Factors associated with appropriate inhaler use in patients with COPD – lessons from the REAL survey

Figures & data

Table 1 Key assessments used in the REAL survey

Question	Variable
Confidence in taking a full dose	Very low confidence
	Low confidence
	Neither high nor low confidence
	Confident
	Very confident
Inhaling correct dose Self-reported adherence	Number of inhalations/puffs
	Patients were considered fully adherent if
	they reported having taken their medication
	every day within the last 30 days
Ease of use	Very difficult
	Somewhat difficult
	Neither difficult nor easy
	Somewhat easy
	Very easy
Did you ever receive any training on how to use the device?	Yes
	If Yes, how did the patient receive training:
	Leaflet
	IFU
	Video
	Demonstration
	Other
	No
Training effectiveness (helpfulness of specific methods mentioned by patient)	Very unhelpful
	Somewhat unhelpful
	Neither helpful nor unhelpful
	Somewhat helpful
	Very helpful

Abbreviations: IFU, instructions for use; REAL, Real-life Experience and Accuracy of inhaler use.

Table 2 Patient demographics

Inhaler	Total	Germany	the Netherlands	Brazil	Japan	France	Italy	UK	USA	Canada
Breezhaler®a	n=186	37	17	36	17	27	22	15	0a	15
Ellipta^®	n=191	19	10	28	12	26	24	22	25	25
Genuair®b	n=194	35	20	0b	17	0b	23	32	33	34
Respimat^®	n=201	22	6	24	26	26	23	19	27	28
Total	n=764c	110c	53	88	70c	77c	92	87c	85	102
Demographics
Sex
Male	51%	50%	47%	24%	81%	47%	59%	61%	48%	50%
Female	49%	50%	53%	76%	19%	53%	41%	39%	52%	50%
Age, years
Mean	56	60	57	48	56	57	55	56	55	57
40–49	31%	17%	21%	65%	36%	25%	33%	31%	28%	24%
50–59	33%	26%	38%	19%	24%	34%	39%	30%	44%	39%
60–69	26%	40%	36%	15%	33%	30%	20%	26%	20%	22%
70–75	10%	16%	6%	1%	7%	12%	9%	13%	8%	16%
Severity of COPD
Mild	26%	13%	42%	24%	43%	17%	27%	36%	13%	29%
Moderate	55%	47%	51%	48%	53%	58%	52%	55%	71%	61%
Severe	15%	26%	8%	25%	4%	21%	17%	9%	14%	8%
Very severe	4%	14%	0%	3%	0%	4%	3%	0%	2%	2%
Time since COPD diagnosis, years
Mean	4.7	7.3	4.2	3.6	5.0	4.9	5.0	4.8	3.4	3.4
COPD diagnosis by
General physician/primary care physician	32%	15%	47%	26%	39%	16%	33%	37%	53%	37%
Pulmonologist	68%	85%	53%	74%	61%	84%	67%	63%	47%	63%

Notes:

a There were no US Breezhaler patients included in the study as the therapy was not available at the time of the survey in the US

b there were no Brazil or France Genuair patients included in the study as the therapy was not available at the time of the survey in Brazil or France

c Total number of patients was lower than sum of patients by device as some patients were using multiple devices.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Figure 1 Length of use by device.

Table 3 Patient disease severity and age

		Age group
		40–49 years n=236		50–59 years n=248		60–69 years n=202		70–75 years n=78
		n	%	n	%	n	%	n	%
Severity	Mild	81a	34	62	25	39	19	15	19
	Moderate	126	53	152b	61	109	54	34	44
	Severe	27	11	30	12	43c	21	18d	23
	Very severe	2	1	4	2	11	5	11e	14

Notes:

a p=0.001 (comparison to 60–69 years);

b p=0.006 (comparison to 70–75 years);

c p=0.005 (comparison to 40–49 years);

d p=0.011 (comparison to 40–49 years);

e p=0.001 (comparison to 40–49 and 50–59 years).

Table 4 Patient adherence

		Adherent n=539		Nonadherent n=225		p-value
		n	%	n	%
Gender	Male	276	51	117	52	p=0.841
	Female	263	49	108	48
Age	≤65 years	412	76	189	84	p=0.020
	>65 years	127	24	36	16
Severity	Mild	141	26	56	25	p=0.711
	Moderate	288	53	133	59	p=0.150
	Severe	86	16	32	14	p=0.549
	Very severe	24	4	4	2	p=0.073
Time since diagnosis	Newly diagnosed (≤12 months)	81	15	45	20	p=0.091
	Long time diagnosis (>12 months)	458	85	180	80

Table 5 Trained and untrained patient influencers

		Trained patients n=535		Untrained patients n=225		p-value
		n	%	n	%
Adherence	Compliant	356	67	181	80	p=0.001
	Noncompliant	179	33	44	20
Confidence that full dose has been taken	Low confidence	15	3	17	8	p=0.003
	Neutral	53	10	43	19	p=0.001
	Confident	467	87	165	73	p=0.001
Correct dosing	Correct dosing	448	84	180	80	p=0.215

Figure 2 Patient preferences for using different training methods.

Abbreviation: IFU, instructions for use.

Table 6 Adherence and optimal inhaler use in checked and unchecked patients

		Checked patients n=524		Unchecked patients n=240		p-value
		n	%	n	%
Adherence	Compliant	383	73	156	65	p=0.020
	Noncompliant	141	27	84	35
Confidence that full dose has been taken	Low confidence	18	3	14	6	p=0.123
	Neutral	50	10	46	19	p=0.001
	Confident	456	87	180	75	p=0.001
Correct dosing	Correct dosing	426	81	205	85	p=0.165

Table 7 Patient-reported confidence of taking full and self-reported correct dose

Parameter	Breezhaler^®	Ellipta^®	Genuair^®	Respimat^®
Confident or very confident of having taken the full dose	93%	80%	84%	76%
“When you think you feel you have not had a full dose, what do you typically do? – I inhale another dose at the same time”	4%	25%	33%	15%
Patients taking correct dosea	97%	93%	91%	50%

Notes:

a Correct dose for Breezhaler and Ellipta represents one puff per dose each day; for Genuair, one puff per dose twice a day; for Respimat, two puffs per dose each day.

Figure 3 Self-reported adherence with COPD medication in last 30 days.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Figure 4 Proportion of device correct dosing.