Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists

To the Editor: Correct inhaler technique is essential for effective drug delivery in asthma. High rates of incorrect technique (28% to 68%) with pressurized metered-dose inhalers and dry-powder inhalers have been reported,1Fink J.B. Rubin B.K. Problems with inhaler use: a call for improved clinician and patient education.Respir Care. 2005; 50: 1360-1374PubMed Google Scholar and poor technique with corticosteroid inhalers has been associated with poor asthma control and increased emergency department visits.2Giraud V. Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability.Eur Respir J. 2002; 19: 246-251Crossref PubMed Scopus (448) Google Scholar We have previously shown that a physical demonstration is a necessary component of device counselling to achieve optimal Turbuhaler (AstraZeneca, New South Wales, Australia) technique.3Basheti I.A. Reddel H.K. Armour C.L. Bosnic-Anticevich S.Z. Counseling about Turbuhaler technique: needs assessment and effective strategies for community pharmacists.Respir Care. 2005; 50: 617-623PubMed Google Scholar Pharmacists are in an excellent position to educate patients about inhaler technique because they are the last health care professionals seen by patients before an inhaled medication is used. In addition, international asthma guidelines recommend that pharmacists should form part of a team approach to patient education about the use of inhalers.4National Asthma Education and Prevention Program Expert Panel report 2. Guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (MD)1997Google Scholar Hence the objective of this randomized controlled study was to investigate the effect on clinical and humanistic outcomes of a simple educational intervention concerning dry-powder inhaler technique delivered by community pharmacists to patients with asthma. The study was approved by the University of Sydney Human Ethics Committee and was completed before mandatory registration of clinical trials. A convenient sample of 120 registered community pharmacists in the Sydney metropolitan area was contacted by telephone. Thirty-one pharmacists were randomized (active, 16; control, 15), and 27 completed the study. Community pharmacists were trained to deliver education on Turbuhaler or Diskus (GlaxoSmithKline, Victoria, Australia) technique and peak flow meter (PFM) technique (active group) or PFM technique alone (control group). After training, all pharmacists demonstrated correct Turbuhaler and Diskus technique. Pharmacists then approached every second asthmatic patient who presented a Turbuhaler or Diskus prescription at their pharmacy. Inclusion criteria for patients were age of 14 years or older, English speaker, physician-diagnosed asthma, self-administration of inhaled corticosteroid through a Turbuhaler or Diskus with or without long-acting β2-agonist, and no change in asthma medication or dose for 1 month. After a 2-week run-in period during which PFM readings were recorded, patients in the active group visited the pharmacy for 5 visits (time = 0, 1, 2, 3, and 6 months) at which the intervention was delivered. The intervention included a specialized “show-and-tell” inhaler technique counselling service,3Basheti I.A. Reddel H.K. Armour C.L. Bosnic-Anticevich S.Z. Counseling about Turbuhaler technique: needs assessment and effective strategies for community pharmacists.Respir Care. 2005; 50: 617-623PubMed Google Scholar with augmented verbal counselling and physical demonstration with a placebo inhaler, addressing all steps in the inhaler technique checklist. Assessment and counselling were repeated up to 3 times if necessary, until the patient demonstrated the correct technique. At each subsequent visit, inhaler technique assessment and education were repeated. Patients in the control group visited the pharmacy for assessment at the same intervals and received standard care. Both groups also performed 2 weeks of peak flow monitoring before visits at 3 and 6 months. Data for humanistic outcomes were collected at 3 and 6 months for both the active and control groups. Turbuhaler and Diskus techniques were assessed by using published 9-point checklists specific for each device.5Van der Palen J. Klien J. Schildkamp A. Comparison of a new multidose powder inhaler (Diskus/Accuhaler) and the Turbuhaler regarding preference and ease of use.J Asthma. 1998; 35: 147-152Crossref PubMed Scopus (81) Google Scholar One hundred sixteen patients were enrolled, and 97 (84%) completed the study. At entry, correct inhaler technique was displayed by 7% of Turbuhaler users and 13% of Diskus users (Table I). Inhaler technique education took an average of 2.5 minutes per patient per visit. The intervention had a significant effect on inhaler technique and clinical and humanistic outcomes for both the Turbuhaler and Diskus groups. At 3 months, the correct technique was demonstrated by 85% of active Turbuhaler users and 96% of active Diskus users (control group not assessed). There was a significant difference in the proportion of Turbuhaler and Diskus users who were able to demonstrate correct technique after 6 months compared with the control group (Turbuhaler: 10/20 [50%] vs 2/14 [14%], P = .032; Diskus: 23/29 [79%] vs 3/21 [14%], P < .001, χ2 test). In the Turbuhaler active group there was a significantly greater proportion of patients demonstrating correct technique at each visit compared with baseline, with a slight trend toward a decrease between 3 and 6 months (P = .531, χ2 test). Results were similar for the Diskus group.Table IBaseline demographics and asthma management characteristics for asthmatic patientsDiskusTurbuhalerVariableActive (n = 30)Control (n = 24)Active (n = 23)Control (n = 20)Female sex (n [%])22 (73)14 (58)14 (61)9 (45)Age (y; mean [SD])51.4 (8.3)41.1 (20.0)45.48 (19.7)38.85 (18.4)Duration of preventer use (y [SD])1.7 (0.3)2.2 (1.9)2.6 (3.5)2.4 (2.9)Min%Max∗Min%Max (an index of peak expiratory flow variability) was calculated as the lowest morning peak expiratory flow over 2 weeks expressed as a percentage of the highest peak expiratory flow over the same 2-week period.6 (mean [SD])71.5 (9.7)76.0 (7.2)74.8 (9.2)71.2 (8.7)AQOL†AQOL7: range, 0 to 4 (best→worst). (mean [SD])1.6 (0.8)1.5 (0.7)1.5 (0.9)1.5 (0.5)PCAQ‡PCAQ (perceived control of asthma questionnaire)8: range, 0 to 55 (worst→best). (mean [SD])36.4 (6.4)39.6 (5.5)38.1 (5.6)38.1 (4.7)Patients with correct technique (n [%])3 (10)4 (17.4)2 (8.7)1 (5.3)∗ Min%Max (an index of peak expiratory flow variability) was calculated as the lowest morning peak expiratory flow over 2 weeks expressed as a percentage of the highest peak expiratory flow over the same 2-week period.6Reddel H.K. Salome C.M. Peat J.K. Woolcock A.J. Which index of peak expiratory flow is most useful in the management of stable asthma?.Am J Respir Crit Care Med. 1995; 151: 1320-1325Crossref PubMed Scopus (125) Google Scholar† AQOL7Marks G.B. Dunn S.M. Woolcock A.J. A scale for the measurement of quality of life in adults with asthma.J Clin Epidemiol. 1992; 45: 461-472Abstract Full Text PDF PubMed Scopus (347) Google Scholar: range, 0 to 4 (best→worst).‡ PCAQ (perceived control of asthma questionnaire)8Katz P.P. Yelin E.H. Eisner M.D. Blanc P.D. Perceived control of asthma and quality of life among adults with asthma.Ann Allergy Asthma Immunol. 2002; 89: 251-258Abstract Full Text PDF PubMed Scopus (88) Google Scholar: range, 0 to 55 (worst→best). Open table in a new tab Improvements in Turbuhaler and Diskus inhaler technique were reflected in improved clinical outcomes. Min%Max (index of peak expiratory flow variability)6Reddel H.K. Salome C.M. Peat J.K. Woolcock A.J. Which index of peak expiratory flow is most useful in the management of stable asthma?.Am J Respir Crit Care Med. 1995; 151: 1320-1325Crossref PubMed Scopus (125) Google Scholar at 3 months and 6 months adjusted for baseline was significantly higher (indicating less variability) for active compared with control patients (3 months: 83.8% ± 8.3% [mean ± SD] vs 77.6% ± 9.2%, P < .001; 6 months: 78.9% ± 9.7% vs 74.4% ± 8.9%, P = .002, 1-way analysis of covariance). When Turbuhaler and Diskus data were analysed separately, both groups showed a significant improvement in Min%Max (reduced variability) between the active and control groups at 3 months (Turbuhaler: 86.2% ± 7.0% vs 76.8% ± 9.8%, P = .005; Diskus: 82.1% ± 8.8% vs 78.5% ± 8.9%, P < .001), with a significant difference at 6 months only for Diskus (78.3% ± 7.9% vs 75.2% ± 8.8%, P = .005). For both inhaler groups combined, there were statistically significant and clinically important differences in asthma-related quality of life (AQOL)7Marks G.B. Dunn S.M. Woolcock A.J. A scale for the measurement of quality of life in adults with asthma.J Clin Epidemiol. 1992; 45: 461-472Abstract Full Text PDF PubMed Scopus (347) Google Scholar and perceived control (PC)8Katz P.P. Yelin E.H. Eisner M.D. Blanc P.D. Perceived control of asthma and quality of life among adults with asthma.Ann Allergy Asthma Immunol. 2002; 89: 251-258Abstract Full Text PDF PubMed Scopus (88) Google Scholar between the active and control groups at 3 months (AQOL: 0.8 ± 0.5 vs 1.35 ± 0.6; PC: 44.0 ± 5.7 vs 39.5 ± 4.4) and 6 months (AQOL: 0.8 ± 0.6 vs 1.3 ± 0.6; PC: 43.8 ± 4.9 vs 39.8 ± 4.0; P < .001 for each; 1-way analysis of covariance). Similar results were seen in the Turbuhaler and Diskus groups separately. In summary, this study demonstrated that a simple educational intervention taking only 2.5 minutes and targeting inhaler technique was feasible for delivery by community pharmacists and resulted in improved clinical and humanistic outcomes for patients with asthma. Active patients had significantly better inhaler technique, reduced peak expiratory flow variability, and improved AQOL and PC of asthma than control patients. For patients in the active group, inhaler technique, although maintained during monthly retraining, tended to decline over the final 3 months during which no further education was delivered. This was associated with a decrease in some asthma outcomes. These observations confirm that rechecking and re-educating patients about inhaler technique needs to be a regular and ongoing process. Community pharmacists are well placed to do this because they can engage the patient every time an inhaler is dispensed. This study thus highlights the critical role of face-to-face pharmacist-patient interactions about inhaled medications. Improved inhaler technique will have an effect on asthma control and health care use.