Comparison of small-group training with self-directed internet-based training in inhaler techniques

Effectiveness of an educational intervention about inhalation technique in healthcare professionals in primary care: a cluster randomized trial

Background: Incorrect inhalation technique (IT) is an important issue for chronic obstructive pulmonary disease (COPD) patients and healthcare professionals. Studies in which counseling is carried out with healthcare professionals beforehand so that they can properly educate their patients are required. The objective of the present trial is to assess the improvement in the performance of the IT in subjects with COPD and prescribed inhaled therapy after the implementation of an educational intervention conducted by their general practitioners. Methods: A cluster randomized clinical trial was conducted. A total of 286 COPD patients received scheduled inhalation therapy from 27 general practices in seven primary care centers. A teach-back educational intervention was implemented for both healthcare professionals and patients. The primary outcome of this study was the performance of the correct inhalation technique. It is considered a good technique if all steps in the inhalation data sheet are correctly performed. The secondary outcomes were assessed using forced spirometry, the basal dyspnea index, the Medical Research Council dyspnea scale, St George's Respiratory Questionnaire (SGRQ), and EuroQoL5D-5L for health-related quality of life. A one-year follow-up was conducted using an intention-to-treat analysis. Results: After the intervention, incorrect IT was observed in 92% of professionals and patients, with rates reaching 50% and 69.2%, respectively. The effectiveness in patients was significant, with a number needed to treat of 2.14 (95% CI 1.79-2.66). Factors related to correct IT in patients included the type of intervention, length of intervention (>25 min), good pulmonary function, age (youngest <=65, oldest >83), and less limitation of activity due to dyspnea. There was no relation with the cluster. Conclusion: This study shows the effectiveness of direct inhaler technique training provided by a trained professional on an appropriate timescale (for example, a specific consultation for medication reviews), aiming to help subjects improve their performance using the teach-back method. This could be an encouraging intervention to improve medication adherence and health promotion in people with COPD. Clinical Trial Registration: clinicaltrials.gov, identifier ISRCTN93725230.

The importance of reminders and patient preferences to improve inhaler technique in older adults with COPD

Objectives: Medication non-adherence in patients with chronic obstructive pulmonary disease is common. The aim is to evaluate the efficacy of two interventions to improve the inhalation technique (IT) in patients with pulmonary disease is common. Also determine optimal IT reminder time and to test the role of preferences in the intervention selection. Method: 726 pulmonary disease in common patients (consecutive sampling) from two trials: 1) TECEPOC-study (patients' preference trial/comprehensive cohort design) 2) TIEPOC-study (randomised controlled trial). Interventions: intervention-A (ad-hoc leaflet with instructions about correct IT according Spanish Respiratory Society), intervention B (intervention A+ individual training by instructors). Four visits were performed (baseline, 3, 6 and 12 months). Data on IT, sociodemographic and clinical characteristics, quality of life and respiratory drugs were recorded. Analysis under intention to treat principle. Multivariate analysis was conducted to measure the potential modifying factors of improvement in the IT along follow-up. Results: 660 patients (90.9%) did not perform a correct IT at baseline 89.75% with Handihaler, 86.95% with Turbuhaler, 84.75% with Accuhaler and 87.35% with pMDI. At 12 months, 221 patients 29.9% performed correctly the IT; a decrease in the slope of the curve (correct IT) was detected at 3 months follow-up. Intervention B was the most effective in both trials compared to control group or intervention A, regardless of preferences: 1) TECEPOC Study (preference trial): Intervention B versus control group, NNT = 3.22 (IC95%, 2.27-5.52); and versus Intervention A, NNT = 3.57 (CI95%, 2.41-6.8). Preferences improved 6.7% in the correct IT without statistical significance. 2) TIEPOC Study (randomized controlled trial): Intervention B versus control group, NNT = 1.74 (IC95%, 1.47-2.17), and versus intervention A, NNT = 3.33 (CI 95%, 2.43-5.55). No differences were measured between Intervention A and control group. Conclusion: Individual training significantly improves IT. Reminders every 3 months are recommended. Preferences do not influence the intervention effectiveness.

Exploring the perspectives of medical students of application on e-learning in medical education during the COVID-19 pandemic

BACKGROUND

The use of e-learning has become mandatory during the COVID-19 pandemic. However, there are many barriers to applying e-learning in medical education.

OBJECTIVE

This study aimed to explore medical students' perspectives on the application of e-learning in medical education during the COVID-19 pandemic.

METHODS

This Q-methodology explorative study was conducted in Kurdistan Region of Iraq. A sample of 37 medical students was purposively selected to represent different characteristics. The students distributed 37 statements representing different aspects of e-learning in medical education into a nine-point scoring grid from "least agree" to "most agree."

RESULTS

Data analysis revealed three distinct viewpoints. The first viewpoint, complete dependence on e-learning, emphasized a preference for e-learning to continue medical education and complete the study year with a minimal return to study halls or practical/clinical sessions. The second viewpoint, opponents of applying e-learning in medical education, included a generally negative view about e-learning and its role in medical education during the COVID-19 pandemic. The third viewpoint, e-learning as a supplement to medical education, emphasized a generally positive view about e-learning and considered it a supplement to the theoretical parts of medical education during the pandemic.

CONCLUSION

The three diverse viewpoints are primarily distinguished by the availability of e-learning experience and skills, availability of technology, risk perception of COVID-19, and the need for in-hospital clinical teaching. Provision of necessary facilities and training is required to strengthen the role of e-learning in medical education. A safe environment is needed for on-campus or hospital clinical teaching.

Ward based inhaler technique service reduces exacerbations of asthma and COPD

BACKGROUND

The management of asthma and COPD is largely dependent on patients being able to use their inhaled medication correctly, but poor inhaler technique continues to be a recurring theme in studies and clinical practice. This is associated with poor disease control, increased risk of exacerbations and hospital admissions, and so there is a need to redesign services for patients to optimise their medicines use.

METHODS

A novel ward-based dedicated inhaler technique service was developed, and pharmacy support workers trained to provide this, focusing on optimising inhaler technique using a checklist and recommending protocol-guided inhaler device switches. Inpatients on adult respiratory wards with a diagnosis of exacerbation of asthma or COPD consented to receive this service, and the impact on exacerbations and hospital admissions were compared in the 6-months before and after the intervention.

RESULTS

266 adults (74 asthma, 188 COPD, and four asthma-COPD overlap) received the inhaler technique service. Six-month exacerbation and hospital admission data were available for 184 subjects. Optimising inhaler technique achieved a significant reduction in the combined asthma and COPD annualised rate of moderate-to-severe exacerbations (Rate Ratio [RR] 0.75, p < 0.05) and annualised rate of hospital admissions (RR 0.57, p < 0.0005). Improvements were also observed in future length of stay (- 1.6 days) and the average cost of admission (-£748).

CONCLUSIONS

This novel inhaler technique service produced a significant reduction in the rate of moderate-to-severe exacerbations of asthma and COPD, and a reduction in the rate hospital admissions, length of stay and average cost of admission.

The effectiveness of telegram-based virtual education versus in-person education on the quality of life in adolescents with moderate-to-severe asthma: A pilot randomized controlled trial

Aim

In recent years, mobile applications have been developed for health education purposes. The aim of this study was to determine whether Telegram-based virtual education versus in-person education can be effective for improving the quality of life in adolescents with moderate-to-severe asthma.

Design

A single-blind randomized trial.

Methods

Participants were 64 adolescents aged 12-19 years and were equally assigned randomly to group A (Telegram-based education) and group B (in-person education) during 22 June 2017-19 February 2018. The educational contents were similar for both groups. The Mini Pediatric Asthma Quality of Life Questionnaire was used prior to intervention and 5 weeks postintervention for both groups of adolescents.

Results

A statistically significant increase was observed in the quality of life in both groups (p < .001). After controlling the quality-of-life scores, there was no statistically significant difference between the groups in terms of the mean score for the quality of life and its domains (p < .05).

Effect of repeated pulmonary function test training on student self-confidence in a clinical skills laboratory

INTRODUCTION

A skills laboratory session was created to train students to perform basic pulmonary function test (PFT) assessments. The objective of this study was to evaluate whether pharmacy student confidence changed after conducting a PFT in a laboratory session and if this was enhanced by adding a second session.

METHODS

A two-week educational activity was designed. For week one, each student completed a PFT with an instructor coaching to assure proper performance. Week two occurred one week later, and in pairs, students again completed an individual PFT, but the paired student served as the coach rather than the instructor. Students completed three surveys, a baseline before training, and after completing the sessions in week 1 and week 2, to assess confidence in PFT procedures on a 10-point scale. Survey results were analyzed using the sign test. A summary of instructor time and supply costs was also estimated.

RESULTS

Forty-five students consented to all surveys (78.9 percent inclusion rate). There was a significant increase in confidence for all items between the first and second surveys. Between the second and third surveys, only two items increased significantly.

CONCLUSIONS

The educational intervention was successful in improving student self-confidence in performing PFTs. However, limited additional confidence was gained by adding a second week of training, especially in context of resource allocation. These findings informed instructors that a one week PFT training may be sufficient and that resources needed for a second PFT training week may be better invested in another teaching opportunity.

What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions

INTRODUCTION

Respiratory inhalers, when used correctly, provide critical treatments for managing pulmonary conditions. However, many patients misuse inhalers, negatively affecting disease control, quality of life, healthcare utilization, and costs. Numerous factors are associated with misuse and are nested within four levels of influence: individual, interpersonal, organizational/institutional, and policy.

AREAS COVERED

This review analyzed published literature and identified the most salient factors at each socio-ecological framework level. English language articles from any year were identified from PubMed, Google Scholar, and Embase databases. Misuse exists across clinical settings, patient populations, and device types. Several potential solutions are highlighted. Published interventions to improve inhaler technique have utilized handouts, in-person, virtual, and biofeedback approaches both inside and outside of healthcare settings with varied effectiveness. However, some interventions have superior effectiveness for improving technique and reducing acute care utilization.

EXPERT OPINION

To robustly address inhaler misuse, future solutions should focus on multi-level approaches to account for the myriad of factors contributing to inhaler misuse. Solutions should also streamline inhaler equipment, identify innovative technology-based solutions, support collaborations across healthcare and non-healthcare settings, and ensure reimbursement to healthcare professionals for inhaler education. Rigorous research studies must be funded and supported to identify and disseminate solutions.

Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management

Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the 'luxury' of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient's make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient's making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.

Errors in the Use of Inhalers by Health Care Professionals: A Systematic Review

BACKGROUND

Inefficient inhaler technique (IT) compromises the optimal delivery of medication. However, the IT knowledge of health care professionals (HCPs) has received scant attention.

OBJECTIVE

The objective of this study was to perform a systematic review of published reports assessing the IT proficiency of HCPs in using pressurized metered dose (pMDI) and dry powder (DPI) inhalers.

METHODS

Studies published between 1975 and 2014 that directly assessed the IT skills of HCPs were selected according to predefined selection criteria.

RESULTS

Data were extracted from 55 studies involving 6,304 HCPs who performed 9,996 tests to demonstrate their IT proficiency. Overall, the IT was considered correct in 15.5% of cases (95% confidence interval [CI], 12-19.3), decreasing over time from 20.5% (95% CI, 14.9-26.8) from the early period (defined as 1975-1995) to 10.8% (95% CI, 7.3-14.8) during the late period (1996-2014). The most common errors in the use of pMDIs were as follows: not breathing out completely before inhalation (75%; 95% CI, 56-90), lack of coordination (64%; 95% CI, 29-92), and postinhalation breath-hold (63%; 95% CI, 52-72). The most common errors using DPI were deficient preparation (89%; 95% CI, 82-95), not breathing out completely before inhalation (79%; 95% CI, 68-87), and no breath-hold (76%; 95% CI, 67-84).

CONCLUSIONS

HCPs demonstrated inadequate knowledge of the proper use of inhalers. The poor understanding of the correct use of these devices may prevent these professionals from being able to adequately assess and teach proper inhalation techniques to their patients.

E-Learning in Medical Education in India

E-learning, or learning and teaching facilitated and supported through the application of technology, is presently being used widely in all fields of education, and also being utilized extensively in medical education. This narrative review aims to introduce the concept of e-learning, and discuss its need and scope in medical education in India. Experience shows that students and faculty are mostly in favor of adopting e-learning side-by-side with traditional learning, and the advantages far outweigh the likely discomfort associated with adoption of this new method.

Inhalation devices, delivery systems, and patient technique

BACKGROUND

In real-life clinical settings, physicians often consider the properties of various inhaled corticosteroids (ICSs), but typically little consideration is given to the properties of different inhalers and formulations.

OBJECTIVE

To discuss the effects of inhalation devices and user technique on efficacy, safety, and adherence with the aim of improving asthma management.

METHODS

Relevant publications were selected to augment discussion.

RESULTS

There are many types of devices available, each with advantages, disadvantages, ease of use, and rate of misuse. Aerosol particle size influences the deposition pattern of a drug in the lungs, and the optimal particle size range is 1 to 5 μm. Retrospective reviews suggest that smaller particles (1-2 μm) could provide improved asthma control, but randomized, prospective studies are needed. Multiple studies have demonstrated high misuse rates in patients for pressurized metered-dose inhalers and dry powder inhalers. Because of this, repeated education should include physical demonstrations of using the device, checking the patient's technique, correcting the technique, and rechecking the technique. This also means that dedicated, trained staff and placebo devices should be available for instructing patients. Furthermore, the device should be selected to be cost effective and to fit the patient's preference and ability to use it correctly to enhance compliance. Asthma management guidelines and algorithms are available to guide the clinician.

CONCLUSION

The choice of inhaler device should depend on cost effectiveness and the patient's preference and ability to use it correctly. Patient inhaler technique should be checked and, if necessary, corrected and rechecked, with retraining if needed, at every opportunity.

Practice makes perfect: self-reported adherence a positive marker of inhaler technique maintenance

Poor inhaler technique and non-adherence to treatment are major problems in the management of asthma. Patients can be taught how to achieve good inhaler technique, however maintenance remains problematic, with 50% of patients unable to demonstrate correct technique. The aim of this study was to determine the clinical, patient-related and/or device-related factors that predict inhaler technique maintenance. Data from a quality-controlled longitudinal community care dataset was utilized. 238 patients using preventer medications where included. Data consisted of patient demographics, clinical data, medication-related factors and patient-reported outcomes. Mixed effects logistic regression was used to identify predictors of inhaler technique maintenance at 1 month. The variables found to be independently associated with inhaler technique maintenance using logistic regression (Χ ² (3,n = 238) = 33.24, p < 0.000) were inhaler technique at Visit 1 (OR 7.1), device type (metered dose inhaler and dry powder inhalers) (OR 2.2) and self-reported adherent behavior in the prior 7 days (OR 1.3). This research is the first to unequivocally establish a predictive relationship between inhaler technique maintenance and actual patient adherence, reinforcing the notion that inhaler technique maintenance is more than just a physical skill. Inhaler technique maintenance has an underlying behavioral component, which future studies need to investigate.

ASTHMA

BEHAVIORAL ELEMENT TO CORRECT LONG-TERM INHALER TECHNIQUES: Patients who consciously make an effort to perfect asthma inhaler technique will maintain their skills long-term. Elizabeth Azzi at the University of Sydney, Australia, and co-workers further add evidence that there is a strong behavioral component to patients retaining correct inhaler technique over time. Poor inhaler technique can limit asthma control, affecting quality of life and increasing the chances of severe exacerbations. Azzi's team followed 238 patients to determine the key predictors of inhaler technique maintenance from factors including age, asthma knowledge and perceived future risks. Correct inhaler technique at initial assessment was the strongest predictor of long-term success, but this was strengthened further when patients reported good adherence to their own medication regimen. This suggests that maintaining correct inhaler technique is more than just a physical skill. Careful guidance towards this 'practice makes perfect' approach may improve patients' long-term technique maintenance.

Interventions to improve inhaler technique for people with asthma

BACKGROUND

Asthma is a common chronic disease worldwide. Inhalers are often prescribed to help control asthma symptoms, improve quality of life and reduce the risk of exacerbations or flare-ups. However, evidence suggests that many people with asthma do not use their inhaler correctly. It is therefore important to evaluate whether interventions aimed specifically at improving technique are effective and safe, and whether use of these interventions translates into improved clinical outcomes.

OBJECTIVES

To assess the impact of interventions to improve inhaler technique on clinical outcomes and safety in adults and children with asthma.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, which contains records compiled from multiple electronic and handsearched resources. We also searched trial registries and reference lists of primary studies. We conducted the most recent search on 23 November 2016.

SELECTION CRITERIA

We included studies comparing a group of adults or children with asthma receiving an inhaler technique intervention versus a group receiving a control or alternative intervention. We included parallel and cluster-randomised trials of any duration conducted in any setting, and planned to include only the first phase of any cross-over trials identified. We included studies reported as full-text articles, those published as abstracts only and unpublished data.

DATA COLLECTION AND ANALYSIS

Two review authors screened the search results for eligible studies. We extracted outcome data, assessed risk of bias in duplicate and resolved discrepancies by involving another review author. We grouped studies making similar comparisons by consensus (e.g. all those comparing enhanced inhaler technique education vs usual care) and conducted meta-analyses only if treatments, participants and the underlying clinical question were similar enough for pooling to make sense. We analysed dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences, all with random-effects models. We described skewed data narratively. We graded the results and presented evidence in 'Summary of findings' tables for each comparison. Primary outcomes were inhaler technique, asthma control and exacerbations requiring at least oral corticosteroids (OCS).

MAIN RESULTS

This review includes 29 parallel randomised controlled trials (RCTs) (n = 2210), although not all reported relevant or useable data. All participants had asthma, and follow-up ranged from 2 to 26 weeks. Most studies were at low or unclear risk of selection and attrition biases and at high risk for biases associated with blinding. We considered most of the evidence to be of low quality owing to these biases and to imprecision in the estimates of effect.We classified studies into three comparisons: enhanced face-to-face training session(s), multi-media-delivered inhaler training (e.g. DVD, computer app or game) and technique feedback devices. Differences between interventions, populations and outcome measures limited quantitative analyses, particularly for exacerbations, adverse events, unscheduled visits to a healthcare provider and absenteeism from work or school.Enhanced inhaler technique education and multi-media training improved technique in most studies immediately after the intervention and at follow-up, although the variety of checklists used meant that this was difficult to assess reliably. For both adults and children, how and when inhaler technique was assessed appeared to affect whether inhaler technique improved and by how much.Analyses of the numbers of people who demonstrated correct or 'good enough' technique were generally more useful than checklist scores. Adult studies of enhanced education showed benefit when this metric was used at 2 to 26 weeks' follow-up (odds ratio (OR) 5.00, 95% confidence interval (CI) 1.83 to 13.65; 258 participants; three studies; 31 per 100 with correct technique in the control group compared with 69 (95% CI 45 to 86) in the education group; moderate-quality evidence). A similar result was seen in studies looking at feedback devices at four weeks' follow-up (OR 4.80, 95% CI 1.87 to 12.33; 97 participants; one study; 51 per 100 with correct technique in the control group compared with 83 (95% CI 66 to 93) in the feedback group; low-quality evidence). However, the benefit of multi-media training for adults even immediately after the intervention was uncertain (OR 2.15, 95% CI 0.84 to 5.50; 164 participants; two studies; I² = 49%; 30 per 100 in the control group with correct technique compared with 47 (95% CI 26 to 70) in the multi-media group; moderate-quality evidence). Evidence tended to be less clear for children, usually because results were based on fewer and smaller studies.Some studies did not report exacerbations in a way that allowed meta-analysis; others provided inconclusive results. Inhaler technique interventions provided some benefit for asthma control and quality of life but generally did not lead to consistent or important clinical benefits for adults or children. Confidence intervals included no difference or did not reach a threshold that could be considered clinically important. Responder analyses sometimes showed improvement among more people in the intervention groups, even though the mean difference between groups was small. We found no evidence about harms.

AUTHORS' CONCLUSIONS

Although interventions to improve inhaler technique may work in some circumstances, the variety of interventions and measurement methods used hampered our ability to perform meta-analyses and led to low to moderate confidence in our findings. Most included studies did not report important improvement in clinical outcomes. Guidelines consistently recommend that clinicians check regularly the inhaler technique of their patients; what is not clear is how clinicians can most effectively intervene if they find a patient's technique to be inadequate, and whether such interventions will have a discernible impact on clinical outcomes.

Real-world asthma management with inhaler devices in Switzerland-results of the asthma survey

BACKGROUND

The aim of the Asthma Survey was to generate insights about the daily practice of physicians with regard to inhaler devices used for treating asthma under real-world conditions in Switzerland.

METHODS

A questionnaire was administered to 605 participating hospital- and practice-based Swiss physicians. Areas of interest were practical aspects of patient education, typical difficulties encountered when prescribing pressurized metered-dose inhalers (pMDI) and dry-powder inhalers (DPI), and reasons for physician preferences. Differences between the German-speaking part of Switzerland (D-CH) and French- and Italian-speaking parts of Switzerland (W-CH) linguistic regions were explored.

RESULTS

Datasets from 529 physicians (291 D-CH and 238 W-CH) were suitable for analysis, 342 internists/general practitioners, 177 pulmonologists/allergologists, and 10 other. Approximately 90% of all participants declared being personally involved in providing inhaler device education to their patients. Practice assistants (33.0% vs. 9.2%, P<0.001) and pharmacists (6.9% vs. 19.7%, P<0.001) were more frequently involved in D-CH compared to W-CH. Patient skills with regard to inhalation technique were generally not monitored on a regular basis with only 34.0% of participants ensuring such checks at the scheduled visits. DPIs were overwhelmingly preferred over pMDI. Although the prevalence of typical handling errors was similar with both inhalers in the two regions, pMDIs were used more frequently in W-CH (P<0.001).

CONCLUSIONS

Real-world asthma management and inhaler preferences differ between D-CH and W-CH. While the importance of patient education is widely acknowledged, inhalation skills monitoring remains suboptimal. The reasons for higher pMDI preference in W-CH compared to D-CH deserve further research.

Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time?

BACKGROUND

Problems with the use of inhalers by patients were noted shortly after the launch of the metered-dose inhaler (MDI) and persist today. We aimed to assess the most common errors in inhaler use over the past 40 years in patients treated with MDIs or dry powder inhalers (DPIs).

METHODS

A systematic search for articles reporting direct observation of inhaler technique by trained personnel covered the period from 1975 to 2014. Outcomes were the nature and frequencies of the three most common errors; the percentage of patients demonstrating correct, acceptable, or poor technique; and variations in these outcomes over these 40 years and when partitioned into years 1 to 20 and years 21 to 40. Analyses were conducted in accordance with recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Strengthening the Reporting of Observational Studies in Epidemiology.

RESULTS

Data were extracted from 144 articles reporting on a total number of 54,354 subjects performing 59,584 observed tests of technique. The most frequent MDI errors were in coordination (45%; 95% CI, 41%-49%), speed and/or depth of inspiration (44%; 40%-47%), and no postinhalation breath-hold (46%; 42%-49%). Frequent DPI errors were incorrect preparation in 29% (26%-33%), no full expiration before inhalation in 46% (42%-50%), and no postinhalation breath-hold in 37% (33%-40%). The overall prevalence of correct technique was 31% (28%-35%); of acceptable, 41% (36%-47%); and of poor, 31% (27%-36%). There were no significant differences between the first and second 20-year periods of scrutiny.

CONCLUSIONS

Incorrect inhaler technique is unacceptably frequent and has not improved over the past 40 years, pointing to an urgent need for new approaches to education and drug delivery.

A systematic review of patient medication error on self-administering medication at home

INTRODUCTION

Medication errors have been analyzed as a health professionals' responsibility (due to mistakes in prescription, preparation or dispensing). However, sometimes, patients themselves (or their caregivers) make mistakes in the administration of the medication. The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems.

AREAS COVERED

This study reviews and describes the methodological approaches and results of published studies on the frequency, causes and consequences of medication errors committed by patients at home. A review of research articles published between 1990 and 2014 was carried out using MEDLINE, Web-of-Knowledge, Scopus, Tripdatabase and Index Medicus.

EXPERT OPINION

The frequency of PE was situated between 19 and 59%. The elderly and the preschooler population constituted a higher number of mistakes than others. The most common were: incorrect dosage, forgetting, mixing up medications, failing to recall indications and taking out-of-date or inappropriately stored drugs. The majority of these mistakes have no negative consequences. Health literacy, information and communication and complexity of use of dispensing devices were identified as causes of PEs. Apps and other new technologies offer several opportunities for improving drug safety.

The effect of using simulation for training pharmacy students on correct device technique

OBJECTIVE

To assess the effect of using simulation in pharmacy student training on correct device technique.

METHODS

A single-blinded, repeated measures, parallel group design study was conducted in 2011, involving all final-year pharmacy students in year 5 (final year) enrolled in the Clinical Pharmacy and Therapeutics course. Students were assessed on device technique at baseline based on previously published checklists for Diskus (DIS), Turbuhaler (TH), and pressurized Metered Dose Inhaler (pMDI). Students were randomly assigned to 2 groups: Intervention A, which included supervised hands-on education in groups and peer assessment/education; and Intervention B, which included supervised hands-on education in groups, peer assessment/education, and a simulated scenario counseling real asthma patients. The simulation involved groups of 6 students counseling 3 asthma patients on inhaler device technique. The counseling involved verbal information and physical demonstration until the patient performed all steps correctly. Student assessments on device technique were repeated 1 week postintervention.

RESULTS

At baseline, none of the students in Intervention A (n=54) or Intervention B (n=55) performed correct technique for any of the 3 devices. One week following the intervention, a significantly higher proportion of students in Intervention B demonstrated correct technique for the Diskus, Turbuhaler, and pMDI (60.0%, 70.9%, and 69.1%, respectively) than did students in Intervention A (27.8%, 40.7%, and 42.6%, respectively, p<0.005).

CONCLUSION

Engaging pharmacy students with real asthma patients in a simulated scenario involving correct device technique education resulted in better device technique demonstration skills among students.

Online eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction

BACKGROUND

Health systems worldwide are facing shortages in health professional workforce. Several studies have demonstrated the direct correlation between the availability of health workers, coverage of health services, and population health outcomes. To address this shortage, online eLearning is increasingly being adopted in health professionals' education. To inform policy-making, in online eLearning, we need to determine its effectiveness.

METHODS

We performed a systematic review of the effectiveness of online eLearning through a comprehensive search of the major databases for randomised controlled trials that compared online eLearning to traditional learning or alternative learning methods. The search period was from January 2000 to August 2013. We included articles which primarily focused on students' knowledge, skills, satisfaction and attitudes toward eLearning and cost-effectiveness and adverse effects as secondary outcomes. Two reviewers independently extracted data from the included studies. Due to significant heterogeneity among the included studies, we presented our results as a narrative synthesis.

FINDINGS

Fifty-nine studies, including 6750 students enrolled in medicine, dentistry, nursing, physical therapy and pharmacy studies, met the inclusion criteria. Twelve of the 50 studies testing knowledge gains found significantly higher gains in the online eLearning intervention groups compared to traditional learning, whereas 27 did not detect significant differences or found mixed results. Eleven studies did not test for differences. Six studies detected significantly higher skill gains in the online eLearning intervention groups, whilst 3 other studies testing skill gains did not detect differences between groups and 1 study showed mixed results. Twelve studies tested students' attitudes, of which 8 studies showed no differences in attitudes or preferences for online eLearning. Students' satisfaction was measured in 29 studies, 4 studies showed higher satisfaction for online eLearning and 20 studies showed no difference in satisfaction between online eLearning and traditional learning. Risk of bias was high for several of the included studies.

CONCLUSION

The current evidence base suggests that online eLearning is equivalent, possibly superior to traditional learning. These findings present a potential incentive for policy makers to cautiously encourage its adoption, while respecting the heterogeneity among the studies.

Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery

INTRODUCTION

The inhaled route has many advantages, but requires the patient to use, and to master the use of, an inhaler device. Poor inhaler technique and non-adherence to therapy lead to a highly variable lung dose in clinical practice, with subsequent loss of clinical efficacy and wastage of economic resources.

AREAS COVERED

This paper discusses problems of poor inhaler technique, non-adherence to inhaler therapy, other issues relating to the precision of dose delivery, the consequences of these problems and how they can be addressed.

EXPERT OPINION

The precision of dosing by the pulmonary route can be improved by appropriate choice of inhaler device and by education. It is vital to educate patients about their disease, about the importance of taking prescribed medications and about correct inhaler use. One-on-one sessions with healthcare professionals probably represent the most effective educational method. For some drugs and patient groups, inhalers containing small microprocessors may also be used to control inhalation technique, and hence, to obtain a more reproducible lung dose. As the range of drugs delivered by inhalation increases, the need for correct inhaler technique, adherence to therapy and precise dosing becomes more and more important.

Promotion of self-directed learning using virtual patient cases

OBJECTIVE

To assess the effectiveness of virtual patient cases to promote self-directed learning (SDL) in a required advanced therapeutics course.

DESIGN

Virtual patient software based on a branched-narrative decision-making model was used to create complex patient case simulations to replace lecture-based instruction. Within each simulation, students used SDL principles to learn course objectives, apply their knowledge through clinical recommendations, and assess their progress through patient outcomes and faculty feedback linked to their individual decisions. Group discussions followed each virtual patient case to provide further interpretation, clarification, and clinical perspective.

ASSESSMENTS

Students found the simulated patient cases to be organized (90%), enjoyable (82%), intellectually challenging (97%), and valuable to their understanding of course content (91%). Students further indicated that completion of the virtual patient cases prior to class permitted better use of class time (78%) and promoted SDL (84%). When assessment questions regarding material on postoperative nausea and vomiting were compared, no difference in scores were found between the students who attended the lecture on the material in 2011 (control group) and those who completed the virtual patient case on the material in 2012 (intervention group).

CONCLUSION

Completion of virtual patient cases, designed to replace lectures and promote SDL, was overwhelmingly supported by students and proved to be as effective as traditional teaching methods.

Inhaler competence in asthma: common errors, barriers to use and recommended solutions

Whilst the inhaled route is the first line administration method in the management of asthma, it is well documented that patients can have problems adopting the correct inhaler technique and thus receiving adequate medication. This applies equally to metered dose inhalers and dry powder inhalers and leads to poor disease control and increased healthcare costs. Reviews have highlighted these problems and the recent European Consensus Statement developed a call to action to seek solutions. This review takes forward the challenge of inhaler competence by highlighting the issues and suggesting potential solutions to these problems. The opportunity for technological innovation and educational interventions to reduce errors is highlighted, as well as the specific challenges faced by children. This review is intended as a policy document, as most issues faced by patients have not changed for half a century, and this situation should not be allowed to continue any longer. Future direction with respect to research, policy needs and practice, together with education requirements in inhaler technique are described.