Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique

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Abstract

Objective

To evaluate the feasibility, acceptability and effectiveness of a brief intervention about inhaler technique, delivered by community pharmacists to asthma patients.

Methods

Thirty-one pharmacists received brief workshop education (Active: n = 16, Control: n = 15). Active Group pharmacists were trained to assess and teach dry powder inhaler technique, using patient-centered educational tools including novel Inhaler Technique Labels. Interventions were delivered to patients at four visits over 6 months.

Results

At baseline, patients (Active: 53, Control: 44) demonstrated poor inhaler technique (mean ± S.D. score out of 9, 5.7 ± 1.6). At 6 months, improvement in inhaler technique score was significantly greater in Active cf. Control patients (2.8 ± 1.6 cf. 0.9 ± 1.4, p < 0.001), and asthma severity was significantly improved (p = 0.015). Qualitative responses from patients and pharmacists indicated a high level of satisfaction with the intervention and educational tools, both for their effectiveness and for their impact on the patient–pharmacist relationship.

Conclusion

A simple feasible intervention in community pharmacies, incorporating daily reminders via Inhaler Technique Labels on inhalers, can lead to improvement in inhaler technique and asthma outcomes.

Practice implications

Brief training modules and simple educational tools, such as Inhaler Technique Labels, can provide a low-cost and sustainable way of changing patient behavior in asthma, using community pharmacists as educators.

Introduction

One of the most important goals of patient management in chronic illnesses is to achieve long-term changes in patient behavior, particularly those relating to self-care. This is particularly important in asthma [1], a chronic disease with a major burden of symptoms, health care utilization, lost productivity or schooling, and cost of medications on the individual and the community [2], [3]. Unlike many other chronic diseases, the medications used for asthma management are not primarily taken by tablet or capsule but by inhalation, to optimize delivery to the target organ. Obtaining the full therapeutic effect requires not only good adherence (itself a challenge [1]) but also correct use of the inhaler. This involves a series of steps which need to be performed correctly to ensure adequate medication delivery and minimize side effects. Incorrect use of inhalers leads to poor asthma control, increased hospital visits and increased cost of treatment [4], [5], [6]. It can also increase side effects due to increased medication deposition in the upper airway. In addition, incorrect inhaler technique can reinforce poor medication adherence, because of patient dissatisfaction with suboptimal response [7]. Unfortunately, incorrect inhaler technique is remarkably common; this is estimated to translate into $US7–15.7 billion wasted in the US each year because of incorrect asthma inhaler use [8]. As a result, international guidelines stress the importance of checking inhaler technique [9].

Dry powder inhalers such as the Turbuhaler and Diskus (Accuhaler) were originally introduced in order to avoid known problems of poor technique with pressurized metered dose inhalers. However, inhaler technique is also a problem with dry powder devices, with 23–54% of Turbuhaler users [10], [11] and 24–50% of Diskus users [10], [11] found to have incorrect technique. Education to improve inhaler technique should thus be an important component of patient education in asthma, regardless of the inhaler device.

Unfortunately, the health care professionals who might be expected to deliver such education as part of routine asthma management perform very little better than patients in their ability to use asthma inhaler devices. The rate of incorrect inhaler technique amongst health care professionals ranges from 31–85% [4], [12], [13], [14], with problems being found at similar levels amongst doctors [12], nurses [15], and community pharmacists [16], [17], [18].

A variety of methods have been used for educating patients about correct inhaler technique. Provision of the manufacturer's instruction sheet alone is ineffective [19], even for those who read the leaflet [10]. Personal instruction by a pharmacist is more effective than written instruction [20], and inclusion of a physical demonstration leads to improved inhaler technique [21], [22]. It has been established that inhaler technique education must be repeated regularly in order to maintain correct technique [23], [24].

However, after such education, it cannot be assumed that patient behavior will change. Brennan and colleagues distinguished between “competence” and “contrivance” with inhalers; following education, patients with asthma may demonstrate correct use of their devices to the health care professional, but then choose to use the device in a suboptimal manner [25]. This can explain why patients revert to their poor technique when they get home after inhaler technique education [26]. Therefore, new strategies need to be evaluated to address this aspect of patient behavior when educating patients with asthma about inhaler technique [25].

We now describe an innovative approach to education about inhaler technique, in patients with asthma. This program used a “Train-the-Trainer” approach, in which community pharmacists were taught how to educate their patients to correctly use dry powder inhalers, using a novel educational tool to provide daily education between dispensing visits. We recently described part of our study which involved a randomized controlled trial [27]. We now detail the educational methods, and report the qualitative feedback from participants, together with the impact of the intervention on inhaler technique score and asthma severity.

Section snippets

Overall study design

Ethics approval was obtained from the University of Sydney Human Ethics Committee, and pharmacists and patients gave written informed consent. The study had a single-blind cluster randomized parallel group design. Community pharmacists were trained in a workshop to deliver education on peak flow meter technique and Turbuhaler and Diskus technique (Active group), or peak flow meter technique alone (Control group); the pharmacists then recruited asthma patients who were taking controller

Pharmacists

Sixteen pharmacists were randomized to the Active group, and 15 to the Control group. At baseline, correct inhaler technique (score 9/9) was demonstrated by only 13 and 6% of pharmacists on Turbuhaler and Diskus respectively, with no significant difference between randomization groups. After the workshop, all Active group pharmacists achieved correct technique on both devices. Three pharmacists (1 Active, 2 Control) withdrew before recruiting any patients, and 15 Active and 12 Control

Discussion

This study demonstrated that a simple educational intervention by pharmacists about inhaler technique, which could be taught in a brief workshop, was feasible for delivery in community pharmacies. The findings reinforce the need for repeat assessment and education at each visit. A novel component of the educational intervention was the use of Inhaler Technique Labels, which were personalized at every visit for the patient's current inhaler skills, and provided daily-customized instruction

Acknowledgements

This study was funded by the Faculty of Pharmacy, University of Sydney. HR was funded by the Asthma Foundation of NSW. Placebo inhalers were provided by AstraZeneca and GlaxoSmithKline. IB, SB and CA have no conflicts of interest to declare. HR is a member of national Advisory Boards for AstraZeneca and GlaxoSmithKline, and her employer, the Woolcock Institute of Medical Research, has received research funding, consultancy payments and travel grants from AstraZeneca, GlaxoSmithKline and

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