a postbronchodilator FEV1/FVC ratio of less than 0.70. According to guidelines from the Case Management Society of America (CMAG) for improving patient adherence to COPD therapies, there are several common features that differentiate COPD and asthma (Table 4) [35]. Not all of the common features will present in every patient, but use of general characteristics can lead to earlier identification and treatment, an important element of improved COPD management.

Table 4
Table 4:
Common features in differential diagnosis of chronic obstructive pulmonary disease versus asthma

Although persistent asthma can be associated with partially reversible airway obstruction, supplementary techniques, such as complete pulmonary function testing and allergy testing, can help distinguish asthma and COPD. The use of Asthma Control Test questionnaire and the Clinical COPD Questionnaire are two potential diagnostic tools to help facilitate a differential diagnosis and monitor disease progression. Many attempts have been and are being made to develop more specific tools for COPD diagnosis and monitoring [3,17,25,36–45], or to find an acceptable biomarker for COPD diagnosis and progression, but none are satisfactory to date [46]. Nevertheless, distinguishing COPD from asthma is essential to properly treat either disease, especially with the potential for overlap and the convergence of these disease states with chronicity and advancing age [12,47–54]. The prevalence of asthma–COPD overlap is estimated at 20% of patients with obstructive lung diseases [55] and 28% of COPD patients from hospital-based studies [56]. Whether asthma–COPD overlap is a single entity or the presence of two separate common diseases continues to be debated. Certainly, no specific guidelines or an absolute definition have been established for asthma–COPD overlap, although GOLD 2017 does describe the process where/how one might evaluate such suspected patients [3].

Differential diagnosis is the foundation for the correct treatment pathway, as specific pharmacologic and nonpharmacologic treatments are targeted for those diagnosed with asthma, those diagnosed with COPD, and those diagnosed with other conditions that present with COPD-like symptoms. The severity of airflow limitation and the stability of disease guide pharmacologic and nonpharmacologic treatment approaches, as patients with severe disease may have more limited noninvasive treatment options. In addition to asthma, several other diseases should be differentiated from COPD, including heart failure, bronchiectasis, tuberculosis, obliterative bronchiolitis, and diffuse panbronchiolitis [35].

Current treatment paradigm for patients with chronic obstructive pulmonary disease

Treatment for COPD should begin with preventing additional lung damage; eliminating exposure to cigarette smoke (active and passive) is key, as well as providing vaccinations (i.e., influenza and pneumococcal) and avoiding bronchial irritants [3,24]. Although there are a wide number of prescription medications available for the treatment of patients with COPD in the United States (Table 5) [3,57], the choice of inhalational therapy is often restricted by the limited availability of medications and their fixed-dose combinations (FDCs) in specific delivery devices. COPD treatment options include monotherapy and/or combination therapy with short-acting and long-acting β2 agonists (SABA and LABA), short-acting and long-acting muscarinic antagonists (also referred to as anticholinergics; SAMA and LAMA, respectively), inhaled corticosteroids (ICS), phosphodiesterase-4 (PDE4) inhibitors, and/or long-acting methylxanthines. Although the cornerstone of pharmacological treatment for asthma is an ICS (with an ICS/LABA FDC indicated in asthma that is persistent and more than mild), the primary pharmacological treatment for COPD is a long-acting bronchodilator (LAMA, LABA, or LAMA/LABA FDC) [47].

Table 5
Table 5:
Commonly used inhaled maintenance medications approved in the United States for use in adults with chronic obstructive pulmonary disease
Table 5
Table 5:
(Continued) Commonly used inhaled maintenance medications approved in the United States for use in adults with chronic obstructive pulmonary disease

The recommended treatment algorithm for patients diagnosed with COPD using the updated GOLD ABCD assessment tool is shown in Fig. 3[3,4]. Patients residing in postacute and LTC settings are mostly in Groups C and D [24]. AMDA guidelines recommend that a LAMA and/or a LABA, complemented with other medications as needed and nonpharmacologic approaches, should be used for the maintenance treatment of most patients with COPD in postacute and LTC settings, with combination therapy suggested for those with frequent exacerbations or ongoing symptoms [24].

Pharmacologic treatment algorithm by Global Initiative for Chronic Obstructive Lung Disease (GOLD) Group (highlighted boxes and arrows indicate preferred treatment pathways). Source: Reproduced with permission from [4].

The guidelines suggest ICS therapy as an adjunct to LABAs or LAMAs in patients with advanced COPD and repeated exacerbations; short-term ICS treatment may be safe and effective, but long-term treatment may increase the risk of pneumonia events [58–65] and is recommended here with caution for older, more severe COPD patients. As an event with a diagnosis alone does not equal harm by itself, one must first ask what harm was associated with the diagnosis of pneumonia in the studies identifying an increased risk of a pneumonia diagnosis. This is best examined with the TOwards a Revolution in COPD Health (TORCH) study data [66], which showed no increase in mortality, hospitalization, or healthcare utilization associated with pneumonia events. Having said this, the number needed to harm has been estimated at 60 for pneumonia associated with COPD, with a statistically significant risk ratio of 1.44 [60], although there was significant heterogeneity between the included studies. One study also found that discontinuing ICS use in COPD patients decreased the risk of serious pneumonia by 37%, which reached 50% 4 months after discontinuation [67]. As respiratory tract infections, including pneumonia, have been shown to be associated with acute exacerbations of COPD [3], it is necessary to preemptively reduce the risk of pneumonia by decreasing the use of ICS in long-term treatment of COPD in LTC residents.

Although PDE4 inhibitors have been introduced to the market as an adjunctive therapy for the maintenance treatment of severe COPD, emerging safety concerns regarding psychiatric and gastrointestinal adverse events may preclude the use of these agents in LTC patients; however, it has been shown that PDE4 inhibitors are associated with reducing the likelihood of COPD exacerbations in select patients with severe airflow limitation, chronic bronchitis, and a history of frequent exacerbation [68]. For those not responding to triple LAMA/LABA/ICS therapy, a macrolide, namely azithromycin, may be considered after factoring in antibiotic resistance and hearing loss, a major concern in the elderly [69]. Methylxanthines are generally not recommended in this population, unless a β2-agonist or muscarinic is not available or affordable, and only if therapeutic monitoring is available, as older patients have a high risk of toxicity due to comorbid conditions and drug–drug interactions with concomitant medications [24].


GOLD 2017 acknowledges the importance of inhaler device use and need the selection of an appropriate inhaler and inhaler education for COPD patients, but notably absent are specific recommendations for which type of inhaler device is appropriate to use in which patients. Inhalation device types include nebulizers, pressurized metered-dose inhalers (pMDIs; used either alone or attached to spacers or valved holding chambers), breath-actuated pMDIs, dry powder inhalers (DPIs), and soft mist inhalers (SMIs). As previously discussed, COPD patients in LTC have a high incidence of both physical and cognitive limitations, which may inhibit proper delivery of inhaled medications, particularly in pMDI/DPI and SMI formulations. Table 6 describes the general advantages and disadvantages of the various inhalation delivery devices, which can be referred to when tailoring the medication delivery system to the patient's needs [70–75].

Table 6
Table 6:
Advantages and disadvantages of various inhaler devices
Table 6
Table 6:
(Continued) Advantages and disadvantages of various inhaler devices

Factors that limit the overall use of breath-actuated inhalers and nebulizers for inhalational therapy include the limited availability of medications and their combinations in these devices. In addition, prescription of and substitution to specific medications is dependent on the individual LTC facility formularies as well as health plans and government programs serving specific patients within those facilities [76]. In choosing a medication for use in an elderly LTC resident with COPD, generalized trial-based efficacy and safety information may not apply to this population [25]; in pharmacological trials for COPD treatment, comorbidity, cognitive impairment, depression, and physical limitations – which are hallmarks in the clinical profile of COPD in the elderly – are among the most recurrent exclusion criteria utilized.

Cognitive functioning, manual dexterity/strength, medication availability, patient preferences, and educational challenges complicate inhaler selection for elderly patients [77]. In particular, patients with low peak inspiratory flow rate (PIFR), cognitive impairment, and/or physical impairment may benefit from nebulization [78]. Sufficient cognitive functioning is necessary to acquire and retain proper inhaler (i.e., nonnebulizer) techniques, and manual dexterity and strength are required to prepare and administer medication. Patients residing in LTC facilities tend to have weaker grip strength and coordination, and may be more prone to forgetting aspects of proper inhaler technique with nonnebulized administration methods.

Medication availability is influenced by drug-formulation availabilities (i.e., SABA devices versus LABA and/or ICS devices), institutional protocols, and insurance coverage. Patient preference of medication and inhaler device is essential to consider in selecting the device, because inconvenient, time consuming, and ineffective administration can impair medication adherence. Meaningful patient education is needed because many patients with COPD make errors with inhalation devices, which can reduce adherence and limit medication delivery [79–87]; nonadherence to COPD medication is associated with increases in hospitalization, death, and healthcare costs [88,89].

Underutilization of nebulization in current practice may be due to a host of factors, including high cost, lack of availability, perceived complexity, lack of awareness and training, and time burden. However, for elderly patients residing in LTC facilities, medication delivery via nebulization may be a more practical approach to COPD treatment. In LTC settings, the caregiver is essential to medication delivery, and due to the extensive variety in inhaler devices and operation, many may not have the training to coach the patient in the proper technique of breathing and medication delivery. Nebulization is less dependent on caregiver and patient technique for operating equipment, a key consideration due to the high prevalence of cognitive impairment among LTC patients. Also, the barriers of needing a pressurized gas source are reduced in most LTC settings, as it is either available ‘in house’ or via home health/durable medical equipment.

Continuity of inhaler device use is necessary for COPD patient benefit. In a review of inhaler devices for use in COPD and asthma patients [90], Bjermer concluded that device continuity is important for maintaining disease control. Findings from the review indicate several factors related to inhaler devices that can affect therapeutic outcomes in COPD and asthma. These factors include variation in inhaler technique required by different devices; variation in drug delivery between similarly designed devices; inadequate, insufficient patient training on correct device usage; variation in the correctness of patient technique; and variation in patient adherence dependent on the device used. Continuity in inhaler device, as well as adequate training and monitoring of patients’ inhaler technique, could alleviate many of these contributors to poor medication usage and adherence. These factors were also reiterated in a review by Melani and Paleari [91].

Importance of patient-level education regarding chronic obstructive pulmonary disease treatments

Patient education on inhaler and nebulizer use is essential for ensuring adherence, medication delivery, and subsequent favorable clinical outcomes. One potential solution to enhancing patient education has been identified as the creation of a simple step-by-step guide (or checklist [92]), with easy readability and applicable visuals, for patients and caregivers – outlining key assembly, interface, inhalation/exhalation, dismantling, cleaning, and maintenance procedures for their device and medication dosage. Beatty et al. [92] compared the change in patient inhaler technique scores between standard hospital medication handouts and handouts specifically developed for patients with low health literacy and the differences in patient satisfaction ratings between the handouts. In this study, the low health literacy tool resulted in a statistically significant improvement of inhaler technique compared with standard educational handouts, with 74% of patients increasing the number of correct steps following administration of either handout and 77% of the steps previously demonstrated incorrectly being carried out correctly after handout administration. However, only one patient of the 23 patients studied was able to correctly demonstrate 100% of the steps [92]. Patient assessment of the ease of handout readability was rated on a seven-point Likert scale (1 = strongly disagree, 7 = strongly agree), with a mean readability score of 5.4 (median, 6.5; range, 1–7) points for patients receiving the control handout compared with a mean readability score of 6.1 (median, 7; range, 3–7) points for patients receiving the low health literacy handout. The difference in mean readability rating was not statistically significant between groups [92].

In addition to patient-level education, assisting clinic staff also should be educated in recognizing the signs and symptoms of worsening COPD. Recognizing changes in the patient's status and earlier treatment interventions for COPD can improve quality of life and outcomes [25,93,94]. Education for staff also should include how to educate the patient on proper inhaler technique [95–97], as errors are frequently made by patients during device assembly (if applicable), inhalation, exhalation, and maintenance; this is especially common for patients with limitations in manual dexterity and/or cognitive functioning, who may forget the proper techniques for assembly (if necessary), inhalation, and exhalation [79–82,89,98–100]. An observational study of COPD patients prescribed nebulized COPD medication for use at home demonstrated that 62% of patients with COPD felt that they had not been adequately informed regarding the correct use of nebulizer therapy, with 24% remembering receiving information only about dose frequency and 14% remembering being informed about how to use and clean the nebulizer [80]. Interestingly, 80% of the patients acquired their nebulizer through a source other than a hospital, and most had received no instruction on its use [80]. In a study evaluating inhaler technique [92], patients reported a mean of only 1.3 (range, 0–3) inhaler instruction sessions prior to the study instruction, even though the average duration of inhaler use was 9 years (range, 1–26). Education preceding study instruction was most commonly set in a physician's office (83%), followed by a pharmacy (17%), and other (17%); one patient could not recall any previous education. Most instructions were provided as a practical demonstration (73%), followed by verbal information (45%), guided practice (27%), and printed information (18%); only 27% of the patients reported being educated with more than one method.

In an observational study of patients with COPD or bronchial asthma [81], 82.3% of patients made at least one error while using a pMDI, pMDI with spacer, DPI, or nebulizer. The most errors while using the device occurred in those using a pMDI (94%), followed by DPI (82%) and pMDI with spacer (78%), while patients using a nebulizer (70%) committed the least number of errors. The most common errors made by the pMDI users were ‘no/short breath hold’ (46%), ‘not exhaling to residual volume’ (40%), ‘poor seal around mouth piece’ (37%), and ‘inhaler not shaken’ (37%). In users of the pMDI with a spacer, the most common errors were ‘inhaler not shaken’ (40%), ‘long delay before inhalation’ (36%), and ‘stopping inhalation as device is fired’ (32%). DPI users had ‘insufficient acceleration’ (52%), ‘not inhaling deeply enough’ (37%), and ‘poor seal around mouth piece’ (29%). For nebulizer users, the most common errors were in ‘deep breathing throughout the treatment’ (52%), ‘poor fitting of the mask’ (46%), and ‘incorrect dose of medication used’ (22%), with older patients (aged 51–60 years; 86%) more commonly making medication errors [81].

In a small study of patients with diagnosed COPD who were admitted to the hospitalist or internal medicine service at a tertiary care hospital, inhaler technique was assessed in patients using a pMDI, a pMDI with spacer, or one of three DPIs (Turbuhaler, Diskus, or HandiHaler) [82]. Critical errors were made by 59% of all patients while demonstrating inhaler technique, with an average of 26% of steps performed incorrectly. The percentage of patients making at least one critical error was highest in pMDI users (93%), followed by DPI users (43%); neither of the two patients demonstrating technique with a pMDI with spacer made any critical errors. The mean percentages of incorrect steps for the pMDI and pMDI with spacer were 34 and 22%, respectively, and for the DPIs (Turbuhaler, Diskus, and HandiHaler) were 14, 28, and 13%, respectively. In addition, the study demonstrated that 62% of the patients reported having received counseling, with 35% stating they had received counseling within the last 6 months [82]. Of the patients who had received counseling, 43% had been counseled by a pharmacist, and 57% had been counseled by a respiratory therapist, physician, nurse, or respirologist. Only 27% of the entire sample reported having previously received counseling from a pharmacist.

Ensuring there is clear communication between clinic staff and patients with COPD is vital for adherence to treatment and improving overall outcomes. Respiratory clinic staff are ideally situated to ensure that the patient is appropriately educated on the symptomatology of the disease, how to manage their disease, necessary lifestyle changes, and appropriate expectations of their treatment plan. The clinic staff can provide appropriate instructions to patients on how to properly use the devices they are prescribed, ensuring that patients understand better the long-term benefits of treatments. In addition, clinic staff can work with patients on necessary lifestyle modifications and medication regimens to ensure maximal opportunities for adherence. Finally, clinic staff can educate patients about the importance of self-monitoring of symptoms, which will help in determining any necessary dosage adjustments or other treatment changes.


Residents within the LTC continuum are frequently transitioned between care settings (Fig. 4) [76,101]. During these transitions, adverse events and avoidable complications commonly occur as a result of poor communication and coordination between caregivers, healthcare professionals, and patients. Older adults with multiple medical problems, cognitive deficits, or depression or other mental health problems are especially vulnerable to transition problems following a hospitalization.

Common transitional directions between care facilities in the long-term care (LTC) continuum. ‘Inpatient Rehabilitation Facilities (IRFs) specialize in intensive rehabilitation care aiming to help patients to function outside of an inpatient environment. Long-Term Acute Care Hospitals (LTACHs) specialize in the treatment of medically complex patients who require a prolonged length of stay (LOS) of at least 25 days. Both IRFs and LTACHs are classified as acute care hospitals and can be either freestanding or hospital-based facilities. Skilled Nursing Facilities (SNFs) are not considered hospitals and provide treatment and continuing observation of medically stable patients who require short-term skilled care (e.g., Medicare fully covers 20 days and 80% of days 21–100. Length of stay determined by medical necessity and response to therapy services) such as nursing or rehabilitation services in an institutional setting. Nearly 90% of the PAC [post-acute care] facilities are free standing, often located in nursing homes. The remainder are located in acute care hospitals and continuing care retirement communities’. Source: Reproduced with permission from [101].

The AMDA Transitions of Care in the Long-Term Care Continuum clinical practice guidelines identify several key problems associated with poor care transitions: hospital readmissions, medication errors, adverse events, communication deficiencies, and segmentation of primary medical care services [76]. These guidelines also characterize barriers to effective care transitions as occurring on three levels: the delivery system, the clinician, and the patient (Table 7). The underlying trend in these barriers is poor communication – between facilities, between care providers, and between providers and patients.

Table 7
Table 7:
Barriers to effective transitions of care in the long-term care continuum at the delivery system, clinician, and patient levels

Rehospitalization rates

An analysis of data from a Medicare claims database for seven states, comprising 42.5% of the total Medicare population, showed that among more than 26 million hospital admissions, 3.5% were indexed for COPD, with the majority (60.5%) of patients being discharged to home without care [102]. Jencks et al.[32] found that an index COPD hospitalization was associated with 4% of all rehospitalizations. The 30-day readmission rate for COPD hospitalizations is estimated at 20% at the national level [103] and for Medicare beneficiaries [32,102], with an 8% 30-day mortality rate [103]. The most common reasons for readmission in those with COPD are COPD, respiratory failure, pneumonia, CHF, and asthma [32,102]. Interestingly, patients with an index COPD hospitalization who were discharged to an SNF had the lowest 30-day readmission rates due to COPD and asthma [102], highlighting the importance of monitoring these patients after an exacerbation.

As COPD is often unrecognized and not one of the primary diagnoses of hospital admission, there is the potential for an increase in the actual COPD mortality and readmission rates [102,104], emphasizing that there should be a heightened index of suspicion for a diagnosis of COPD or asthma in elderly patients who have recurrent acute exacerbations and hospitalizations. The risk of hospital readmission for acute exacerbation of COPD increases with each hospital admission (Fig. 5) [105]. Using data from the Medicare Provider Analysis and Review file, Jencks et al.[32] found that index hospitalization diagnosis, number of previous hospitalizations, and length of hospital stay had more influence on the rehospitalization risk than demographic factors, including age, sex, race, supplemental security income status, and presence or absence of disability. The study mapped the geographic pattern of rehospitalization rates within 30 days after discharge in the United States (and two of its territories), which demonstrated a large disparity across states (Fig. 6). In fact, the rehospitalization rate was 45% higher in the five states with the highest rates than in the five states with the lowest rates. These findings emphasize the need for a comprehensive and uniform system for hospital discharge procedures and demonstrate that further study is needed to gauge the reasons for the difference across states.

Cumulative risk of successive hospital admissions for acute exacerbation of chronic obstructive pulmonary disease (COPD). Source: Reproduced with permission from [105].
Rates of rehospitalization within 30 days after hospital discharge. The rates include all patients in fee-for-service Medicare programs who were discharged between 1 October 2003 and 30 September 2004. The rate for Washington, DC, which does not appear on the map, was 23.2%. Source: Reproduced with permission from [32].

In the study by Jencks et al.[32], there was no outpatient bill for a physician visit for 50% of Medicare patients discharged to the community who were subsequently rehospitalized within 30 days, highlighting a significant deficiency in patient–provider communication posthospitalization. Both patients and physicians should be aware of the heightened risk of rehospitalization that occurs when there is a lack of communication after a hospital discharge, especially within the first 10 days, in which more than 90% of patients who were hospitalized did not have a bill for an outpatient physician visit (Fig. 7). Increased collaboration between hospitals and physicians is needed to improve the promptness and reliability of follow-up care.

Patients for whom there was no bill for an outpatient physician visit between discharge and rehospitalization. Data are for patients in fee-for-service Medicare programs who were discharged to the community between 1 January 2003 and 31 December 2003, after an index hospitalization for a medical condition. Data are derived from claims maintained in the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Source: Reproduced with permission from [32].

Compliance with federal regulations for nursing homes may create competing priorities with regard to COPD care in the LTC setting (e.g., F-tag F329 for unnecessary drugs and F20x for transfer/discharge [102]); however, in 2014, COPD was added to the Hospital Readmission Reduction Program (HRRP), a federal policy targeted to the Medicare population, which requires Centers for Medicare and Medicaid Services (CMS) to reduce payments to inpatient-prospective-payment-system hospitals with excess readmissions. The incidence rates of rehospitalization due to COPD may be affected by the diagnosis codes (used for the HRRP) assigned when the patient is admitted and discharged [106–108]. In an analysis of International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code algorithms for hospitalizations, Stein et al.[109] found that the prevalence of acute exacerbations of COPD in hospitalized patients ranged from 0.4 to 7.9%, depending on the restrictiveness of the stratum codes; this emphasizes significant potential for underestimation of the burden of hospitalizations for COPD exacerbations. Diagnostic code selection may be confounded by an emphasis on maximizing reimbursement. A trend of recoding patients was observed recently with the primary diagnosis of pneumonia, another condition included in the HRRP, with many pneumonia cases being coded as sepsis or respiratory failure [110], a practice that seems to reduce in-hospital pneumonia mortality, as well as improve Diagnosis-Related Group payments for such patients [111,112]. As COPD was recently added to the HRRP, a similar trend may prevail, with patients being coded with diagnoses that result in larger in-patient costs and reimbursements. In addition, COPD rehospitalization rates may be affected by competing reasons for hospitalization (other than COPD) because these SNF patients generally are sicker, with more comorbidities [102].

Certain interventions at the time of hospital discharge can sharply reduce rehospitalization rates [113–116]. One area of potential impact in reducing rehospitalization rates would be the provision of medication on discharge to enhance compliance. In a study of the effects of implementing multidose medication dispensing on discharge (MMDD) – a process in which a patient being discharged is given an appropriately labeled medication for outpatient use pursuant to a physician's order to continue the medication – on all-cause hospital readmissions [117], the percentage of patients readmitted within 30 days for any cause was statistically greater for the preintervention group (21%) versus the postintervention group (9%), resulting in a significant reduction in all-cause 30-day readmissions (odds ratio, 2.5) after MMDD implementation. All-cause 60-day readmission rates were 33% in the preintervention group and 23% in the postintervention group, with a significant reduction in risk after MMDD implementation (odds ratio, 1.8). Interestingly, MMDD implementation was associated with savings of over $20 000 in medication costs [117].

Importance of continuity of care in long-term care patients with chronic obstructive pulmonary disease

Continuity of care is important for LTC patients. Several underlying themes in the patients’ experience with continuity of care were identified in a meta-summary of qualitative studies in a wide variety of health conditions and care contexts [118]. Many patients want and expect to be involved and acknowledged in care decisions, specifically in communicating, monitoring, and self-management; however, patients who are not familiar with the health system, have low health literacy, or are simply not able to advocate for themselves are less likely to be willing or able to take on such a role. Patients prefer to receive a functional care plan that accounts for comorbidities and resource availability and describes how their health condition will likely change over time and what actions they can take (especially in situations when things go wrong). During transitions of care, patients often do not understand institutional and functional boundaries and find it difficult to actively negotiate the system. Breakdowns in communication between care providers defined patients’ experience of discontinuity in almost two-thirds of the studies included in the meta-summary [118].

Breakdowns in communication, including failure to transfer or use appropriate and updated information regarding comorbidities, life circumstances, and other physicians’ treatment decisions, force patients to repeat medical information to each care provider. An analysis of care transitions of older adults receiving long-term services and supports (LTSS) demonstrated that LTSS recipients and family caregivers had limited involvement in care transition discussions and that LTSS recipients were often uncertain and wanted more information about their care [119]. Over a third (37%) of LTSS recipients and family caregivers reported that no professional staff in the LTSS setting discussed with them the reason for hospital transfer, and nearly a third (30%) of LTSS recipients reported having no conversations with a hospital physician regarding acute medical conditions or planned treatments. During hospital stays, the involvement of LTSS recipients and caregivers with hospital physicians, nurses, and social workers was inconsistent and usually restricted [119].

Medication reconciliation/errors occur often and can lead to adverse events [120–124]. In a study of nursing home residents, investigators found that changes in medication are common during transfers between hospital and nursing home and are a cause of adverse events related to medication [120]. The average number of medication changes was significantly greater in the transition from nursing home to hospital than from hospital to nursing home [3.1 and 1.4 (not including new prescriptions), respectively], with discontinuations, dose changes, and class substitutions comprising the most common alterations. In 86% of transfers from nursing home to hospital and 64% of transfers from hospital to nursing home, at least one medication was changed. Overall, 21% of medication changes occurring at nursing home readmission were reversions to medications and dosages prescribed prior to hospital admission (of medications that were altered in the hospital) [120].

In a study of nursing home residents (mean age, 84 years) who were hospitalized in a tertiary care hospital and subsequently returned to the nursing home, Boockvar et al.[121] examined the effect of pharmacist-conducted medication reconciliation (i.e., the intervention) on the occurrence of discrepancy-related adverse events associated with medications ordered at the time of a resident's return to the nursing home. A total of 11 adverse events associated with medication discrepancies were identified after a return to the nursing home following hospitalization, five of which were first observed during the transition from the nursing home to the hospital and six of which were first observed during the transition from hospital to nursing home. The incidence of discrepancy-related adverse events in the preintervention and postintervention groups was 14.5 and 2.3%, respectively [121]. There was an average of 6.4 identified drug discrepancies for residents receiving pharmacist-conducted medication reconciliation; the most common types of discrepancies were omissions, additions, and dosage changes, and the most common drug classes involved were cardiovascular, neuropsychiatric, and analgesic/anti-inflammatory agents. As part of the study, pharmacists communicated medication discrepancies to the physician; however, only three-quarters (76%) of physicians signed and returned the medication reconciliation form. Of those acknowledging and returning the form, physicians responded to only 86% of the total identified prescribing discrepancies – with 72% indicating awareness of the discrepancy, 8% indicating intention to adjust the drug regimen, 7% indicating intention to review the drug regimen, and 4% indicating intention to initiate additional monitoring. Physicians ordered prescription changes that were (plausibly) related to 10% of the total identified discrepancies [121]. Notably, the nursing home in this study had an on-site pharmacy department, making it feasible to involve a pharmacist in medication reconciliation, which is not a current standard of care in all institutions; however, pharmacist-conducted medication reconciliation appears to significantly reduce medication discrepancies that could lead to adverse drug events.

Transferring relevant patient health information across transition locations is a key component of timely and appropriate patient care; however, LTC is behind most other settings in the adoption of health information technologies (HITs). Tools and systems have been proposed and evaluated; however, technological and standardization barriers have precluded widespread adoption of any single method for sharing important patient information between care facilities.

All Medicare-certified SNFs and HHAs [long-term postacute care facilities (LTPACs)] collect and transmit electronic patient assessment information (Minimum Data Set and Outcome and Assessment Information Set, respectively) to the CMS. A tool is now available that can intercept each electronic Minimum Data Set or Outcome and Assessment Information Set transmission to CMS and transform the transition-relevant clinical content into a standard Continuity of Care Document (CCD) (i.e., the KeyHIE Transform LTPAC-to-CCD translation tool). In a survey of 50 state health information exchanges (HIEs) [125], 38% of respondents were aware of the LTPAC-to-CCD translation tool and 83% indicated potential interest in the tool. All HIEs indicated that clinicians would most like to have information regarding medications and allergies included in the CCD, with most HIEs also indicating information on advance directives (88%), cognitive functioning (71%), pain status (67%), immunization (62%), family member/caregiver contact (58%), and activities of daily living (54%). Of HIEs expressing interest in the LTPAC-to-CCD translation tool, 95% anticipated it would lead to safer transitions across care setting, 86% to the inclusion of SNFs and HHAs in the health information ecology, 73% to less reliance on slower means of communication (e.g., paper forms, faxing), and 68% to patient and caregiver access to nursing home or HHA assessments. All respondents believed that insufficient technology, connectivity, and/or expertise at nursing homes and HHAs would be a barrier to effective implementation of the translation tool [125]. These results provide an initial foundation on which to develop a universal HIE tool and to integrate LTPAC patient assessment information into the health information ecology.

A 20-month pilot study conducted in five SNFs located within Oklahoma used HIT and secure messaging in LTC to facilitate electronic information exchange during transitions of care [126]. The HIT implemented was an electronic clinical documentation tool that was mounted on the wall outside residents’ rooms; information was bi-directional between the SNF and the state HIE, allowing acute care facilities to access SNF information as well as vice versa and was exchanged securely. Two standardized forms were used across facilities: a Situation/Background/Assessment/Recommendation document to record changes in patient status and a universal transfer form in the event that a resident required a transfer. Results demonstrated a decreasing trend over the course of the pilot in the rates of 30-day hospital readmission and return emergency department visits [126].

LTC facility priorities may compete with COPD care needs. An online survey of nursing facilities and RCFs examined the status of healthcare transition models currently being implemented to identify key barriers in reducing hospital admissions and readmissions [127]. Most nursing facility administrators (93%) affirmed being engaged in a program to reduce hospital admissions and readmissions, with 64% of RCFs affirming engagement. A larger proportion of nursing facility respondents indicated that residents are treated under a transitional care program compared with RCF respondents (39 versus 21%, respectively); in contrast, a larger proportion of RCF respondents indicated there was no plan to work on implementing a care transition intervention compared with nursing facility respondents (30 versus 5%, respectively). Nursing facilities also were more likely to report currently working on a transitional care model than were RCFs (34 versus 24%, respectively). Nursing facilities reported more partnerships, both formal and informal, than did RCFs, with RCFs reporting more informal partnerships than formal [127], highlighting the difference in accessibility to patient records and the continuum of care. Evidence-based practice models were being worked on or implemented by 72% of nursing facilities and 42% of RCFs, with the Interventions to Reduce Acute Care Transitions model as the most commonly indicated (64% of nursing facilities and 28% of RCFs). New or hybrid models were developed by 25% of RCFs and 17% of nursing facilities, and 45% of RCFs and 17% of nursing facilities reported not knowing which model, if any, provided the basis for their program [127]. The most frequently cited major barriers to care transition intervention implementation for both RCFs and nursing facilities reflected financial (e.g., reimbursement rates, additional funding for program implementation, and slow, inconsistent, or unreliable payment) and healthcare system culture issues (e.g., competition within the LTC community, differences in technology between facilities, and attitudes of healthcare providers toward nursing facilities and/or RCFs) [127].


Though a variety of guidelines for the treatment of COPD exist [3,24,35], recent literature has identified that many patients are not receiving the current standard of care. According to an analysis of a nationally representative sample of older adults (age ≥67 years) who participated in the Medicare Current Beneficiary Survey (1992–2002) [21], 70% of older adults diagnosed with COPD or asthma did not receive any respiratory pharmacotherapy. In addition, the analysis showed that only 13% of older adults with either COPD or asthma received at least one spirometry examination during the past year and 72% received influenza vaccinations as recommended by guidelines. As COPD is a heterogeneous condition that may or may not be progressive [3], regular assessment of disease severity through spirometry is of value every 1–3 years, unless a change in a patient's status is of concern or there exists the possibility of an alternative diagnosis to be considered.

A retrospective analysis of nursing home residents diagnosed with COPD suggested that bronchodilators, especially the long-acting forms, are underutilized in LTC settings [10]. In this analysis, 17% of nursing home residents diagnosed with COPD received no respiratory medications. Of residents filling a pharmacy claim for a COPD medication, more patients received nebulized SABA (49%) or SAMA (23%) medications compared with hand-held SABA (15%) and SAMA (2%) medications. Residents were also more likely to fill a prescription claim for hand-held LAMAs (22%) compared with hand-held LABAs (4%) and nebulized LABAs (2%) [10]. More than 20% of COPD patients experienced at least two acute exacerbations during the 12-month study, with as many as 60% not receiving hand-held LABA/ICS combination therapy [10]. Despite the prevalence of exacerbations requiring treatment with a respiratory antibiotic alone or with ICS, 28% of patients with COPD received inhaled LABA/ICS combination therapy as recommended by COPD guidelines [3,24].

Multiple studies show the value of long-acting bronchodilators as compared to short-acting bronchodilators in the maintenance treatment of COPD and the prevention of COPD exacerbations. A study by Bollu et al.[128] showed that patients receiving nebulized LABAs had a significantly lower readmission risk within 6 months following a COPD-related hospitalization versus patients treated with nebulized SABAs (hazard ratio, 0.53, i.e., 47% lower risk with nebulized LABAs). Patients in the nebulized LABA cohort had a longer time to readmission compared with patients in the nebulized SABA cohort [128].

Baker et al.[129] conducted an observational study to examine patterns of prescription fills for bronchodilator medications after a hospitalization for COPD (index) using claims data from the Truven Health MarketScan Commercial and Medicare Supplemental Research Databases. This study showed that 26% of patients with COPD did not fill any SABD or long-acting bronchodilator (LABD) prescriptions within the 90-day preindex period or within the 90-day postindex period, with 84% of those patients continuing to not fill an SABD or LABD prescription during the 91-day to 180-day postindex period. In addition, 43% of patients did not fill an LABD or SABD/LABD prescription during the entire 1-day to 180-day postindex period. Significantly more patients filled an LABD prescription in the 1-day to 90-day postindex period than in the 90-day preindex period (51 versus 41%) and more than in the 91-day to 180-day postindex period (51 versus 44%). These findings suggest that a significant number of COPD patients are not filling prescriptions for LABD medications, even after being hospitalized for COPD, with only 28% of patients initiating LABD (with or without SABD) treatment after hospitalization [129]. Interestingly, this analysis showed that patients who filled an LABD (with or without an SABD) prescription within the 90-day postindex period had higher rates of outpatient physician visits, emergency department visits, and hospitalizations in both the 90-day and 180-day postindex periods than did the group without a claim for an LABD. The authors suggest that this counterintuitive finding could be driven by care priority (e.g., other health concerns took precedence over COPD), by LABD prescriptions increasing these visits, or possibly by disease severity, in which those who filled an LABD prescription could have more severe COPD [129].

Underutilization of maintenance therapies by patients with COPD may lead to potentially avoidable hospitalizations [12,38,104,129], follow-up issues [12], rehospitalization [32], and insufficient knowledge of how and when to use treatment pro re nata (denoting ‘as needed’ or ‘as the situation arises’). According to updated guidance for LTC facility participation in the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents – Payment Reform (the Initiative) by the CMS [38], research shows that of the six conditions linked to approximately 80% of potentially avoidable hospitalizations among LTC facility residents – pneumonia, dehydration, CHF, urinary tract infection, skin ulcers/cellulitis, and COPD/asthma – COPD and asthma account for 6.5% of all potentially avoidable hospitalizations. These guidelines also indicate that the ability to provide nebulizer and/or respiratory therapy is one requirement for treating these conditions, namely COPD. The Initiative guidelines specifically identify AMDA tools as examples for documenting and communicating the early identification and treatment of a resident's change in condition, including hospital transfers; GOLD guidelines are not mentioned [38].

Physician factors contributing to suboptimal COPD management include understanding of and attitude toward the disease and awareness of disease management guidelines [11]. In addition, it is important for physicians to confidently and reliably distinguish COPD and asthma diagnoses. LTC staff cannot properly treat COPD without proper diagnosis, especially with asthma–COPD overlap and the convergence of these disease states with chronicity and advancing age [12,47–54].

Polypharmacy is very common in elderly COPD patients, and it is frequently unclear to which extent guidelines for individual diseases apply to such a complex patient [25]. Inappropriate prescribing in the elderly is an emerging health issue: specific to patients with COPD, issues such as inappropriate dose, formulation, duration and/or drug delivery, use of unnecessary medications, omission of necessary medications, and possible drug–drug interactions and adverse effects are all of increasing concern [130]. AMDA guidelines [24] have listed medications that are absolutely contraindicated in COPD (Table 8) as well as medications commonly used in chronic care with precautions for use in COPD patients (Table 9). The appropriateness of specific chronic medications with precautions in COPD is decided on an individual patient basis, and it is encouraged that those working with elderly patients with COPD weigh the risks and benefits of combining treatments based on the full health status of the specific patient.

Table 8
Table 8:
Medications that are absolutely contraindicated in chronic obstructive pulmonary disease
Table 9
Table 9:
Medications commonly used in chronic care with precautions for chronic obstructive pulmonary disease

Inappropriate medications can be detected using various screening tools assessing of the quality and safety of prescriptions (e.g., the screening tool of older persons’ potentially inappropriate prescription (STOPP) and the screening tool to alert doctors to the right treatment (START) (Table 10). Although Gooneratne et al. [130] suggests regular ICS usage in COPD when FEV1 is lower than 50% predicted, this is not a current recommendation for care in COPD and is not recommended here for the treatment of COPD in LTC residents.

Table 10
Table 10:
Inappropriate drug prescriptions for patients with chronic obstructive pulmonary disease: criteria for screening tool to alert doctors to the right treatment and screening tool of older persons’ potentially inappropriate prescription


From the perspective of the LTC facility, there are issues with insufficient resources in the LTC facility [131], inconsistent medication reconciliation [120–122,124], lack of robust and differential education of COPD (including recognition, diagnosis, treatment, and management) [132–135], and compliance with federal regulations [102].

Specific to LTC resources, about 67 000 paid, regulated LTC-service providers (i.e., nursing homes, RCFs, HHAs, hospices, and adult day service providers) served approximately 9 million people in the United States in 2014 [131]. LTC services were primarily provided by RCFs, followed by nursing homes, HHAs, adult day services providers, and hospices. More than 1.5 million nursing employee full-time equivalents and approximately 35 200 social work employee full-time equivalents worked in the five LTC sectors, serving roughly 9 million people in 2014. Average nursing staff hours per resident (or participant) per day were higher in nursing homes than in RCFs and adult day services centers for all types of nursing staff (i.e., registered nurses, licensed practical nurses, licensed vocational nurses, and aides) (Fig. 8). The average of total nursing hours per resident per day in nursing homes was more than twice the ratio for adult day services centers. In licensed nursing staff (i.e., registered nurses, licensed practical nurses, and licensed vocational nurses), the average hours per resident per day were 1.41 (1 h 25 min) for nursing home residents, 0.46 (28 min) for adult day services centers participants, and 0.37 (22 min) for RCF residents [131]. Most nursing homes (97.4%) and the majority of RCFs (82.4%) offered pharmacy or pharmacist services, compared with only 4.8% of HHAs (4.8%) [131].

Average hours per resident or participant per day, by sector and staff type: United States, 2014. ‘Notes: Only employees are included for all staff types; contract staff are not included. For adult day services centers and residential care communities, aides refer to certified nursing assistants, home health aides, homecare aides, personal care aides, personal care assistants, and medication technicians or medication aides. For home health agencies and hospices, aides refer to home health aides. For nursing homes, aides refer to certified nurse aides, medication aides, and medication technicians. Social workers include licensed social workers or persons with a bachelor's or master's degree in social work in adult day services centers and residential care communities; medical social workers in home health agencies and hospices; and qualified social workers in nursing homes. For adult day services centers, average hours per participant per day was computed by multiplying the number of full-time equivalent employees for the staff type by 35 h, divided by the average daily attendance of participants and by 5 days. For nursing homes and residential care communities, average hours per resident per day was computed by multiplying the number of full-time equivalent employees for the staff type by 35 h, divided by the number of current residents and by 7 days. Hours per patient per day could not be provided for home health agencies or hospices, because the administrative data available provided total number of all patients served in a year, not the number served on a given day, which is needed to produce this estimate. Sources: CDC/NCHS, National Study of Long-Term Care Providers and Table 2 in Appendix B’. Source: Reproduced with permission from [131].

The greater percentage of LTC service users are patients aged at least 65 years: 94.4% of hospice patients, 92.9% of RCF residents, 84.9% of nursing home residents, 82.6% of HHA patients, and 63.7% of participants in adult day services centers participants [131] (Fig. 9). Age composition varied by sector, with RCFs (52.6%), hospices (47.3%), and nursing homes (41.6%) serving more persons aged at least 85 years.

Percentage distribution of long-term care (LTC) service users, by sector and age group: United States, 2013 and 2014. ‘Notes: Denominators used to calculate percentages for adult day services centers, nursing homes, and residential care communities were the number of current participants enrolled in adult day services centers, the number of current residents in nursing homes, and the number of current residents in residential care communities in 2014, respectively. Denominators used to calculate percentages for home health agencies and hospices were the number of patients who received care from Medicare-certified home health agencies at any time in 2013 and the number of patients who received care from Medicare-certified hospices at any time in 2013, respectively. Percentages may not add to 100 because of rounding. Percentages are based on the unrounded numbers. Sources: CDC/NCHS, National Study of Long-Term Care Providers and Table 4 in Appendix B’. Source: Reproduced with permission from [131].

The CMS guidelines for the Initiative identify several services to increase and implement for decreasing the proportion of potentially avoidable hospitalizations, many of which are relevant for patients suffering from COPD:

  1. Purchasing of tools that aid in the early identification and treatment of changes in conditions (e.g., AMDA tools)
  2. Increased nursing (e.g., registered nurses) presence in the facility
  3. Enhanced training of existing staff (e.g., parenteral therapy including intravenous, intramuscular, subcutaneous fluids, or medications including antibiotics, complex wound care, etc.)
  4. Enhanced provision of nebulizer or respiratory therapy
  5. Health information technology solutions that support the creation, exchange, and/or reuse of interoperable assessment data, care plans, and data at times of transitions in care.

These guidelines aim to improve the quality of care for long-stay Medicare–Medicaid enrollees residing in LTC facilities by reducing avoidable hospitalizations; therefore, the services listed above are ultimately relevant for improving health outcomes and transitions of care, while simultaneously reducing cost for the same quality of care.


To ensure optimal patient management, effective care models should identify the right treatment for the right patient at the right time [129]. Although the GOLD guidelines provide general recommendations for the medication pathway for patients with COPD [3], specific recommendations are needed for COPD patients living in LTC facilities. A proposed algorithm by Dekhuijzen et al.[47] for deciding on the appropriate inhaler device begins with deciding whether or not the patient can inhale medication consciously, followed by whether or not the patient has sufficient PIFR and ending with whether or not the patient has adequate hand–lung coordination. In this algorithm, nebulizers are reserved for patients who cannot consciously inhale, as well as for patients who can consciously inhale but cannot generate a minimal respiratory flow and have poor hand–lung coordination.

The authors propose a potential treatment algorithm for patients with COPD in LTC settings, which focuses on three primary patient aspects to consider when deciding on medication and device: inspiratory flow, hand dexterity and coordination, and cognitive capacity (Fig. 10). The algorithm begins with a resident with diagnosed COPD or who has recurrent respiratory symptoms that could indicate a new diagnosis of COPD or could help to rediscover patients previously diagnosed with COPD but whose diagnosis may have been lost over the years due to numerous transfers between facilities (or some other breakdown of communication). Patients with PIFR of less than 60 l/min would be precluded from devices requiring higher flow rates (namely, DPIs), as would patients with poor dexterity and/or significant cognitive impairment. Patients should be monitored during treatment to verify proper inhaler technique, as well as to determine whether the medication is working.

Proposed COPD treatment algorithm for patients with COPD in long-term care (LTC) settings. BAI, breath-actuated inhaler; DPI, dry powder inhaler; pMDI+spacer, pressurized metered-dose inhaler with a spacer; pMDI, pressurized metered-dose inhaler; COPD, chronic obstructive pulmonary disease; SMI, soft mist inhaler.

Managing patients with chronic obstructive pulmonary disease in long-term care

The authors would like to acknowledge that many more concerns exist within the spectrum of care for LTC residents with COPD that were not discussed in detail in this supplement. Advance care planning is a critical step in all LTC patients and an important part of the evaluation and treatment of these patients. In addition, a thorough assessment of comorbidities, impairments, and current medications should be performed in all LTC patients when considering the appropriate type and delivery of treatment for their COPD. Lastly, there are several nonpharmacological approaches to COPD treatment that may be of benefit to LTC patients, including exercise training, nutritional counseling, education, psychological support, and pulmonary rehabilitation.


The quality of care for LTC residents with COPD is heterogeneous in regard to both the patient and the facility. For patients, care should be driven by appropriate diagnosis, symptom severity, and comorbidities. For facilities, care should be driven by staff education, interstaff communication, and interfacility communication. Appropriate treatment for LTC residents with COPD ultimately needs to be based on patient preference, patient's ability to perform treatment, and patient prognosis. It is the consensus of this group that nebulization should be used for LTC patients with low PIFR, cognitive impairment, and/or physical impairment, which may preclude them from using other inhalation devices. In addition, given that COPD is major cause of morbidity and mortality and can result in economic and social burden, LTC facilities should put more emphasis on acknowledging and addressing COPD, which in turn may improve health outcomes, improve quality of life, and lower patient/facility costs.



Financial support and sponsorship

This supplement was funded by Mylan Pharmaceuticals.

Conflicts of interest

Writing and editorial support were provided by Nicole Coolbaugh and David S. Berger, PhD, with HealthLogiX (Parsippany, New Jersey) with funding from Mylan Pharmaceuticals.

M.S.-B. has received payments for his study efforts involving board membership: Mylan Pharmaceuticals and Sunovion Pharmaceuticals; involving consultancy: Merck, Mylan Pharmaceuticals, and Sunovion Pharmaceuticals; involving lectures: Mylan Pharmaceuticals and Sunovion Pharmaceuticals; involving travel support to attend meetings for study or other purposes: Mylan Pharmaceuticals; and for provision of writing assistance, medicines, equipment, or administrative support: HealthLogiX. J.L.M. has received consultancy fees from Mylan Pharmaceuticals. G.T.F. receives consulting fees from Mylan Pharmaceuticals and his institution has received payments from the following companies based on his study efforts involving board membership: Astra Zeneca, Pearl Therapeutics, Boehringer Ingelheim, Sunovion Pharmaceuticals, Novartis, Innoviva, Verona Pharma; involving consultancy: Astra Zeneca, Pearl Therapeutics, Boehringer Ingelheim, Sunovion Pharmaceuticals, Novartis, Theravance Biopharma, Forest Laboratories, Inc.; and involving development of educational presentations: Astra Zeneca, Boehringer Ingelheim. S.C. has received consulting fees from Mylan Pharmaceuticals and payment from the American Society of Consultant Pharmacists for development of educational presentations.

Appendix A. The Chronic Obstructive Pulmonary Disease Assessment Test


Freely available from Accessed 1 May 2017.

Appendix B. The Modified Medical Research Council Dyspnea Scalea



1. National Institutes of Health (NIH). Long-term care – frequently asked questions. 2015. [Accessed 8 February 2017]
2. Centers for Disease Control and Prevention (CDC). Nursing homes and assisted living (long-term care facilities [LTCFs]). [Accessed 15 February 2017]
3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2017 report). 2016. [Accessed 16 December 2016]
4. Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 Report: GOLD Executive Summary. Eur Respir J 2017; 49:1700214.
5. Mayo Clinic. COPD symptoms and causes. [Accessed 15 February 2017].
6. National Institutes of Health (NIH) National Heart L, and Blood Institute (NHLBI). What is COPD? [Accessed 15 February 2017].
7. Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease (COPD) – data and statistics – COPD death rates in the United States; 2016. [Accessed 16 December 2016]
8. Wheaton AG, Ford ES, Cunningham TJ, Croft JB. Chronic obstructive pulmonary disease, hospital visits, and comorbidities: National Survey of Residential Care Facilities, 2010. J Aging Health 2015; 27:480–499.
9. Centers for Medicare & Medicaid Services. Physical and mental health condition prevalence and comorbidity among fee-for-service Medicare-Medicaid enrollees. 2014. [Accessed 16 December 2016].
10. Zarowitz BJ, O'Shea T. Chronic obstructive pulmonary disease: prevalence, characteristics, and pharmacologic treatment in nursing home residents with cognitive impairment. J Manag Care Pharm 2012; 18:598–606.
11. Cooke CE, Sidel M, Belletti DA, Fuhlbrigge AL. Review: clinical inertia in the management of chronic obstructive pulmonary disease. COPD 2012; 9:73–80.
12. Donner CF, Virchow JC, Lusuardi M. Pharmacoeconomics in COPD and inappropriateness of diagnostics, management and treatment. Respir Med 2011; 105:828–837.
13. Lamprecht B, Soriano J, Studnicka M, et al. Determinants of underdiagnosis of COPD in national and international surveys. Chest 2015; 148:971–985.
14. Lindberg A, Jonsson AC, Ronmark E, et al. Prevalence of chronic obstructive pulmonary disease according to BTS, ERS, GOLD and ATS criteria in relation to doctor's diagnosis, symptoms, age, gender, and smoking habits. Respiration 2005; 72:471–479.
15. Singh G, Zhang W, Kuo YF, Sharma G. Association of psychological disorders with 30-day readmission rates in patients with COPD. Chest 2016; 149:905–915.
16. van Dam van Isselt EF, Spruit M, Groenewegen-Sipkema KH, et al. Geriatric rehabilitation for patients with advanced chronic obstructive pulmonary disease: a naturalistic prospective cohort study on feasibility and course of health status. Chron Respir Dis 2014; 11:111–119.
17. Fragoso CA. Epidemiology of chronic obstructive pulmonary disease (COPD) in aging populations. COPD 2016; 13:125–129.
18. Hung WW, Wisnivesky JP, Siu AL, Ross JS. Cognitive decline among patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2009; 180:134–137.
19. Schlitzer J, Haubaum S, Frohnhofen H. Treatment of chronic obstructive pulmonary disease in hospitalized geriatric patients. Z Gerontol Geriatr 2014; 47:288–292.
20. Taffet GE, Donohue JF, Altman PR. Considerations for managing chronic obstructive pulmonary disease in the elderly. Clin Interv Aging 2014; 9:23–30.
21. Craig BM, Kraus CK, Chewning BA, Davis JE. Quality of care for older adults with chronic obstructive pulmonary disease and asthma based on comparisons to practice guidelines and smoking status. BMC Health Serv Res 2008; 8:144.
22. Torres-Sanchez I, Rodriguez-Alzueta E, Cabrera-Martos I, et al. Cognitive impairment in COPD: a systematic review. J Bras Pneumol 2015; 41:182–190.
23. Zimmerman S, Sloane PD, Reed D. Dementia prevalence and care in assisted living. Health Aff (Millwood) 2014; 33:658–666.
24. AMDA – The Society for Post-Acute, Long-Term Care MedicineCOPD management in the postacute and long-term care setting clinical practice guideline. Columbia, MD: AMDA; 2016.
25. Incalzi RA, Scarlata S, Pennazza G, et al. Chronic obstructive pulmonary disease in the elderly. Eur J Intern Med 2014; 25:320–328.
26. Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet 2007; 370:786–796.
27. Sharafkhaneh A, Altan AE, Colice GL, et al. A simple rule to identify patients with chronic obstructive pulmonary disease who may need treatment reevaluation. Respir Med 2014; 108:1310–1320.
28. Hurst JR, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med 2010; 363:1128–1138.
29. Laurin C, Moullec G, Bacon SL, Lavoie KL. Impact of anxiety and depression on chronic obstructive pulmonary disease exacerbation risk. Am J Respir Crit Care Med 2012; 185:918–923.
30. Rizkallah J, Man SFP, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2009; 135:786–793.
31. Wells JM, Dransfield MT. Pathophysiology and clinical implications of pulmonary arterial enlargement in COPD. Int J Chron Obstruct Pulmon Dis 2013; 8:509–521.
32. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418–1428.
33. Jones PW, Harding G, Berry P, et al. Development and first validation of the COPD Assessment Test. Eur Respir J 2009; 34:648–654.
34. Hajiro T, Nishimura K, Tsukino M, et al. Analysis of clinical methods used to evaluate dyspnea in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 158:1185–1189.
35. Aliotta S, Mullen A. CMAG case management adherence guidelines, version 1.0, chronic obstructive pulmonary disease; 2010. [Accessed 7 February 2017].
36. Fletcher CM, Elmes PC, Fairbairn AS, Wood CH. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br Med J 1959; 2:257–266.
37. Goel M, Saba E, Stiber M, et al. SpiroCall: Measuring lung function over a phone call. In Proceedings of the 2016 CHI Conference on Human Factors in Computing Systems (CHI ’16). ACM, New York, NY, USA, 5675–5685. doi:
38. Centers for Medicare & Medicaid Services. Updated guidance for long-term care (LTC) facility participation in the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents – payment reform; 2016. [Accessed 12 December 2016].
39. Jones RC, Dickson-Spillmann M, Mather MJ, et al. Accuracy of diagnostic registers and management of chronic obstructive pulmonary disease: the Devon primary care audit. Respir Res 2008; 9:62.
40. Labor M, Vrbica Z, Gudelj I, et al. Exhaled breath temperature as a novel marker of future development of COPD: results of a follow-up study in smokers. COPD 2016; 13:741–749.
41. Marin JM, Carrizo SJ, Casanova C, et al. Prediction of risk of COPD exacerbations by the BODE index. Respir Med 2009; 103:373–378.
42. Mittal R, Chhabra SK. GOLD classification of COPD: discordance in criteria for symptoms and exacerbation risk assessment. COPD 2017;14:1–6.
43. Slok AH, Bemelmans TC, Kotz D, et al. The Assessment of Burden of COPD (ABC) scale: a reliable and valid questionnaire. COPD 2016; 13:431–438.
44. Middle East Technical University. METU Department of Industrial Design. 2012–2013 Graduation Projects – ‘Spiro-Plus’. 2013. [Accessed 15 January 2017].
45. Berk. SPIRO-PLUS. 2016. [Accessed 15 January 2017].
46. Chen YW, Leung JM, Sin DD. A systematic review of diagnostic biomarkers of COPD exacerbation. PLoS One 2016; 11:e0158843.
47. Dekhuijzen PN, Vincken W, Virchow JC, et al. Prescription of inhalers in asthma and COPD: towards a rational, rapid and effective approach. Respir Med 2013; 107:1817–1821.
48. Ejiofor S, Turner AM. Pharmacotherapies for COPD. Clin Med Insights Circ Respir Pulm Med 2013; 7:17–34.
49. Gao Y, Zhai X, Li K, et al. Asthma COPD overlap syndrome on CT densitometry: a distinct phenotype from COPD. COPD 2016; 13:471–476.
50. Kaplan AG. Applying the wisdom of stepping down inhaled corticosteroids in patients with COPD: a proposed algorithm for clinical practice. Int J Chron Obstruct Pulmon Dis 2015; 10:2535–2548.
51. Louie S, Zeki AA, Schivo M, et al. The asthma-chronic obstructive pulmonary disease overlap syndrome: pharmacotherapeutic considerations. Expert Rev Clin Pharmacol 2013; 6:197–219.
52. Nakawah MO, Hawkins C, Barbandi F. Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome. J Am Board Fam Med 2013; 26:470–477.
53. Page C, Cazzola M. Bifunctional drugs for the treatment of asthma and chronic obstructive pulmonary disease. Eur Respir J 2014; 44:475–482.
54. Postma DS, Rabe KF. The asthma-COPD overlap syndrome. N Engl J Med 2015; 373:1241–1249.
55. Gibson PG, McDonald VM. Asthma-COPD overlap 2015: now we are six. Thorax 2015; 70:683–691.
56. Alshabanat A, Zafari Z, Albanyan O, et al. Asthma and COPD Overlap Syndrome (ACOS): a systematic review and meta analysis. PLoS One 2015; 10:e0136065.
57. Ferguson G, Make B. Up to Date. Management of stable chronic obstructive pulmonary disease. 2016. [Accessed 7 February 2017].
58. Andreeva-Gateva PA, Stamenova E, Gatev T. The place of inhaled corticosteroids in the treatment of chronic obstructive pulmonary disease: a narrative review. Postgrad Med 2016; 128:474–484.
59. Mattishent K, Thavarajah M, Blanco P, et al. Meta-review: adverse effects of inhaled corticosteroids relevant to older patients. Drugs 2014; 74:539–547.
60. Singh S, Loke YK. An overview of the benefits and drawbacks of inhaled corticosteroids in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2010; 5:189–195.
61. Wedzicha JA, Calverley PM, Seemungal TA, et al. The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide. Am J Respir Crit Care Med 2008; 177:19–26.
62. Singh S, Amin AV, Loke YK. Long-term use of inhaled corticosteroids and the risk of pneumonia in chronic obstructive pulmonary disease: a meta-analysis. Arch Intern Med 2009; 169:219–229.
63. Drummond MB, Dasenbrook EC, Pitz MW, et al. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA 2008; 300:2407–2416.
64. Calverley PMA, Stockley RA, Seemungal TAR, et al. Reported pneumonia in patients with COPD: findings from the INSPIRE study. Chest 2011; 139:505–512.
65. Thornton Snider J, Luna Y, Wong KS, et al. Inhaled corticosteroids and the risk of pneumonia in Medicare patients with COPD. Curr Med Res Opin 2012; 28:1959–1967.
66. Crim C, Calverley PM, Anderson JA, et al. Pneumonia risk in COPD patients receiving inhaled corticosteroids alone or in combination: TORCH study results. Eur Respir J 2009; 34:641–647.
67. Suissa S, Coulombe J, Ernst P. Discontinuation of inhaled corticosteroids in COPD and the risk reduction of pneumonia. Chest 2015; 148:1177–1183.
68. Chong J, Leung B, Poole P. Phosphodiesterase 4 inhibitors for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2013. CD002309.
69. Ramos FL, Criner GJ. Use of long-term macrolide therapy in chronic obstructive pulmonary disease. Curr Opin Pulm Med 2014; 20:153–158.
70. Fromer L, Goodwin E, Walsh J. Customizing inhaled therapy to meet the needs of COPD patients. Postgrad Med 2010; 122:83–93.
71. Rogliani P, Calzetta L, Coppola A, et al. Optimizing drug delivery in COPD: The role of inhaler devices. Respir Med 2017; 124:6–14.
72. van der Palen J, Thomas M, Chrystyn H, et al. A randomised open-label cross-over study of inhaler errors, preference and time to achieve correct inhaler use in patients with COPD or asthma: comparison of ELLIPTA with other inhaler devices. NPJ Prim Care Respir Med 2016; 26:16079.
73. Melzer AC, Ghassemieh BJ, Gillespie SE, et al. Patient characteristics associated with poor inhaler technique among a cohort of patients with COPD. Respir Med 2017; 123:124–130.
74. Molimard M, Raherison C, Lignot S, et al. Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients. Eur Respir J 2017; 49:1601794.
75. Chrystyn H, van der Palen J, Sharma R, et al. Device errors in asthma and COPD: systematic literature review and meta-analysis. NPJ Prim Care Respir Med 2017; 27:22.
76. American Medical Directors Association. Transitions of Care in the Long-Term Care Continuum Clinical Practice Guideline. Columbia, MD: AMDA; 2010.
77. Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in elderly patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm 2011; 68:1221–1232.
78. Fraser M, Patel M, Norkus EP, Whittington C. The role of cognitive impairment in the use of the Diskus inhaler. J Am Med Dir Assoc 2012; 13:390–393.
79. Aggarwal B, Gogtay J. Use of pressurized metered dose inhalers in patients with chronic obstructive pulmonary disease: review of evidence. Expert Rev Respir Med 2014; 8:349–356.
80. Alhaddad B, Smith FJ, Robertson T, et al. Patients’ practices and experiences of using nebuliser therapy in the management of COPD at home. BMJ Open Respir Res 2015; 2:e000076.
81. Arora P, Kumar L, Vohra V, et al. Evaluating the technique of using inhalation device in COPD and bronchial asthma patients. Respir Med 2014; 108:992–998.
82. Batterink J, Dahri K, Aulakh A, Rempel C. Evaluation of the use of inhaled medications by hospital inpatients with chronic obstructive pulmonary disease. Can J Hosp Pharm 2012; 65:111–118.
83. Braido F, Chrystyn H, Baiardini I, et al. Trying, but failing – the role of inhaler technique and mode of delivery in respiratory medication adherence. J Allergy Clin Immunol Pract 2016; 4:823–832.
84. Bryant J, McDonald VM, Boyes A, et al. Improving medication adherence in chronic obstructive pulmonary disease: a systematic review. Respir Res 2013; 14:109.
85. Capstick TG, Clifton IJ. Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma. Expert Rev Respir Med 2012; 6:91–101.
86. Lareau SC, Hodder R. Teaching inhaler use in chronic obstructive pulmonary disease patients. J Am Acad Nurse Pract 2012; 24:113–120.
87. van Boven JF, Tommelein E, Boussery K, et al. Improving inhaler adherence in patients with chronic obstructive pulmonary disease: a cost-effectiveness analysis. Respir Res 2014; 15:66.
88. Bender BG. Nonadherence in chronic obstructive pulmonary disease patients: what do we know and what should we do next? Curr Opin Pulm Med 2014; 20:132–137.
89. Virchow JC, Akdis CA, Darba J, et al. A review of the value of innovation in inhalers for COPD and asthma. J Mark Access Health Policy 2015; 3:28760.
90. Bjermer L. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration 2014; 88:346–352.
91. Melani AS, Paleari D. Maintaining control of chronic obstructive airway disease: adherence to inhaled therapy and risks and benefits of switching devices. COPD 2016; 13:241–250.
92. Beatty CR, Flynn LA, Costello TJ. The impact of health literacy level on inhaler technique in patients with chronic obstructive pulmonary disease. J Pharm Pract 2017; 30:25–30.
93. Calverley PM. COPD: early detection and intervention. Chest 2000; 117:365S–371S.
94. Wilkinson TM, Donaldson GC, Hurst JR, et al. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004; 169:1298–1303.
95. Takemura M, Mitsui K, Itotani R, et al. Relationships between repeated instruction on inhalation therapy, medication adherence, and health status in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2011; 6:97–104.
96. Tan JY, Chen JX, Liu XL, et al. A meta-analysis on the impact of disease-specific education programs on health outcomes for patients with chronic obstructive pulmonary disease. Geriatr Nurs 2012; 33:280–296.
97. VanderSchaaf K, Olson KL, Billups S, et al. Self-reported inhaler use in patients with chronic obstructive pulmonary disease. Respir Med 2010; 104:99–106.
98. Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med 2008; 102:593–604.
99. Melani AS, Canessa P, Coloretti I, et al. Inhaler mishandling is very common in patients with chronic airflow obstruction and long-term home nebuliser use. Respir Med 2012; 106:668–676.
100. Pascual S, Feimer J, De Soyza A, et al. Preference, satisfaction and critical errors with Genuair and Breezhaler inhalers in patients with COPD: a randomised, cross-over, multicentre study. NPJ Prim Care Respir Med 2015; 25:15018.
101. Society of Hospital Medicine. Overview – Post-Acute Care Transitions Toolkit.–46db-a00f-89f07f021958. [Accessed 7 February 2017].
102. Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest 2015; 147:1219–1226.
103. Medicare. Readmissions and Deaths – National. [Accessed 16 December 2016].
104. Ouslander JG, Diaz S, Hain D, Tappen R. Frequency and diagnoses associated with 7- and 30-day readmission of skilled nursing facility patients to a nonteaching community hospital. J Am Med Dir Assoc 2011; 12:195–203.
105. Hunter LC, Lee RJ, Butcher I, et al. Patient characteristics associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (COPD) following primary care COPD diagnosis: a cohort study using linked electronic patient records. BMJ Open 2016; 6:e009121.
106. Marcus P, Braman SS. International classification of disease coding for obstructive lung disease: does it reflect appropriate clinical documentation? Chest 2010; 138:188–192.
107. O’Malley KJ, Cook KF, Price MD, et al. Measuring diagnoses: ICD code accuracy. Health Serv Res 2005; 40:1620–1639.
108. Stein BD, Charbeneau JT, Lee TA, et al. Hospitalizations for acute exacerbations of chronic obstructive pulmonary disease: how you count matters. COPD 2010; 7:164–171.
109. Stein BD, Bautista A, Schumock GT, et al. The validity of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for identifying patients hospitalized for COPD exacerbations. Chest 2012; 141:87–93.
110. Lindenauer PK, Lagu T, Shieh MS, et al. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003–2009. JAMA 2012; 307:1405–1413.
111. Rothberg MB, Pekow PS, Priya A, Lindenauer PK. Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis. Ann Intern Med 2014; 160:380–388.
112. Sjoding MW, Iwashyna TJ, Dimick JB, Cooke CR. Gaming hospital-level pneumonia 30-day mortality and readmission measures by legitimate changes to diagnostic coding. Crit Care Med 2015; 43:989–995.
113. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006; 166:1822–1828.
114. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 2004; 52:675–684.
115. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009; 150:178–187.
116. Voss R, Gardner R, Baier R, et al. The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med 2011; 171:1232–1237.
117. Blee J, Roux RK, Gautreaux S, et al. Dispensing inhalers to patients with chronic obstructive pulmonary disease on hospital discharge: effects on prescription filling and readmission. Am J Health Syst Pharm 2015; 72:1204–1208.
118. Haggerty JL, Roberge D, Freeman GK, Beaulieu C. Experienced continuity of care when patients see multiple clinicians: a qualitative metasummary. Ann Fam Med 2013; 11:262–271.
119. Toles MP, Abbott KM, Hirschman KB, Naylor MD. Transitions in care among older adults receiving long-term services and supports. J Gerontol Nurs 2012; 38:40–47.
120. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004; 164:545–550.
121. Boockvar KS, Carlson LaCorte H, Giambanco V, et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother 2006; 4:236–243.
122. Chhabra PT, Rattinger GB, Dutcher SK, et al. Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 2012; 8:60–75.
123. Desai R, Williams CE, Greene SB, et al. Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. Am J Geriatr Pharmacother 2011; 9:413–422.
124. Eisenhower C. Impact of pharmacist-conducted medication reconciliation at discharge on readmissions of elderly patients with COPD. Ann Pharmacother 2014; 48:203–208.
125. Hassol A, Goodman L, Younkin J, et al. Survey of state health information exchanges regarding inclusion of Continuity of Care Documents for long-term postacute care (LTPAC) patient assessment. Perspect Health Inf Manag 2014; 11:1g.
126. Yeaman B, Ko KJ, Alvarez del Castillo R. Care transitions in long-term care and acute care: health information exchange and readmission rates. Online J Issues Nurs 2015; 20:5.
127. Berish DE, Applebaum R, Straker JK. The residential long-term care role in healthcare transitions. J Appl Gerontol 2016; Nov 1. doi: 10.1177/0733464816677188. [Epub ahead of print].
128. Bollu V, Guerin A, Gauthier G, et al. Readmission risk in chronic obstructive pulmonary disease patients: comparative study of nebulized beta2-agonists. Drugs Real World Outcomes 2017; 4:33–41.
129. Baker CL, Zou KH, Su J. Long-acting bronchodilator use after hospitalization for COPD: an observational study of health insurance claims data. Int J Chron Obstruct Pulmon Dis 2014; 9:431–439.
130. Gooneratne NS, Patel NP, Corcoran A. Chronic obstructive pulmonary disease diagnosis and management in older adults. J Am Geriatr Soc 2010; 58:1153–1162.
131. Harris-Kojetin L, Sengupta M, Park-Lee E, et al. Long-term care providers and services users in the United States: data from the National Study of Long-Term Care Providers, 2013–2014. Vital Health Stat 2016; 3:x–xii. 1–105.
132. Kshatriya RM, Khara NV, Paliwal RP, Patel SN. Evaluation of proficiency in using different inhaler devices among intern doctors. J Family Med Prim Care 2016; 5:362–366.
133. Lathia A, Rothberg M, Heflin M, et al. Effect of a novel interdisciplinary teaching program in the care-continuum on medical student knowledge and self-efficacy. J Am Med Dir Assoc 2015; 16:848–854.
134. Sancar M, Sirinoğlu Y, Okuyan B, et al. The effect of pharmacist-led education on inhaler use skills in hospitalised patients with chronic obstructive pulmonary disease. Eur J Hosp Pharm 2015; 22:366–368.
135. White HK. The nursing home in long-term care education. J Am Med Dir Assoc 2008; 9:75–81.

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