An evaluation of impact of educational interventions on the technique of use of metered-dose inhaler by patients

Interventional, Quasi-Experimental Study of a Chronic Obstructive Pulmonary Disease Education Care Plan for Hospital Discharge

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity, mortality, and reduced quality of life for patients. Proper use of inhaler devices is critical for effective drug delivery and prevention of COPD progression. The primary endpoint of this study was a mean percent increase in correct steps associated with inhaler technique after pharmacist education. The co-primary endpoint was a 25% increase in the proportion of patients correctly identifying the appropriate use of short-acting versus long-acting inhaler types. This was an interventional quasi-experimental study of patients hospitalized at a 491-bed tertiary academic medical center with a COPD exacerbation to assess a pharmacist-led COPD care plan. Eligible patients included general floor, adult patients admitted with a primary diagnosis of COPD exacerbation. The primary investigator recorded initial inhaler technique scores through a paper checklist, and provided education about device types and usage. Patients were reassessed within 48 h to determine if pharmacist education improved inhaler knowledge. A total of 67 patients received the COPD care plan before hospital discharge. At baseline, patients scored a median of 81.8% (67.5–97.0) of steps correct across all inhaler device types. After pharmacist education, patient scores increased to a median of 100% (90.9–100.0) (p < 0.0001). The proportion of patients correctly identifying when to use short-acting versus long-acting inhalers increased from 73.1% to 98.5% (p < 0.0001). Implementation of a pharmacist-led care plan for patients admitted for COPD exacerbation was associated with an increase in correct steps for appropriate inhaler technique and understanding of inhaler device types after pharmacist education.

Implementation of mouth rinsing after use of inhaled corticosteroids in Australia

BACKGROUND

Clinical guidelines recommend that patients using inhaled corticosteroids should rinse their mouth following inhalation. There is however, a paucity of research regarding patient implementation of this recommendation and the impact it has on the occurrence of adverse effects.

OBJECTIVE

The aim of this study was to determine how well patients implement mouth rinsing after using inhaled corticosteroids in practice and their understanding of the rationale, information sources and the impact of mouth rinsing on adverse effects.

SETTING

Australians aged 18 years and over with a diagnosis of asthma and/or chronic obstructive pulmonary disease who were currently using an inhaled corticosteroid.

METHOD

Participants were recruited via Facebook to complete an online survey.

MAIN OUTCOME MEASURE

Implementation of a mouth rinse which aligned to current guideline recommendations.

RESULTS

Of 380 eligible responses, 30.5% of patients reported suboptimal mouth rinsing after using inhaled corticosteroids. Receiving advice on mouth rinsing from a healthcare professional increased the likelihood of correct implementation (P < 0.001) and improved patient understanding of the rationale (P = 0.01). Whilst most (90.0%) patients were aware rinsing may reduce oropharyngeal adverse effects, few (5.5%) were aware of its potential to reduce systemic adverse effects. Patients were more likely to report their rinsing procedure had a positive impact if they had experienced oral candidiasis (P < 0.001) or sore mouth/throat (P = 0.01), compared to cough or hoarse voice.

CONCLUSION

Almost one-third of patients reported a suboptimal mouth rinsing procedure after using an inhaled corticosteroid. Interventions are required to improve awareness and correct implementation of mouth rinsing.

Evaluation of Antidiabetic Injectable Technique: Is There an Association between Accuracy and Health Literacy or Duration of Diabetes?

Introduction:

Effective diabetes pharmacotherapy often involves injectable medications, which if used inappropriately represents a type of unintentional medication nonadherence that leads to poor outcomes.

Objectives:

The primary objective of this study was to assess the percent of patients who accurately prepared, administered, stored, and disposed of their injectable diabetes medication. Secondary objectives included comparing the accuracy of injectable use among those with diabetes <5 years vs. ≥ 5 years duration and those with limited vs. proficient health literacy.

Methods:

This was a prospective analysis conducted on a convenience sample of patients who received a pilot pharmacist-led, quality improvement service at an urban, ambulatory care clinic. The service components included health literacy screening, using the Rapid Assessment of Adult Literacy in Medicine – Short Form (REALM-SF) tool, evaluation of injectable technique by use of a standardized questionnaire, and provision of medication education. Duration of diabetes was determined by patient self-report. Chi-square and Fisher’s exact tests were utilized to assess accuracy of injectable technique in two group comparisons: (1) patients with limited vs. proficient health literacy and (2) patients with diabetes <5 years vs. ≥5 years.

Results:

Thirty-five patients were included in the analysis. Despite the majority (71.4%) of patients reporting prior education on injectable use, 54.3% reported at least one error in product use. Significant findings noted were that those with limited health literacy had higher rates of accurately using the skin-fold technique and appropriate angle for injection vs. those with proficient health literacy (p<0.05 for both comparisons). Likewise, more patients in the cohort of diabetes duration ≥5 years accurately rotated the injection site vs. those with a duration <5 years (p=0.001).

Conclusion:

Errors in injectable technique were common in this study and spanned across health literacy levels and duration of diabetes. Patients prescribed injectable diabetes medications should be routinely educated on proper technique for use.

Outcome of illustrated information leaflet on correct usage of asthma-metered dose inhaler

Background

Research globally has shown that metered dose inhaler (MDI) technique is poor, with patient education and regular demonstration critical in maintaining correct use of inhalers. Patient information containing pictorial aids improves understanding of medicine usage; however, manufacturer leaflets illustrating MDI use may not be easily understood by low-literacy asthma patients.

Aim

To develop and evaluate the outcome of a tailored, simplified leaflet on correct MDI technique in asthma patients with limited literacy skills.

Setting

A rural primary health care clinic in the Eastern Cape, South Africa.

Methods

Pictograms illustrating MDI steps were designed to ensure cultural relevance. The design process of the leaflet was iterative and consultative involving a range of health care professionals as well as patients. Fifty-five rural asthma patients were recruited for the pre-post design educational intervention study. Metered dose inhaler technique was assessed using a checklist, and patients were then educated using the study leaflet. The principal researcher then demonstrated correct MDI technique. This process was repeated at follow-up 4 weeks later.

Results

The number of correct steps increased significantly post intervention from 4.6 ± 2.2 at baseline to 7.9 ± 2.7 at follow-up (p < 0.05). Statistically significant improvement of correct technique was established for 10 of the 12 steps. Patients liked the pictograms and preferred the study leaflet over the manufacturer leaflet.

Conclusion

The tailored, simple, illustrated study leaflet accompanied by a demonstration of MDI technique significantly increased correct MDI technique in low-literacy patients. Patients approved of the illustrated, simple text leaflet, and noted its usefulness in helping them improve their MDI technique.

A comparative analysis of errors in inhaler technique among COPD versus asthma patients

Purpose

This study was designed to evaluate errors in inhaler technique in COPD vs asthma patients and to investigate the association of poor inhaler technique with patient demographics and clinical variables.

Patients and methods

A total of 509 adult patients with COPD (n=328) or asthma (n=181) who were currently using an inhaler device were included in this study. Data on patient demographics, duration of disease, type and duration of inhaler therapy, and assessment of inhaler technique were recorded.

Results

Metered dose inhaler (MDI) was the most common type of inhaler used by a similarly high percentage of patients in both COPD (83.2%) and asthma (77.3%) groups. Failure to exhale before inhaling through device (75.8% and 68.5% for MDIs; 73.2% and 71.8% for Aerolizer^®/Handihaler^®; 53.1% and 66.7% for Turbuhaler^®) was the most common error in inhaler technique, in both COPD and asthma groups. Device-specific errors in inhaler techniques were more common in asthma patients as compared with COPD patients, particularly for MDIs (P-values ranged from 0.046 to 0.0005), as associated with female gender (failure to press the buttons on both sides of Aerolizer^®/Handihaler^®, P=0.006), shorter duration of disease (failure to hold MDI or head in a vertical position, P<0.001, and to keep Turbuhaler^® upright, P=0.005), and shorter duration of inhaler usage (failure to hold head in a vertical position during MDI usage, P=0.006, and to keep Turbuhaler^® upright, P=0.012).

Conclusion

In conclusion, our findings revealed that errors in inhaler technique in terms of inhalation maneuvers and device handling were similarly common in COPD and asthma patients. Errors in certain device handling maneuvers, particularly with MDIs, were more common among asthma patients than among COPD patients and associated with female gender and shorter durations of disease and inhaler therapy.

Exacerbation of asthma due to inadvertent use of a dummy inhaler

Asthma is a common airways disease. Fortunately most patients respond well to inhaled therapy. Regular use of a combination inhaler delivering corticosteroid and a long-acting beta-2 agonist, is the mainstay of treatment and allows asthmatics to live a relatively normal life. However, management of asthma depends not only on the choice of drug/inhaler but also on patient compliance and optimal inhaler technique. This report describes a patient who continued to deteriorate despite adhering to prescribed treatment and demonstrating a good inhaler technique. Unfortunately the combination inhaler she was taking inadvertently was a designated placebo device for a branded product. This error was identified and corrected only after she was admitted with an asthma attack.