Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique
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
References (48)
Overcoming barriers to nonadherence in asthma treatment
J Allergy Clin Immunol
(2002)- et al.
Does introduction of new “easy to use” inhalational devices improve medical personnel's knowledge of their proper use?
Ann Allergy Asthma Immunol
(2002) Improper patient techniques with metered dose inhalers: clinical consequences and solutions to misuse
J Allergy Clin Immunol
(1995)How do patients’ views about medication affect their self-management in asthma?
Patient Educ Counselling
(1997)- et al.
Inhalation technique and variables associated with misuse of conventional metered-dose inhalers and newer dry powder inhalers in experienced adults
Ann Allergy Asthma Immunol
(2004) - et al.
Medical personnel's knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers
Chest
(1994) - et al.
The ability of the community pharmacist to learn the proper actuation techniques of inhaler devices
J Allergy Clin Immunol
(2001) - et al.
Pharmacist knowledge and ability to use inhaled medication delivery systems
Chest
(1993) - et al.
Inappropriate inhaler use: assessment of use and patient preference of seven inhalation devices
Respir Med
(2000) - et al.
True device compliance: the need to consider both competence and contrivance
Respir Med
(2005)
Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists
J Allergy Clin Immunol
The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team
Respir Med
Evaluation of the long-term effectiveness of three instruction modes for inhaling medicines
Patient Educ Couns
We are the experts: people with asthma talk about their medicine information needs
Patient Educ Couns
Asthma patient's satisfaction with the frequency and content of pharmacist counseling
J Am Pharm Assoc
Asthma symptoms associated with depression and lower quality of life: a population survey
Med J Aust
Bridging the gap between doctors’ and patients’ expectations of asthma management
J Asthma
Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability
Eur Respir J
Inhalers in asthma management: is demonstration the key to compliance?
Respir Care
Comparison of a new multidose powder inhaler (Diskus/Accuhaler) and the Turbuhaler regarding preference and ease of use
J Asthma
Metered-dose inhalers. Do health care providers know what to teach?
Arch Int Med
Inability of physicians to use metered-dose inhalers
J Asthma
Metered dose inhalers: system for assessing technique in patients and health professionals
Pharm J
Cited by (134)
A systematic review of methods of scoring inhaler technique
2023, Respiratory MedicineIndividualized aerosol medicine: Integrating device into the patient
2023, Paediatric Respiratory ReviewsThe impact of inhaler technique on clinical outcomes in adolescents and adults with asthma: A systematic review
2022, Respiratory MedicineCitation Excerpt :In view of the demonstrated associations between inhaler misuse, poor asthma outcomes and their contribution to the economic burden of asthma, concerted efforts to check and reinforce good inhaler technique are crucial. Previous studies have shown that training leads to better inhaler technique together with improved asthma control [6,52,65,66], and significant cost savings [65]. Improving patients’ inhaler knowledge and skills requires prescribers knowing how to use different devices correctly and in them choosing the most appropriate device to suit individual patient needs [3].
Ward based inhaler technique service reduces exacerbations of asthma and COPD
2021, Respiratory MedicineImpact of training on use of inhalational techniques of different inhaler devices: A single institutional cross sectional observation study
2021, Indian Journal of Tuberculosis