Pharmacists' understanding of patient education on metered-dose inhaler technique

Assessment of Educational Inhaler Technique Interventions Among Community Pharmacists: A Systematic Review

Objective

Community pharmacists are the last point of contact before patients are provided with an inhaled asthma device and are expected to adequately educate and train patients on its use. Evidence has shown that pharmacists lack the knowledge and skills required to appropriately counsel patients on these devices. The aim of this systematic review was to focus on evaluating the effects of educational interventions on community pharmacists knowledge of inhaler technique.

Methods

A literature search was conducted using the databases Pubmed and Embase with no applied time restrictions. The databases were searched from inception to December 2018. Articles were eligible for inclusion if they reported outcomes evaluating the improvement in pharmacists knowledge of inhaler technique after an educational intervention and provided details of the intervention. Pharmacists working in settings other than community pharmacies and inhaler devices used for conditions other than asthma were excluded.

Results

Five studies met the eligibility criteria. Workshops and one-on-one instruction were the main educational strategies used in these studies to augment the pharmacists knowledge of asthma inhaler devices. A checklist was utilized by all studies to evaluate the pharmacists improvement of inhaler technique after an educational intervention. All studies showed an improvement in inhaler technique of pharmacists post-intervention.

Conclusion

Studies identified in this systematic review have shown that an educational intervention produced positive outcomes related to the pharmacists knowledge on the steps involved in using asthma inhaler devices. However, the study findings focused on short-term retention of knowledge of inhaler technique and did not address the application of these results in clinical practice.

Teaching Pharmacy Undergraduate Students Inhaler Device Technique and Exploring Factors Affecting Maintenance of Technique

Aim

To determine the effect of inhaler device technique education on the maintenance of the inhaler device technique of undergraduate pharmacy students over time and to determine the factors, if any, related to inhaler device technique maintenance in the academic setting.

Methods

This study took the form of a prospective, unpaired samples repeated measures design. Participants had their inhaler technique assessed at baseline. Participants were then shown how to use an inhaler as a group. Participants then worked in pairs and took turns teaching and assessing each other on the correct inhaler technique using the 9-step checklist. Immediately following the delivery of the intervention, participants had their inhaler technique reassessed. All participants were then trained to mastery through individualised training. Twelve months following the collection of baseline data, all participants had their inhaler technique assessed and completed two questionnaires.

Results

Following the delivery of the intervention, there was a significant increase in the proportion of participants with the correct inhaler technique when compared to baseline (11% to 61%, resp.). There was a significant reduction in the proportion of participants demonstrating the correct technique 12 months following training (28%). The strongest determinant of inhaler technique maintenance is experience with showing patients how to use their inhalers.

Conclusion

Repeated training is essential to ensure that the technique is mastered and maintained, and consolidation of skills through exposure to train others may be most effective.

Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life

BACKGROUND

COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence.

METHODS

In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention.

RESULTS

A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, P = .01), fatigue (+0.6 points, P < .001), emotional function (+0.5 points, P = .001), and mastery (+0.7 points, P < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, P = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points (P < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 (P = .045). The pharmacist reported technical issues in 64% of visits.

CONCLUSIONS

Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.

Effectiveness of Various Methods of Teaching Proper Inhaler Technique

OBJECTIVE

To compare the effectiveness of 4 different instructional interventions in training proper inhaler technique.

DESIGN

Randomized, noncrossover trial.

SETTING

Health fair and indigent clinic.

PARTICIPANTS

Inhaler-naive adult volunteers who spoke and read English.

INTERVENTIONS

Subjects were assigned to complete the following: (1) read a metered dose inhaler (MDI) package insert pamphlet, (2) watch a Centers for Disease Control and Prevention (CDC) video demonstrating MDI technique, (3) watch a YouTube video demonstrating MDI technique, or (4) receive direct instruction of MDI technique from a pharmacist.

PRIMARY OUTCOME

Inhaler use competency (completion of all 7 prespecified critical steps).

RESULTS

Of the 72 subjects, 21 (29.2%) demonstrated competent inhaler technique. A statistically significant difference between pharmacist direct instruction and the remaining interventions, both combined ( P < .0001) and individually ( P ≤ .03), was evident. No statistically significant difference was detected among the remaining 3 intervention groups. Critical steps most frequently omitted or improperly performed were exhaling before inhalation and holding of breath after inhalation.

CONCLUSION

A 2-minute pharmacist counseling session is more effective than other interventions in successfully educating patients on proper inhaler technique. Pharmacists can play a pivotal role in reducing the implications of improper inhaler use.

Knowledge of and barriers to health literacy in Illinois

OBJECTIVE

To examine Illinois pharmacists' knowledge of and barriers to health literacy.

DESIGN

Cross-sectional descriptive study.

SETTING

Illinois, August to November 2009.

PARTICIPANTS

701 Illinois pharmacists.

INTERVENTION

Mail survey.

MAIN OUTCOME MEASURES

Pharmacists' knowledge (percent correct), mean barrier factors, and percent agreement of barrier items.

RESULTS

Usable responses were obtained from 701 respondents out of 1,457 pharmacists receiving surveys (48.1%). Percent correct for knowledge items ranged from 31.5% to 95.4% with only 19% to 27% of respondents answering a majority of the items correctly. Pharmacists had poor knowledge (percent correct) about prevalence of low health literacy (31.5%), its relationship to years of schooling (46.9%) and its lack of relationship to reading comprehension (48.4%). Overall process and practice-related barrier domain items were the most important barriers. In particular, the most frequently cited barriers towards low health literacy interventions were lack of adequate time (90.4%), use of mail order (83.8%), and presence of convenient delivery mechanisms (82.8%), all process barriers. Majority of respondents (57.3%) agreed that lack of knowledge about health literacy and its consequences is a barrier. Significant differences existed for barrier factors by demographics. Multivariate analysis examining the relationship between knowledge and barriers after controlling for demographics revealed no significant differences.

CONCLUSION

Pharmacists have limited knowledge of health literacy. We suggest training programs designed to address poor knowledge, interpreter services, access to written information tailored for various reading grade levels, and minimizing functional barriers such as time constraints.

Pharmacoeconomic assessment of clinical pharmacist interventions for patients with moderate to severe asthma in outpatient clinics : experience in taiwan

OBJECTIVE

To assess the economic and humanistic outcomes of clinical pharmacist interventions for patients with asthma and to assess the effect on patients' quality of life.

STUDY DESIGN

A prospective cohort study was conducted at a medical centre in southern Taiwan.

PATIENTS AND METHODS

Seventy patients with moderate to severe asthma were enrolled in the study from July 2003 to December 2003. Patients who were 17-53 years of age and were attending the outpatient clinic were referred to the pharmacist intervention programme. Patients were educated about their disease, pharmacotherapy, self-management and inhalation and peak flow meter techniques to use during the intervention period. A modified Asthma Quality-of-Life Questionnaire (AQLQ) was given to the patients at the first intervention (baseline) and 3 months later (intervention period) to assess quality of life. An asthma general knowledge questionnaire and an asthma diary chart were also used to assess patients' knowledge about asthma and the improvement in their symptoms. The cost effectiveness was evaluated based on the reduction in total costs/mean cost at each visit.

RESULTS

Of the 70 asthmatic patients enrolled in the study; 55 completed the questionnaires at baseline and after the intervention period. Only 25 of 55 (45.5%) patients completed the asthma diary chart. After the pharmacist intervention period, the patients' quality of life, common knowledge about asthma, and peak expiratory flow rate (PEFR) were significantly improved as compared with baseline (p < 0.001). The frequency of use of beta(2)-agonists and corticosteroids were also reduced, although the reduction was not statistically significant. Total cost per patient at baseline was statistically different from that after the 3-month intervention period (New Taiwanese dollars [$NT] 2880 vs $NT1683, respectively; costings are costs during the study period).

CONCLUSION

For patients with moderate to severe asthma, pharmacist intervention can be a cost-effective addition to the management of patients at an outpatient clinic by improving PEFR and patient quality of life, and saving medical resources.

Intern pharmacists as change agents to improve the practice of nonprescription medication supply: provision of salbutamol to patients with asthma

BACKGROUND

Earlier work established an evidence practice gap during provision of nonprescription salbutamol (albuterol). Pharmacist interns are hypothesized to be in a position to improve professional practice in the community pharmacy setting.

OBJECTIVE

To explore the potential of intern pharmacists to improve the professional practice of community pharmacy staff in the provision of nonprescription salbutamol.

METHODS

Intern pharmacists (n = 157) delivered an asthma intervention in 136 pharmacies consisting of an educational activity to pharmacy staff and a health promotion campaign to consumers. Post-intervention, simulated patients presented to 100 intervention and 100 control community pharmacies with a request for salbutamol. The appropriate outcome was medical referral for poor asthma control and correction of poor inhaler technique. Incidence and quantity of patient assessment and counseling provided during the visit were also assessed. Logistic regression was used to determine the predictors of medical referral.

RESULTS

A doubling in the rate of medical referral was seen in the intervention group (19% vs 40%; p = 0.001). Assessment of reliever use frequency was the main predictor of medical referral (OR = 22.7; 95% CI 9.06 to 56.9). Correction of poor inhaler technique did not improve; however, a reduction in salbutamol supplied without patient assessment (23% vs 8%; p = 0.009) or counseling (75% vs 48%; p < 0.001) was noted.

CONCLUSIONS

A doubling in the rate of medical referral showed a clear improvement in professional practice during the provision of nonprescription salbutamol. The improved patient outcome in the intervention group was due to increased assessment of reliever use frequency. Identification of poor inhaler technique remained near zero in both groups, which suggests that intern pharmacists were able to improve the current practice of community pharmacies yet were unable to establish a new practice behavior. This study provides evidence that intern pharmacists can act as change agents to improve pharmacy practice.

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

OBJECTIVES

To compare the effectiveness of small-group training in correct inhaler technique with self-directed Internet-based training.

DESIGN

Pharmacy students were randomly allocated to 1 of 2 groups: small-group training (n = 123) or self-directed Internet-based training (n = 113). Prior to intervention delivery, all participants were given a placebo Turbuhaler and product information leaflet and received inhaler technique training based on their group. Technique was assessed following training and predictors of correct inhaler technique were examined.

ASSESSMENT

There was a significant improvement in the number of participants demonstrating correct technique in both groups (small group training, 12% to 63%; p < 0.05; and Internet-based training, 9% to 59%; p < 0.05) post intervention, with no significant difference between the groups in the percent change (n = 234, p > 0.05). Increased student confidence following the intervention was a predictor for correct inhaler technique.

CONCLUSIONS

Self-directed Internet-based training is as effective as small-group training in improving students' inhaler technique.

Factors affecting pharmacists' pediatric asthma counseling

OBJECTIVE

To explore various factors that may influence community pharmacists' pediatric asthma counseling.

DESIGN

Cross-sectional.

SETTING

Maryland from September 2002 through March 2003.

PARTICIPANTS

Random sample of 400 community pharmacists.

INTERVENTION

Mail survey.

MAIN OUTCOME MEASURES

Pharmacists' attitude, subjective norm, perceived behavioral control, intention to provide pediatric asthma counseling, and reported counseling using the theory of planned behavior as a framework; demographic and pharmacy characteristics.

RESULTS

98 of 389 (25%) eligible pharmacists responded. Most acknowledged the importance of providing asthma counseling to children (54%) or caregivers (68%). However, only a small number reported demonstrating to children or caregivers or asking them to demonstrate how to use antiasthmatic medications. Multivariate logistic regressions revealed that intention to counsel was a significant predictor of providing counseling for children or caregivers (odds ratio [OR], 3.95 and 3.09, respectively). Intention to counsel children was significantly associated with subjective norm (OR, 1.88) and perceived ease of counseling (OR, 1.48); intention to counsel caregivers was significantly associated with perceived ease (OR, 1.45). Pharmacists also reported the following barriers that made counseling difficult: lack of time, lack of parent's interest, and lack of placebo devices useful for demonstration of inhalation technique.

CONCLUSION

Despite a positive attitude toward providing asthma counseling, the majority of pharmacists reported not fully engaging in counseling. A number of barriers to counseling were reported that, if targeted, could improve the management of pediatric asthma through pharmacist-initiated counseling.

Readability characteristics of consumer medication information for asthma inhalation devices

PURPOSE

Successful control of asthma relies heavily on patient adherence to prescribed inhalation therapies. Many patients are unable to use inhalers correctly and, therefore, do not reap the full therapeutic benefits. The purpose of this study was to assess the readability and related characteristics of Consumer Medication Information (CMI) for all prescription asthma inhalation devices currently available in the United States.

METHODS

We identified all brand-name (n = 18) and generic (n = 2) asthma inhalation devices currently available in the United States. English language CMI was obtained from pharmaceutical manufacturers of each identified product. The CMI from these products was evaluated for readability characteristics, including reading grade level using the Fry formula, text point size, dimensions (length and width), diagrams, and directions.

RESULTS

The mean Fry readability of the CMI was at grade level 8.2 +/- 1.5 (range = 5-11), while the average text point size was 9.2 +/- 2.2 (range = 6-12). The mean length of the pages on which the CMI was printed was 33.7 +/- 21.5 cm, while the average width of pages was 12.9 +/- 9.5 cm. There was an average of 6.2 +/- 3.6 (range = 2-12) illustrations per CMI, while a device overview diagram was included in 14 (70%). Eleven (n = 11) instructions included detailed step-by-step diagrams to supplement directions.

CONCLUSIONS

Overall, most CMI for prescription inhalers is presented with a reading difficulty level, text size, diagrams, and instructions that make it suboptimal for patient education. Prescription inhaler manufacturers should consider revising their CMI to comply with generally accepted guidelines preparing patient education information.

[Pharmacists' role in the management of asthma: a survey of 120 pharmacists in Bas-Rhin]

INTRODUCTION

The pharmacist plays an essential role in the management of the asthmatic patients on account of their frequent visits to the pharmacy to obtain their medication.

METHODS

In order to evaluate the practice and knowledge of asthma among the pharmacists of the department of Bas-Rhin, 120 pharmacists were selected at random to reply to a standardised questionnaire.

RESULTS

The 86 pharmacists who replied to the questionnaire had a good general understanding of asthma and its treatment. However, only 26.4% knew all the criteria of the severity of an attack of asthma. Among the 57 pharmacists who gave a demonstration of the use of inhaler devices, 16.3% showed all the steps in the use of a metered dose aerosol. These results are comparable to those of non-specialist doctors and nurses in whom poor techniques were found in 63-100% and 65-96% respectively. The mean scores of the pharmacists were 10.5/12 (+/- 1.2) steps for metered dose aerosols, 10.4/11 (+/- 1.0) for the Tubuhaler, 9.3/12 (+/- 1.7) for the Autohaler and 8.1/9 (+/- 0.9) for the Volumatic spacer. The asthmatic patient's main expectation of the pharmacist concerned the use of the prescribed systems (87.2%), underlining the lack of information received by the patient at the time of prescription.

CONCLUSIONS

An improvement in the knowledge of the signs of severity of asthma and the use of inhaled devices could usefully be one of the objectives in the training of a dispensing pharmacist.

Assessment of inhalation technique in primary care asthmatic patients using metered-dose inhalers with or without a spacer

BACKGROUND

Asthma is a chronic disease with increasing morbidity and mortality. Although the development of metered-dose inhalers (MDIs) was a landmark in asthma management, their use is burdened by inappropriate training. Inadequate inhalation technique is reported in 24% to 89% of patients. We assessed how a sample of adult asthmatic patients seen in primary healthcare clinics (PHCs) in Riyadh used their metered-dose inhalers (MDI).

PATIENTS AND METHODS

We conducted a cross-sectional survey of asthmatic adults â yen 18 years of age who attended PHCs and used an MDI with or without a spacer device. Patient inhalation technique was observed independently by the primary researcher and a respiratory therapist using a checklist based on US (National Heart, Lung and Blood Institute) asthma management guidelines.

RESULTS

The mean age of the 191 patients in the survey was 40.64 years (range, 18 to 80 years). Fifty-nine percent were females and 41% were males. Most (77%) were illiterate and most (86%) had received previous education on MDI inhalation technique. Ninety-three percent were using an MDI without a spacer, but none could use their MDI without committing at least one error in both groups. In patients using an MDI without a spacer, the most common error was not tilting the head backward slightly and breathing out to residual volume (85%), followed by not breathing in slowly (84%). In patients using an MDI with a spacer, the most common errors were not tilting the head back slightly and breathing out slowly to residual volume (77%), and not holding the breath for 10 seconds (77%).

CONCLUSION

Despite that MDIs are a mainstay in the management of our asthmatic patients, inhalation technique is very poor among our patients.

Evaluation of the impact of a pharmaceutical care program in children with asthma

The objective of this study was to evaluate the impact of a pharmaceutical care program on children with asthma. A comprehensive asthma education and monitoring program that includes basic asthma knowledge, symptoms and exacerbation evaluation, pharmacotherapy assessment including inhaler technique, and quality of life measurements was developed and applied in an outpatient paediatric clinic of the Catholic University of Chile. All patients with moderate asthma scheduled for outpatient visits with their internist over a 1-year period were referred for pharmacist intervention. Patients (aged 7-17) with moderate asthma attending the clinic were allocated to the intervention (group A) or control group (group B). Intervention patients were educated on their disease, pharmacotherapy, self-management, and inhalation techniques. The group B were children with their regular treatment for asthma but without pharmaceutical intervention. A paediatric asthma quality of life questionnaire (PAQLQ) was applied to both groups at 0, 2, and 9 weeks to assess the quality of life. Spirometry was done at the beginning and at the completion of the 9-week study. Beta-agonists used by each patient were also recorded. Eleven children (10.0+/-0.7 years) were included in the pharmaceutical care program, and ten children (9.9+/-0.6 years) in group B. For the individual domains of activities (A), emotions (E), and symptoms (S) there was a significant improvement in the children who received pharmaceutical care in comparison with those who did not receive it. The scores of group B did not change during the 9 weeks of follow-up. There were no significant changes in spirometric values in either group.