Patient and Provider Perspectives Driving Inhaler Choice

Significant discussion in the medical literature of the environmental impact of respiratory inhaler propellants1Usmani O.S. Scullion J. Keeley D. Our planet or our patients: is the sky the limit for inhaler choice?.Lancet Respir Med. 2019; 7: 11-13Google Scholar, 2Keeley D. Scullion J.E. Usmani O.S. Minimising the environmental impact of inhaled therapies: problems with policy on low carbon inhalers.Eur Respir J. 2020; 55Google Scholar, 3Wilkinson A. Woodcock A. The environmental impact of inhalers for asthma: a green challenge and a golden opportunity.Br J Clin Pharmacol. 2022; 88: 3016-3022Google Scholar has led some health care systems to incentivize switching patients to lower global warming potential inhalers to target reductions in greenhouse gas emissions.4NHS Long Term PlanHealth and the Environment. 2023.https://www.longtermplan.nhs.uk/online-version/appendix/health-and-the-environment/#refGoogle Scholar However, unsupervised inhaler switching has adverse patient consequences,5Björk E. Thind P. Qvarfordt M. Svartengren M. Anderson M. Computerized measurements of inhalation ability with a dry powder inhaler in patients with severe COPD.Eur Respir J. 2020; 56: 644Google Scholar,6Usmani O.S. Bosnic-Anticevich S. Dekhuijzen R. et al.Real-world impact of nonclinical inhaler regimen switches on asthma or COPD: a systematic review.J Allergy Clin Immunol Pract. 2022; 10: 2624-2637Google Scholar especially because respiratory health care professionals (HCPs) lack knowledge in inhaler use.7Plaza V. Giner J. Rodrigo G.J. Dolovich M.B. Sanchis J. Errors in the use of inhalers by health care professionals: a systematic review.J Allergy Clin Immunol Pract. 2018; 6: 987-995Google Scholar This research aimed to gather HCP and asthma/COPD patient priorities when prescribing or choosing an inhaler device for medical, nonmedical, and environmental reasons. We present a perspective on driving inhaler choice and optimized sustainable health care. We conducted a global self-selecting cross-sectional survey spanning 42 countries and six continents. Two online questionnaires, developed independently, using clinical experience and available literature,8Lewis H. Dickinson E. Usmani O.S. Opinions on the environmental impact of inhaler devices in UK respiratory care.Eur Respir J. 2019; 54PA4196Google Scholar,9d'Ancona G. Sethi K. Holman N. et al.What do people with asthma think about switching to a more environmentally friendly inhaler?.Eur Respir J. 2022; 60: 3143Google Scholar were undertaken between August and November 2021 involving HCPs and asthma/COPD patients, respectively, recruited via the Respiratory Effectiveness Group network and international respiratory societies. Given the exploratory nature of the survey, formal validation was not required. Respondents ranked their priorities (1 = not a priority to 5 = highest priority) when choosing an inhaler and answered Likert-style questions (1 = strongly disagree to 5 = strongly agree) relating to inhaler contribution to climate change. Ethical approval for the study was granted by the Anonymized Data Ethics mean age 48.5 ± 10.9 years; respiratory specialist, 55.4%; clinician, 22.8%; nurse, 9.4%; pharmacist, 6.7%; other, 5.7%) from 39 countries across Europe and Central Asia (65.6%), United Kingdom (12.2%), East Asia and Pacific (9.5%), Latin America and Caribbean (9.1%), North America (2.7%), Middle East and North Africa (0.6%), Sub-Saharan Africa (0.2%), and 270 patients (female 80.2%; mean age, 47 ± 13 years) from 15 countries (Europe and Central Asia, 23.9%; United Kingdom, 14.3%; East Asia and Pacific, 0.7%; Latin America and Caribbean, 52.2%; North America, 8.5%; and Middle East and North Africa, 0.4%). Inhaler usage among patients included dry powder inhalers (51%), pressurized metered-dose inhalers (45%), and soft mist inhalers (12.5%), with 21% on a combination of different inhalers. Fewer than half (45.9%) of HCPs and less than two thirds (60.1%) of patients were concerned about potential inhaler contribution to climate change (P < .001), although overall, HCPs (83.0%) and patients (84.0%) were concerned about climate change (P < .001). When choosing an inhaler, HCPs ranked as highest priority (5 points) "efficacy" (72.2%), "ease of use" (67.8%), and "perceived patient adherence" (61.8%) (Fig 1A), and patients ranked as highest priority "preventing future deterioration of health" (80.7%); "symptom control' (78.6%), and "safety" (78.2%) (Fig 1B). Environmental impact and recyclability were ranked lowest for both groups. Approximately one quarter of HCPs reported access to inhaler recycling schemes, and only 11.2% of patients were aware of any existing inhaler recycling programs. When choosing between prioritizing clinical efficacy (rated 1) or environmental impact (rated 5) of an inhaler on a 5-point scale, 73.2% of HCPs favored prioritizing efficacy in prescribing inhalers (P < .001) (Fig 2A). Similarly, 76.7% of patients preferred efficacy ("controls my symptoms") as crucial for their inhaler, with no statistically significant difference between HCPs and patients (P = .40). Both groups leaned toward the pharmaceutical industry rather than governments being responsible for ensuring their prescribed inhalers were environmentally friendly (Fig 2B), and almost half of patients (48.4%) viewed it as the complete responsibility of the pharmaceutical industry compared with HCPs (25.5%) (P < .001). Despite societal concerns for inhaler contribution to climate change, in this large multinational survey, both HCPs and patients prioritize clinical efficacy over climate change. Previous findings in a smaller national survey also identified efficacy as the top priority for UK HCPs and patients and environmental impact as lowest priority.8Lewis H. Dickinson E. Usmani O.S. Opinions on the environmental impact of inhaler devices in UK respiratory care.Eur Respir J. 2019; 54PA4196Google Scholar Nearly all HCPs and patients were concerned about climate change, but only half and 60% of HCPs and patients, respectively, were concerned about the environmental impact of inhalers, suggesting the personal importance of managing their respiratory condition. Both HCPs and patients leaned toward environmentally friendly inhalers being the responsibility of the pharmaceutical industry. Development of greener inhalers through regulated pharmaceutical innovation, rather than encouraging switching device via policy, may address this concern and provide consumer-driven change. The European Union has recently provided an incentive for the pharmaceutical industry to pursue cleaner alternatives to current propellants in pressurized metered-dose inhalers, where fluorinated gases will be phased down to near zero by 2030.10European Parliament agrees on updated rules to phase out F-gases—Euractiv Internet. 2024.https://www.euractiv.com/section/health-consumers/news/european-parliament-agrees-on-updated-rules-to-phase-out-f-gases/Google Scholar Most HCPs and patients neither had an inhaler recycling scheme at their center nor were aware of one, a critical gap in sustainable health care practices. Emphasizing the environmental impact of health care practices, including inhaler usage and lack of recycling, could lead to more balanced and informed decision-making, aligning health care practices with broader sustainability goals. To achieve global representation, we collaborated with international respiratory societies and patient associations in our recruitment strategy. Despite endeavors for balanced geographic participation, the self-selecting nature of surveys may have led to higher contribution of certain regions, reflecting an inherent challenge in global surveys. Although acknowledging potential geographical skew in the responses, the substantial and diverse sample size collected across multiple continents provides valuable insights into the priorities of HCPs and patients on a global scale. We have identified that clinical reasons for prescribing or choosing an inhaler are the highest priorities for both HCPs and patients, respectively, despite concern of inhaler contribution to climate change. Our findings underscore the necessity for a firm understanding of both clinical and environmental priorities in inhaler selection for patients. Bridging the gap between patient and HCP perspectives, particularly on environmental concerns, can contribute to more patient-centered care, with the need for increased awareness campaigns targeting both patients and physicians. Prescribing the appropriate inhaler for the right patient, making informed treatment choices, while using greener inhalers and introducing inhaler recycling schemes, is the way forward for greener health care. This research was funded by unrestricted grants from AstraZeneca, Boehringer Ingelheim, Chiesi Ltd, and Kindeva.