Physician-targeted program on inhaled therapy for childhood asthma

A systematic review of methods of scoring inhaler technique

Many inhaler devices are currently used in clinical practice to deliver medication, with each inhaler device offering different benefits to overcome technique issues. Inhaler technique remains poor, contributing to reduced airway drug deposition and consequently poor disease control. Scoring inhaler technique has been used within research as an outcome measure of inhaler technique assessment, and this systematic review collates and evaluates these scoring methods. The review protocol was prospectively registered in PROSPERO (CRD42020218869). A total of 172 articles were screened with 77 included, and the results presented using narrative synthesis due to the heterogeneity of the study design and data. The most frequently used scoring method awarded one point per step in the inhaler technique checklist and was included in 59/77 (77%) of articles; however limited and varied guidance was provided for score interpretation. Other inhaler technique scoring methods included grading the final inhaler technique score, expressing the total score as a percentage/ratio, deducting points from the final score when errors were made, and weighting steps within the checklist depending on how crucial the step was. Vast heterogeneity in the number of steps and content in the inhaler technique checklists was observed across all device types (range 5-19 steps). Only 4/77 (5%) of the inhaler technique measures had undertaken fundamental steps required in the scale development process for use in real world practice. This review demonstrates the demand for a tool that measures inhaler technique and highlights the current unmet need for one that has undergone validation.

Inhaler technique in a pediatric emergency department: Impact of an education intervention among healthcare professionals

BACKGROUND

Inhaler technique (IT) knowledge among healthcare providers is poor. The aim was to improve Pediatric Emergency Department (PED) healthcare providers' IT technique by carrying out an education intervention and sustain it for 6 months.

METHODS

Open-label, quasi-experimental, prospective, and unicentric study. Healthcare professionals working at the PED were enrolled. The study was developed in three phases: baseline evaluation and education intervention (P1) and reevaluation 1 month (P2) and 6 months (P3) after the education intervention. Participants fulfilled an eight-question theoretical test. Practical skills were evaluated by demonstrating IT in all three phases. The education intervention consisted in a verbal explanation of IT followed by a demonstration of IT with metered-dose inhaler using a mannequin.

RESULTS

A total of 84 healthcare providers (medical residents, nurses, and nursing assistants) were involved. In the theoretical questionnaire, the mean score at baseline was 4.4/8 (SD 1.7) improving to 6.3/8 (SD 1.2) in P2 and 6.47/8 (SD 1.1) in P3. In the IT evaluation for children <7 years old, the score improved from 5.7/7 (SD 1.3) to 6.5/7 in P2 and 6.7/7 in P3 (p < 0.001). For children >7 years old, the mean score of IT at baseline was 3.1/10 (SD 4), which improved to 7.4/10 (SD 3) and 8.2/10 in P2 and P3, respectively (p < 0.001). Only professional category influenced results at baseline.

CONCLUSION

Healthcare providers' theoretical knowledge and practical skills on IT are low. The education intervention performed is a useful strategy to ameliorate IT among healthcare providers.

Evaluation of health-care providers' knowledge in the science of aerosol drug delivery: Educational sessions are necessary

BACKGROUND:

Aerosolized drugs are widely used to treat and control a variety of pulmonary diseases. However, there is increasing evidence that patients are unable to use their drug delivery device correctly. The failure of aerosolized treatment is usually the result of poorly communicated instructions. The aim of this investigation was to evaluate the knowledge of health-care providers in the science of aerosol drug delivery (ADD) and assess the impact of further education on their knowledge.

MATERIALS AND METHODS:

One hundred and seventeen health-care providers attended a 4-hour educational course on ADD science. The course was conducted from June to August 2018 in Jeddah, Riyadh, and Dammam. Pre-course assessment done with a 12-item multiple-choice questionnaire. Post-course assessment was conducted after the end of course in which participants were asked to rate their knowledge of ADD on a scale of 1–10 (before and after the course).

RESULTS:

Sixty-six health-care providers (physicians, pharmacists, respiratory therapists, and health educators) completed the course. The participants' clinical experience, on average (±standard deviation), was 7.6 ± 7.3 years. Clinical experience favored physicians over other groups. The precourse score for all participants was 3.2 ± 1.9 out of 12 and the postcourse score was 6.97 ± 2.7. There was a significant statistical difference between pre- and postcourse assessment scores (P < 0.05). Differences between the four specialties were insignificant (P = 0.216), without a correlation between clinical experience and preassessment scores (P = 0.202).

CONCLUSION:

The present data indicate that health-care providers' knowledge of ADD is completely inadequate. There is an urgent need to introduce an ADD educational package in the curricula. An annual competency-based evaluation for health-care providers is critical as well.

Upskilling healthcare professionals to manage clinical allergy

It has long been recognised that given the high prevalence and considerable impact of allergic disease globally, there needs to be a focus on appropriate training for clinical professionals. The health-economic consequences of allergic disease are significant, with both direct healthcare costs (doctor, nurse and dietitian consultations, hospital admissions and prescribed medications) and indirect costs (lost school and work time, reduced productivity and over-the-counter medications). There is also a well-recognised impairment of quality of life, with less tangible costs including anxiety, distress, discomfort, disability and, occasionally, death. To help to mitigate these effects, there is a need to upskill the professional workforce at all levels, and also to equip those trained with the skills to become future healthare professional trainers. Upskilling the workforce from the grass-roots of undergraduate study in Medical, Nursing and Allied Health Professionals (AHP) through the entirety of training to senior consultant levels could have a major beneficial impact on the patient and their families, lead to a reduction in emergency use of clinical service, and help increase economic productivity.

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.

Metered-dose inhaler for asthma patients: knowledge and effects of a theoretical and practical guidance for pediatricians

OBJECTIVE

To evaluate the effect of a theoretical and practical guidance on knowledge of pediatricians regarding the use of metered dose inhalers with spacers. To identify major deficiencies, correct them and train these physicians on the correct use of the devices.

METHODS

Pediatricians who participated in a theoretical-practical program focusing on the use of inhaler devices answered a questionnaire with five questions about the use of these devices before and after the program. A comparison of the scores obtained in the pre- and post-training tests was performed by Wilcoxon test for related samples, and a significance level of 0.05 was adopted.

RESULTS

Twenty pediatricians performed pre- and post-training tests. The performance of pediatricians in the post-training test was significantly better than baseline (p<0.001).

CONCLUSION

A brief orientation program for pediatricians significantly improved their knowledge on the use of metered-dose inhalers with spacers, which may translate into an improvement in quality and quantity of prescriptions of these devices in clinical practice. The questions with higher rates of errors in the pre-training test were the questions about the waiting time between two sprays in successive applications and about the correct way to attach the inhaler to the spacer, both with high levels of success in the post-training test.

Knowledge of oxygen administration, aerosol medicine, and chest physiotherapy among pediatric healthcare workers in Italy

BACKGROUND

Oxygen administration, aerosol devices and drugs, or the use of chest physiotherapy are common practices in pediatrics; however, little is known about the knowledge of pediatric healthcare workers concerning the right utilization of these tools. The aim of this study was to fill this gap as a preliminary step in the implementation of appropriate educational programs.

METHODS

This cross-sectional survey of a nationally representative sample of Italian pediatricians and nurses was carried out between September 1 and October 8, 2008. A self-administered, anonymous questionnaire concerning the approach to respiratory disease in infants and children was distributed to all of the participants at the Annual Congress of the Italian Society of Pediatrics, together with a stamped envelope addressed to the trained study researchers.

RESULTS

Of the 900 distributed questionnaires, 76.7% were completed and returned by 606 physicians (199 primary care pediatricians, 245 hospital pediatricians, and 162 pediatric residents) and 84 pediatric nurses. The vast majority of the respondents did not know the percentage of hemoglobin saturation indicating hypoxemia that requires oxygen administration. Most of the nurses admitted to overusing mucolytics and inhalatory corticosteroids, did not know the role of ipratropium bromide, were unable to indicate the first-line drug for respiratory distress, and did not know the correct dose of salbutamol. Only a minority of the respondents were able to specify the indications for chest physiotherapy. The nurses gave the fewest correct answers regardless of their age, gender, work setting, or the frequency with which they cared for children with respiratory distress in a year cared.

CONCLUSIONS

The knowledge of primary care pediatricians, hospital pediatricians, and pediatric nurses in Italy concerning the use of pulse oximetry, aerosol devices and drugs, and chest physiotherapy is far from satisfactory and should be improved. Educational programs are therefore required for both nurses and pediatricians.

Inappropriate techniques used by internal medicine residents with three kinds of inhalers (a metered dose inhaler, Diskus, and Turbuhaler): changes after a single teaching session

BACKGROUND

While initial education and regular evaluation of inhaler technique in patients are emphasized in the management of asthma and chronic obstructive pulmonary disease, health care professionals are not experienced in using inhalers. This study assessed whether internal medicine residents used common inhalers correctly and whether a single teaching session successfully improved their performance.

METHODS

We evaluated 142 internal medicine residents from six university hospitals in Korea for their techniques with three different inhaler devices: a metered dose inhaler (MDI), Diskus, and Turbuhaler. We assessed whether participants completed each step in using the three inhalers and classified overall performance as good, adequate, or inadequate for each inhaler type. To estimate the effect of a single teaching session, reassessment was performed 2 months after education.

RESULTS

Performance grade was inadequate for 50.7% of participants with a MDI, 43.0% for Diskus, and 51.4% for Turbuhaler. An early year of residency was associated significantly with inappropriate technique for Diskus (p = 0.003), but not for MDI and Turbuhaler. After a single teaching session, overall skills improved significantly for all three inhalers. The proportion of subjects with good or adequate skill changed notably from 39.7% to 83.8% for MDI (p = 0.001), from 50.0% to 86.8% for Diskus (p = 0.001), and from 44.1% to 88.2% for Turbuhaler (p = 0.001).

CONCLUSIONS

These findings demonstrate that a high proportion of internal medicine residents cannot use inhalers correctly and just a single teaching can effectively enhance their inhaler technique.

Interventions for educating children who are at risk of asthma-related emergency department attendance

BACKGROUND

Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.

OBJECTIVES

To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).

SELECTION CRITERIA

We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data.

MAIN RESULTS

A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.

AUTHORS' CONCLUSIONS

Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

[Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metered-dose inhalers]

OBJECTIVE

To evaluate health professionals working at a tertiary pediatric hospital in terms of their knowledge regarding the practical use of metered-dose inhalers.

METHODS

Practical and written tests on the use of metered-dose inhalers were applied to physicians, physical therapists, nurses and nursing assistants. A score from 0 to 10 was assigned to each evaluation, and median scores were calculated for each professional category. Questions with higher and lower correct values were identified, and a descriptive comparison was made regarding the performance of the various professional categories. Statistical analysis was performed using the Kruskal-Wallis method for comparison of medians. A sequential logistic multiple regression analysis was also performed.

RESULTS

A total of 30 resident physicians or interns in the pediatrics department, 23 attending physicians, 29 physical therapists, 33 nurses and 31 nursing assistants were evaluated. Resident physicians, physical therapists and attending physicians performed significantly better than did nurses and nursing assistants. Only resident physicians had a median score greater than 6.

CONCLUSIONS

The health professionals evaluated, particularly the nurses and nursing assistants, who are directly involved in the practical use of metered-dose inhalers, possess insufficient knowledge regarding the use of such inhalers.

Evaluation of a paediatric asthma education package for health professionals

AIM

To evaluate an evidence-based paediatric asthma management education package designed for health professionals with particular emphasis on formulation of written asthma action plans (AAPs) and inhalation device technique.

METHODS

A prospective cohort study was conducted involving graduate medical programme medical students and tertiary paediatric hospital junior house staff. Three case-based Microsoft Powerpoint presentations were used to highlight important aspects of asthma management including the formulation of an AAP and inhalation device technique. This was delivered in small-group sessions to medical students and as a self-directed learning exercise to junior house staff. Outcome measures were ability to write an accurate AAP, confidence and competence in using and teaching asthma devices, and knowledge of asthma.

RESULTS

Forty medical students and 14 junior house staff were recruited. Mean scores for the written AAP improved from 4.2 (out of 19) to 16.2 for medical students (mean change 12.0; 95% confidence interval (CI) 11.0-13.0; P < 0.001) and from 11.5 to 16.8 for junior doctors (mean change 5.3; 95% CI 3.5-7.2; P < 0.001). Confidence in using and teaching asthma inhalation devices also improved (P < 0.001 for students and P < 0.05 for house staff), as did asthma knowledge and skills in using the devices in the students (P < 0.001).

CONCLUSION

The education package was effective in teaching participants how to write an accurate AAP and improved their confidence and ability in demonstrating proper inhalation device technique. We believe that the package has the potential to be used more widely for either small-group or self-directed learning.

The Yes We Can Urban Asthma Partnership: a medical/social model for childhood asthma management

Pediatric asthma programs have struggled to integrate children's medical and social needs. We developed and piloted an integrated team model for asthma care for low-income children through the Yes We Can Urban Asthma Partnership. Program evaluation demonstrated increases in prescribing controller medications (p <0.05), use of action plans (p<0.001), and the use of mattress covers (p<0.001); and decrease in asthma symptoms (p<0.01). Additional changes occurred within the local system of asthma care to support ongoing efforts to improve asthma management. We conclude that pediatric asthma programs can effectively target the social and medical needs of children in a sustainable manner.

Written action plans for asthma in children

BACKGROUND

While all asthma consensus statements recommend the use of written action plan (WAP) as a central part of asthma management, a recent systematic review of randomised trials highlighted the paucity of trials where the only difference between groups was the provision or not of a written action plan.

OBJECTIVES

The objectives of this review were firstly to evaluate the independent effect of providing versus not providing a written action plan in children and adolescents with asthma, and secondly to compare the effect of different written action plans.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (November 2004), which is derived from searches of CENTRAL, MEDLINE, EMBASE, CINAHL, as well as handsearched respiratory journals, and meeting abstracts. We also searched bibliographies of included studies and identified review articles.

SELECTION CRITERIA

Randomised controlled trials were included if they compared a written action plan with no written action plan, or different written action plans with each other.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. Study authors were contacted for additional information.

MAIN RESULTS

Four trials (three RCTs and one quasi-RCT) involving 355 children were included. Children using symptom-based WAPs had lower risk of exacerbations which required an acute care visit (N = 5; RR 0.73; 95% CI 0.55 to 0.99). The number needed to treat to prevent one acute care visit was 9 (95% CI 5 to 138). Symptom monitoring was preferred over peak flow monitoring by children (N = 2; RR 1.21; 95% CI 1.00 to 1.46), but parents showed no preference (N = 2; RR 0.96; 95% CI 0.18 to 2.11). Children assigned to peak flow-based action plans reduced by 1/2 day the number of symptomatic days per week (N = 2; mean difference: 0.45 days/week; 95% CI 0.04 to 0.26). There were no significant group differences in the rate of exacerbation requiring oral steroids or admission, school absenteeism, lung function, symptom score, quality of life, and withdrawals.

AUTHORS' CONCLUSIONS

The evidence suggests that symptom-based WAP are superior to peak flow WAP for preventing acute care visits although there is insufficient data to firmly conclude whether the observed superiority is conferred by greater adherence to the monitoring strategy, earlier identification of onset of deteriorations, higher threshold for presentation to acute care settings, or the specific treatment recommendations.

A cluster randomised intervention trial of asthma clubs to improve quality of life in primary school children: the School Care and Asthma Management Project (SCAMP)

AIM

To evaluate the effectiveness of a programme of asthma clubs in improving quality of life in primary school children with asthma.

METHODS

A cluster randomised intervention trial was undertaken in 22 primary schools within the urban area of south and east Belfast, Northern Ireland. Schools were randomised in pairs to immediate or delayed groups. The study subjects comprised 173 children aged 7-11 years whose parents had notified the school of their asthma diagnosis. Children attended school based weekly clubs over an 8 week period. The main outcome measures were the interview administered Paediatric Quality of Life Questionnaire scores, ranging from 1 (worst) to 7 (best), spirometry, and inhaler technique.

RESULTS

Over 15 weeks, small but non-significant improvements in the overall quality of life score (mean 0.20; 95% confidence interval (CI) -0.20 to 0.61) and in each of its three components, activity limitation (0.20; -0.43 to 0.84), symptoms (0.23; -0.23 to 0.70), and emotional function (0.17; -0.18 to 0.52), were observed in the immediate compared with the delayed group. Inhaler technique at week 16 was markedly better in the immediate group, with 56% having correct technique compared with 15% in the delayed group. No significant effect of the intervention on spirometry results could be demonstrated.

CONCLUSION

This primary school based asthma education programme resulted in sustained improvements in inhaler technique, but changes in quality of life scores were not significant.

Education of physicians-in-training can decrease the risk for vascular catheter infection

BACKGROUND

Procedure instruction for physicians-in-training is usually nonstandardized. The authors observed that during insertion of central venous catheters (CVCs), few physicians used full-size sterile drapes (an intervention proven to reduce the risk for CVC-related infection).

OBJECTIVE

To improve standardization of infection control practices and techniques during invasive procedures.

DESIGN

Nonrandomized pre-post observational trial.

SETTING

Six intensive care units and one step-down unit at Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.

PARTICIPANTS

Third-year medical students and physicians completing their first postgraduate year.

INTERVENTION

A 1-day course on infection control practices and procedures given in June 1996 and June 1997.

MEASUREMENTS

Surveys assessing physician attitudes toward use of sterile techniques during insertion of CVCs were administered during the baseline year and just before, immediately after, and 6 months after the first course. Preintervention and postintervention use of full-size sterile drapes was measured, and surveillance for vascular catheter-related infection was performed.

RESULTS

The perceived need for full-size sterile drapes was 22% in the year before the course and 73% 6 months after the course (P < 0.001). The perceived need for small sterile towels at the insertion site decreased reciprocally (P < 0.001). Documented use of full-size sterile drapes increased from 44% to 65% (P < 0.001). The rate of catheter-related infection decreased from 4.51 infections per 1000 patient-days before the first course to 2.92 infections per 1000 patient-days 18 months after the first course (average decrease, 3.23 infections per 1000 patient-days; P < 0.01). The estimated cost savings of this 28% decrease was at least $63000 and may have exceeded $800000.

CONCLUSIONS

Standardization of infection control practices through a course is a cost-effective way to decrease related adverse outcomes. If these findings can be reproduced, this approach may serve as a model for physicians-in-training.

Self-management education and regular practitioner review for adults with asthma

BACKGROUND

A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. This review was conducted to examine the strength of evidence supporting Step 6 of the Australian Asthma Management Plan: "Educate and Review Regularly"; to test whether health outcomes are influenced by education and self-management programmes.

OBJECTIVES

The objective of this review was to assess the effects of asthma self-management programmes, when coupled with regular health practitioner review, on health outcomes in adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised trials of self-management education in adults over 16 years of age with asthma.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation.

MAIN RESULTS

Twenty-five trials were included. Self-management education was compared with usual care in 22 studies. Self-management education reduced hospitalisations (odds ratio 0.57, 95% confidence interval 0.38 to 0.88); emergency room visits (odds ratio 0.71, 95% confidence interval (0.57 to 0.90); unscheduled visits to the doctor (odds ratio 0.57, 95% confidence interval 0.40 to 0.82); days off work or school (odds ratio 0.55, 95% confidence interval 0.38 to 0. 79); and nocturnal asthma (odds ratio 0.53, 95% confidence interval 0.39 to 0.72). Measures of lung function were little changed. Self-management programmes that involved a written action plan showed a greater reduction in hospitalisation than those that did not (odds ratio 0.35, 95% confidence interval 0.18 to 0.68). People who managed their asthma by self-adjustment of their medications using an individualised written plan had better lung function than those whose medications were adjusted by a doctor.

REVIEWER'S CONCLUSIONS

Training in asthma self-management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan appears to improve health outcomes for adults with asthma. Training programmes which enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.

Limited (information only) patient education programs for adults with asthma

BACKGROUND

A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. At its simplest level, education is limited to the transfer of information about asthma, its causes and its treatment. This review focused on the effects of limited asthma education.

OBJECTIVES

The objective of this review was to assess the effects of limited (i.e. information only) asthma education on health outcomes in adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised and controlled trials of individual asthma education involving information transfer only in adults over 16 years of age.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing information.

MAIN RESULTS

Eleven trials were included. They were of variable quality. Limited asthma education did not reduce hospitalisation for asthma (weighted mean difference -0.03 average hospitalisations per person per year, 95% confidence interval -0.09 to 0.03). There was no effect on doctor visits, lung function and medication use. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity, but perceived asthma symptoms did improve after limited asthma education (odds ratio 0.40, 95% confidence interval 0.18 to 0.86). In one study, limited asthma education was associated with reduced emergency department visits (weighted mean difference -2.76 average visits per person per year, 95% confidence interval -4.34 to 1.18).

REVIEWER'S CONCLUSIONS

Use of limited asthma education as it has been practiced does not appear to improve health outcomes in adults with asthma. However the use of information in the emergency department may be effective, but this needs to be confirmed.

Impact of education for physicians on patient outcomes

OBJECTIVES

This study was conducted to assess the impact of an interactive seminar based on self-regulation theory on 1) the treatment practices and communications and education behavior of physicians, 2) the health status and medical care utilization of their pediatric patients with asthma, and 3) the satisfaction with care of the subjects' parents.

METHODS

A total of 74 general practice pediatricians were assigned to either a program or a control group in a randomized controlled study. Data were collected from physicians at baseline, and 69 (93%) provided follow-up data 5 months after the program. Data were also collected from 637 of their patients at baseline, and in a 22-month window after the intervention, 472 (74%) of this number provided follow-up data.

RESULTS

After the seminar, physicians in the program group were more likely than were control group physicians to address patients' fears about medicines, review written instructions, provide a sequence of educational messages, write down how to adjust the medicines at home when symptoms change, and report that they spent less time with their patients. Parents of the children treated by program physicians were significantly more likely than were control group parents to report that the physician had been reassuring, described as a goal that the child be fully active, and gave information to relieve specific worries. After a visit with the physician, these parents were also more likely to report that they knew how to make management decisions at home. After the intervention compared to controls, patients of physicians in the program group were more likely to have received a prescription for inhaled antiinflammatory medicine and to have been asked by the physician to demonstrate how to use a metered-dose inhaler. After the intervention, children seen by program physicians made significantly fewer nonemergency office visits and visits for follow-up of an episode of symptoms; however, there were no differences in emergency department visits and hospitalizations. Among children who were placed on inhaled corticosteroids during this study, however, children treated by physicians who had received education had significantly fewer symptoms and fewer follow-up office visits, nonemergency physician office visits, emergency department visits, and hospitalizations.

CONCLUSIONS

The interactive seminar based on theories of self-regulation led to patient-physician encounters that were of shorter duration, had significant impact on the prescribing and communications behavior of physicians, led to more favorable patient responses to physicians' actions, and led to reductions in health care utilization.

Development of a scale to measure children's metered-dose inhaler and spacer technique

BACKGROUND

A measure of metered dose inhaler (MDI) and spacer technique would help health care providers to estimate the degree to which technique may confound clinical efficacy of inhaled medications.

OBJECTIVE

Our purpose was to extend earlier efforts to develop a rating scale to assess the accuracy of children's technique in using an MDI with three of the newer spacer devices.

METHODS

Subjects were children, 7 to 17 years old, with moderate to severe asthma attending a follow-up appointment in an outpatient specialty clinic for asthma. Nurse practitioners and/or physicians completed a rating scale (MDI Check-list) for 50 children using an Optihaler spacer, 29 using Azmacort, and 21 using InspirEase.

RESULTS

Depending on the spacer used, 14% to 26% of the children failed to demonstrate the critical skills for delivering medicine to the conducting airways, with the InspirEase group showing the best results. Items vary in difficulty (percent correct). The scale has excellent internal consistency reliability for Optihaler.

CONCLUSIONS

The scale can be used (1) by health care providers to instruct patients or colleagues, (2) by parents to monitor and correct their children's MDI/spacer technique, and (3) by researchers to estimate drug delivery in studies of clinical outcome or adherence.

The effect of structured versus conventional inhaler education in medical housestaff

Despite the importance of adequate inhaler technique in the care of asthma and chronic obstructive pulmonary disease, physicians have often been shown to have poor knowledge of correct inhaler use. At present, postgraduate teaching programs appear to leave physicians to acquire inhaler handling skills informally in the context of day-to-day patient care. We undertook the present study to determine if one brief structured educational intervention would be adequate to teach postgraduate physicians inhaler skills that would be retained over long periods of time. We also compared the efficacy of this intervention to traditional education methods. We recruited 52 postgraduate trainees in internal medicine at a large university hospital; 26 were in the educational intervention group and 26 were in the control group. Physicians in the intervention group were asked to respond to a questionnaire on inhaler use and to demonstrate the correct use of a metered-dose inhaler (MDI), an MDI with a pacing chamber and a multidose dry-powder inhaler. These intervention subjects were then instructed on proper inhaler usage by a qualified nurse educator. Eight months later, testing was repeated in the intervention group and was undertaken in the control group. Questionnaire scores were significantly higher in the intervention group at the 8-month follow-up than at baseline (59% vs. 42%; p < 0.05). Similarly, the scores of the intervention group at follow-up were significantly higher than those of the control group (59% vs. 39%; p < 0.05). There was no significant difference between the baseline scores of the intervention group and those of the control group. The mean demonstration score was significantly higher in the intervention group at follow-up than at baseline (68% vs. 39%; p < 0.001) and was also higher than that of the control group (68% vs. 44%; p < 0.001). There was no significant difference between the scores for all devices between the intervention group before education and the control group. Our data show that one brief teaching session is sufficient to produce a sustained improvement in knowledge and handling of inhalers by postgraduate physicians. The knowledge and skills of the physicians educated in our study were not only better than before they had received instruction, but were better than the knowledge and skills of postgraduate trainees from the same institution who had received no formal training. This latter observation suggests a failure of traditional unstructured postgraduate training programs to teach this practical patient care skill.

Medication compliance and asthma: overlooking the trees because of the forest

A number of reviews have described medication compliance and asthma. The consensus emerging from the analyses and discussion of the topic is that compliance to treatment regimens is generally poor. The current article describes several trees overlooked in the forest of data generated about compliance and asthma. The paper focuses on neglected issues concerning determinants of compliance, assessment, and changing noncompliant behavior. Based on available data, the conclusion is that it is time for health care personnel and patients to share the blame for the lack of medication compliance in asthma.