Is there a lack of patient education when it comes to nebulizers? Thomas F. Plaut, MD, an asthma consultant and author in Amherst, Mass, certainly thinks so. “The manufacturers of the drugs don’t tell you how to use a nebulizer, doctors don’t know how [to use them], nurses don’t know how, respiratory therapists don’t know how,” he says.

“This is not complex, but people are sloppy. Professionals are very sloppy regarding the way they use medicines, they’re very sloppy in the way they choose nebulizer cups.”

What this means for HME providers is that often it is up to companies that supply the nebulizers to fill in the gaps in patient education. While providing patient education and support is an opportunity to strengthen relationships with overworked referral sources who do not have time to teach patients about their nebulizers adequately, it also presents problems because the profit margins are thin. Medicare pays less than $20 for the most common type of nebulizer.

But whether you are a giant company like the 480-location Apria Healthcare headquartered in Lake Forest, Calif, or a smaller provider like the nine-location Airway Oxygen Inc headquartered in Grand Rapids, Mich, providing patient support and meeting the bottom line are possible.

Carrying the Right Nebulizer Brands
When nebulizer providers take on the role of educating patients, they often also become responsible for ensuring patients derive the benefit of their nebulizer treatments and take the treatments on a regular basis. This is why providers must carefully choose nebulizer models that will motivate compliance.

The first step in ensuring compliance is providing a nebulizer that is effective. According to Plaut, the fundamental issue that should concern providers when choosing a device is how much of the medicine is nebulized and how much enters the lungs. Respirable doses vary from 4% of the charge to 28%. However, those with the best statistics may not be the best choice for the patient. “It turns out that the best one takes about twice as long [to reach the lungs], but it is not twice as good,” Plaut says. “However, the next best is as fast as any of them.”

For Airway Oxygen Inc, there are several criteria involved in choosing nebulizers, including longevity, valve design, and ease of maintenance, says John Zombor, CRT, complex respiratory patient specialist for Airway Oxygen. For Apria Healthcare the choice is determined by the marketplace with the company carrying only those most prescribed by referring physicians, says Bob Fary, RRT, national director of respiratory services. However, both companies will provide brands they do not regularly carry if a referral source or patient requests them.

Educating for Compliance
It seems like a losing proposition to provide resources for education to make sure patients are compliant with their treatment, but education is key to providing the customer service patients expect, Fary says. “It is just part of the full basket of respiratory services that we provide,” he says. “When it comes to services versus reimbursement, we try to be as efficient as possible while being clinically appropriate.”

At Airway Oxygen, education may occur in either a storefront location or in the patient’s home and may take as long as an hour, with little notice to the provider. “Often, the patient receives a treatment in the doctor’s office, and we get an order, and we need to get this to the patient before the next treatment is due, which is generally in 4 hours or so,” Fary says.

Airway Oxygen starts the education process by asking patients to review the manufacturer instruction sheet for the nebulizer and watching a video. Both Airway Oxygen and Apria use respiratory therapists to instruct patients about using nebulizers, going over the device’s use piece by piece. Their demonstrations usually include what to expect from the treatment, warning signs of an asthma attack, and under what circumstances the patient should call either the provider or their physician. In addition, Airway Oxygen uses a check-off sheet during the setup to make sure the respiratory therapist covers all the basic operations and maintenance of the nebulizer.

Airway Oxygen also has the patient do a follow-up demonstration, which allows the company representative to make sure that the patient really understands how to use the nebulizer. The company maintains a 24-hour phone service and follows up with the patient within 5 days to make sure that all is going well. The system has proven to be very successful, limiting the amount of time and money spent reinstructing patients. If the patient successfully completes the return demo and is doing well at the time of the follow-up, they are usually “pretty well set,” Zombor says.

Make the Patient Your Ally
Fundamentally, compliance is not just about education, it is about motivating the patient to use the nebulizer. “The reason people [do not] do what a doctor tells them to do is because they do not believe the doctor, so the doctor says that the patient is noncompliant,” Plaut says. “I say compliance is for wimps. Any time I hear that somebody is not compliant, my first question is, ‘Does the patient understand the reason for the medicine and how to give it?’ In my opinion you have to set up a situation where the patient can see and be convinced that the treatment is helpful.”

Zombor adds that physician interaction is an underused compliance method, because doctors and their staff see patients regularly. “As far as long-term compliance, I think physicians and nurses need to be more proactive when they see patients and go a little deeper than simply asking [if they are using their nebulizer],” he says. “Just because somebody is doing something does not mean they are doing it correctly.”

Compliance is also a matter of understanding how the patient learns best, whether it is through the use of visual materials, written instructions, or one-on-one demonstrations. There is no one method that fits every patient. This means that patient education is an evolving process, and should be reviewed frequently. “Just because you have a process in place does not mean it is necessarily effective,” Zombor says. “Education is an ongoing process. It is not just for the patient, it is for the people administering it.”

For Apria, compliance is literally a package deal—with instruction booklet, video, and nebulizer being bundled together. “I think the more information you can give to the patient, the more likely you are to positively affect the compliance,” Fary says.

C.A. Wolski is associate editor of Dealer/Provider.