Prompt treatment of chronic obstructive pulmonary disease (COPD) exacerbations with oral steroids and/or antibiotics, ideally within 3 days of onset of symptoms, can decrease the severity and duration of exacerbations and may reduce the risk of COPD hospitalizations. One approach to accomplishing early treatment is to use a supported self-management program that includes an action plan with a home prescription for steroids and/or antibiotics. However, recent studies suggest that supported self-management programs may not be appropriate for the majority of COPD patients, and may in fact be harmful. Therefore, a new approach is needed that does not rely on patient self-management. This study will examine Veterans' care-seeking behaviors focusing on Veterans perceived need for care and perceived access to care and how these factors delay seeking care for COPD exacerbations, increasing the risk for hospitalizations. This study will also evaluate one novel approach of identifying early exacerbations through the use of a remote inhaler monitoring system. There is little data on the factors that influence when patients decide to seek care. To obtain this needed data, this study will enroll a cohort of 410 Veterans with COPD at high-risk for exacerbations and follow every patient for 1 year.
The Specific Aims are: 1) Examine the barriers to seeking care for COPD exacerbations or worsening breathing; 2) Test the use of a real-time remote inhaler monitor to identify early exacerbations. 410 participants at VA Puget Sound and the VA Eastern Colorado will be enrolled in the study.
For Aim 1 a and 1b, approximately 60 participants who reported a COPD exacerbation and were either hospitalized, treated as outpatients, or did not seek treatment will participate in an in-depth semi-structured interview by a trained research staff to understand how they responded to their worsening symptoms and decided whether to seek care. When available, the caregivers for these Veterans will be interviewed to obtain their perspective on the exacerbation event.
In Aim 1 c, participants will attend one in-person baseline visit to complete spirometry and baseline questionnaires. Participants will be contacted every 2 weeks for 1 year using an interactive voice response system that will screen for COPD exacerbations with 4 yes/no questions. Participants with a positive screen will be called back by research staff to obtain additional detailed information on the exacerbation and how it was treated. Data analysis will examine where access to care and baseline factors are associated with a delay in treatment.
In Aim 2, 200 participants from Aim 1 will use an inhaler monitor with their albuterol inhaler, which will transmit data in real-time about their daily inhaler use. They will use this monitor for the 12-month follow-up period. Data analysis will measure ability of a change in albuterol use to predict patient reported COPD exacerbations to determine the appropriate cut-offs that can be used in a future intervention trial.
These aims will provide critical detailed information on how best to intervene to ensure prompt identification and treatment of COPD exacerbations without relying on self-management. New health care delivery approaches will assist Veterans in early identification of exacerbations and provide early access to care that can be integrated into the VA primary care, emergency medicine and pulmonary specialty care settings.

Public Health Relevance

Timely treatment of chronic obstructive pulmonary disease (COPD) exacerbations is essential since delaying care can lead to worsening symptoms and increase the risk of hospitalization. This study will examine Veterans? care-seeking behaviors to see whether lack of perceived need for care or lack of access to care leads to delays in getting care for COPD exacerbations. Participants will complete a baseline in-person visit and receive calls every two weeks for one year to monitor for COPD exacerbations. Detailed information about each exacerbation and time to care will be obtained. A sample of participants and their caregivers will participate in more in-depth interviews. Approximately half the participants will also use a remote inhaler monitor to record their albuterol inhaler use to see if this approach can identify early exacerbations. Results from this study will be used to develop an intervention that will assist Veterans in the early identification, evaluation, and treatment of exacerbations, and will be integrated with the VA primary care team.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-2 Determinants of Patient Response to Care (HSR2)
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VA Puget Sound Healthcare System
United States
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