Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique

Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique

Patient Education and Counseling 72 (2008) 26–33 www.elsevier.com/locate/pateducou Evaluation of a novel educational strategy, including inhaler-base...

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Patient Education and Counseling 72 (2008) 26–33 www.elsevier.com/locate/pateducou

Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique Iman A. Basheti a, Carol L. Armour a, Sinthia Z. Bosnic-Anticevich a, Helen K. Reddel b,* b

a Faculty of Pharmacy, University of Sydney, Australia Woolcock Institute of Medical Research, University of Sydney, P.O. Box M77, Missenden Road PO, Camperdown, NSW 2050, Australia

Received 7 December 2007; accepted 5 January 2008

Abstract Objective: To evaluate the feasibility, acceptability and effectiveness of a brief intervention about inhaler technique, delivered by community pharmacists to asthma patients. Methods: Thirty-one pharmacists received brief workshop education (Active: n = 16, Control: n = 15). Active Group pharmacists were trained to assess and teach dry powder inhaler technique, using patient-centered educational tools including novel Inhaler Technique Labels. Interventions were delivered to patients at four visits over 6 months. Results: At baseline, patients (Active: 53, Control: 44) demonstrated poor inhaler technique (mean  S.D. score out of 9, 5.7  1.6). At 6 months, improvement in inhaler technique score was significantly greater in Active cf. Control patients (2.8  1.6 cf. 0.9  1.4, p < 0.001), and asthma severity was significantly improved ( p = 0.015). Qualitative responses from patients and pharmacists indicated a high level of satisfaction with the intervention and educational tools, both for their effectiveness and for their impact on the patient–pharmacist relationship. Conclusion: A simple feasible intervention in community pharmacies, incorporating daily reminders via Inhaler Technique Labels on inhalers, can lead to improvement in inhaler technique and asthma outcomes. Practice implications: Brief training modules and simple educational tools, such as Inhaler Technique Labels, can provide a low-cost and sustainable way of changing patient behavior in asthma, using community pharmacists as educators. # 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Asthma; Community pharmacists; Patient education; Educational tools; Inhaler technique; Counseling; Feasibility; Turbuhaler; Diskus

1. Introduction One of the most important goals of patient management in chronic illnesses is to achieve long-term changes in patient behavior, particularly those relating to self-care. This is particularly important in asthma [1], a chronic disease with a major burden of symptoms, health care utilization, lost productivity or schooling, and cost of medications on the individual and the community [2,3]. Unlike many other chronic diseases, the medications used for asthma management are not primarily taken by tablet or capsule but by inhalation, to optimize delivery to the target organ. Obtaining the full therapeutic effect requires not only good adherence (itself a

* Corresponding author at: Woolcock Institute of Medical Research, P.O. Box M77, Missenden Road PO, Camperdown, NSW 2050, Australia. Tel.: +61 2 9515 7026; fax: +61 2 9550 5865. E-mail address: [email protected] (H.K. Reddel). 0738-3991/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.01.014

challenge [1]) but also correct use of the inhaler. This involves a series of steps which need to be performed correctly to ensure adequate medication delivery and minimize side effects. Incorrect use of inhalers leads to poor asthma control, increased hospital visits and increased cost of treatment [4–6]. It can also increase side effects due to increased medication deposition in the upper airway. In addition, incorrect inhaler technique can reinforce poor medication adherence, because of patient dissatisfaction with suboptimal response [7]. Unfortunately, incorrect inhaler technique is remarkably common; this is estimated to translate into $US7–15.7 billion wasted in the US each year because of incorrect asthma inhaler use [8]. As a result, international guidelines stress the importance of checking inhaler technique [9]. Dry powder inhalers such as the Turbuhaler and Diskus (Accuhaler) were originally introduced in order to avoid known problems of poor technique with pressurized metered dose inhalers. However, inhaler technique is also a problem with dry powder devices, with 23–54% of Turbuhaler users [10,11] and

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24–50% of Diskus users [10,11] found to have incorrect technique. Education to improve inhaler technique should thus be an important component of patient education in asthma, regardless of the inhaler device. Unfortunately, the health care professionals who might be expected to deliver such education as part of routine asthma management perform very little better than patients in their ability to use asthma inhaler devices. The rate of incorrect inhaler technique amongst health care professionals ranges from 31–85% [4,12–14], with problems being found at similar levels amongst doctors [12], nurses [15], and community pharmacists [16–18]. A variety of methods have been used for educating patients about correct inhaler technique. Provision of the manufacturer’s instruction sheet alone is ineffective [19], even for those who read the leaflet [10]. Personal instruction by a pharmacist is more effective than written instruction [20], and inclusion of a physical demonstration leads to improved inhaler technique [21,22]. It has been established that inhaler technique education must be repeated regularly in order to maintain correct technique [23,24]. However, after such education, it cannot be assumed that patient behavior will change. Brennan and colleagues distinguished between ‘‘competence’’ and ‘‘contrivance’’ with inhalers; following education, patients with asthma may demonstrate correct use of their devices to the health care professional, but then choose to use the device in a suboptimal manner [25]. This can explain why patients revert to their poor technique when they get home after inhaler technique education [26]. Therefore, new strategies need to be evaluated to address this aspect of patient behavior when educating patients with asthma about inhaler technique [25]. We now describe an innovative approach to education about inhaler technique, in patients with asthma. This program used a ‘‘Train-the-Trainer’’ approach, in which community pharmacists were taught how to educate their patients to correctly use dry powder inhalers, using a novel educational tool to provide daily education between dispensing visits. We recently described part of our study which involved a randomized controlled trial [27]. We now detail the educational methods, and report the qualitative feedback from participants, together with the impact of the intervention on inhaler technique score and asthma severity.


corticosteroid/long-acting b2-agonist) by Turbuhaler or Diskus. After a 2-week run-in period to assess baseline status, the pharmacists delivered the educational intervention and assessments, and repeated this process after 1, 2, 3 and 6 months. Patient assessments took place between April 2003 and 2004. 2.2. Pharmacist education Pharmacists attended one of three evening workshops in the Faculty of Pharmacy at the University of Sydney. After arrival, pharmacists were allocated randomly by computer-generated list to Active or Control groups. During the workshops, all pharmacists received general information about asthma, inhaled medications, and peak flow meter technique. The pharmacists’ inhaler technique was scored on Turbuhaler and Diskus using published checklists (see Section 2.4), without any feedback being given. Pharmacists were then separated into their randomization groups for the remainder of the workshop, in which they were shown how to teach peak flow meter technique and complete the data collection forms. The Active group pharmacists were also trained to assess and educate patients about Turbuhaler and Diskus technique. The study materials which were provided to pharmacists included Inhaler Technique Labels, a novel educational tool (see Section 2.5). The Active group workshop concluded with re-assessment of the pharmacists’ inhaler technique, with any residual problems corrected before patient recruitment commenced. 2.3. Patient recruitment Pharmacists were asked to approach patients presenting Turbuhaler or Diskus prescriptions for asthma during a predetermined period, with the aim of recruiting 2–4 patients using each device. Patient inclusion criteria were: age 14 years, doctor-diagnosed asthma, use of inhaled corticosteroid by Turbuhaler or Diskus with or without long-acting b2-agonist, and no change in asthma medication or dose for 1 month. Patients were excluded if they did not self-administer their medication, did not speak or understand English, were not able to return for all visits, or were involved in another study. 2.4. Inhaler technique and asthma assessments

2. Methods 2.1. Overall study design Ethics approval was obtained from the University of Sydney Human Ethics Committee, and pharmacists and patients gave written informed consent. The study had a single-blind cluster randomized parallel group design. Community pharmacists were trained in a workshop to deliver education on peak flow meter technique and Turbuhaler and Diskus technique (Active group), or peak flow meter technique alone (Control group); the pharmacists then recruited asthma patients who were taking controller treatment (inhaled corticosteroid or inhaled

At Visit 1 (Screening), demographic and baseline data were collected. Both groups of pharmacists educated the patients on measurement of peak expiratory flow (PEF) for assessment of peak flow variability [28], using a MiniWright or AirZone peak flow meter. Active pharmacists also assessed their patients’ Turbuhaler or Diskus technique on a placebo inhaler, without giving any feedback to patients as to whether their technique was correct. Inhaler technique was scored using checklists developed from published data and unpublished qualitative research (Table 1) [11,21]. One point was assigned for each correctly performed step, giving a maximum Inhaler Technique score of 9 for each device.


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Table 1 Inhaler Technique Checklists used in the study Number



1 2 3 4 5 6 7 8 9

Remove the cap from the inhaler Keep inhaler upright Rotate grip anti-clockwise then back until a click is heard Exhale to residual volume Exhale away from the mouthpiece Place mouthpiece between teeth and lips Inhale forcefully and deeply Hold breath for 5 s Exhale away from mouthpiece

Open inhaler Push lever back completely Exhale to residual volume Exhale away from mouthpiece Mouthpiece between teeth and lips Inhale forcefully and deeply Hold breath for 5 s Exhale away from mouthpiece Close inhaler


Checklist for Turbuhaler technique

Checklist for Diskus technique

Checklists based on previous published literature [11,21].

During the run-in period, one researcher (IB) independently assessed inhaler technique for half of the Active patients (for independent confirmation of the pharmacists’ baseline assessments) and for all Control patients (to establish their baseline inhaler technique without providing information about correct inhaler technique to the Control pharmacists). No education was provided to patients during these assessments. The primary outcome variable for the study was peak flow variability, calculated as Min%Max (lowest morning PEF over 2 weeks, as a percentage of highest PEF over the same period) [28], which, together with patient-centered outcomes, was reported elsewhere [27]. Secondary outcome variables included Inhaler Technique Score, and categorization of asthma severity based on the Australian Asthma Management Handbook [29]. Patients in both groups returned for follow-up assessments at 1, 2, 3 and 6 months. All patients were given reminder calls for follow-up visits and to commence the PEF diary. 2.5. Pharmacist–patient educational intervention and the Inhaler Technique Labels At Visit 2, Active pharmacists again assessed patients’ inhaler technique on the placebo inhaler, then educated the patient using a specialized ‘‘Show and Tell’’ Inhaler Technique counseling service based on our previously published methods [21], going through each step on the checklist to describe and demonstrate correct use. This cycle of assessment and counseling was repeated up to three times if necessary, until the patient had correct technique on all steps (Fig. 1). At the completion of counseling, the pharmacist used a highlighter pen to identify any incorrect steps from that day’s initial assessment on an ‘‘Inhaler Technique Label’’ which was preprinted with the relevant checklist (Table 1, Fig. 2). The pharmacist attached the highlighted label to the patient’s own controller medication inhaler (not the box), without covering any essential information. Pharmacists recorded the time taken for inhaler technique assessment/education. At each subsequent visit, Active pharmacists repeated inhaler technique assessment/education, and a new label was placed on the patient’s replacement inhaler (or on the old one if still in use). If no steps were incorrect on the initial assessment at any visit, the label was attached to the patient’s inhaler with no highlighting. Any new inhalers dispensed after the 3-month

visit were not given an Inhaler Technique Label. An investigator (IB) observed each pharmacist’s delivery of inhaler technique education to one patient early during patient recruitment, to identify any problems with understanding or use of the study tools or data collection forms. For Control patients, the researcher re-assessed inhaler technique at the end of the study, then provided Inhaler Technique counseling. During the study, all comments (positive or negative) which were made by pharmacists or patients to the investigators about the study or the educational intervention were recorded in writing, with the permission of the participant. 2.6. Statistical analysis Sample size for patients was based on peak flow variability, with 19 subjects required in each of the four treatment groups (Turbuhaler or Diskus, Active or Control), to detect a clinically important difference of change in Min%Max of 5.5  8.4 percentage points ( p < 0.05, power 80%) [30]. Sample size was increased to 28 for each group (total 112) to allow for dropouts, but given the small cluster size (1–4 patients/inhaler type/ pharmacist), no adjustment was needed for the cluster design [31]. Data were analysed by intention to treat, using Statistical

Fig. 1. Inhaler Technique Education. The specialized Inhaler Technique Education included initial assessment and education about incorrect steps, with reassessment and re-education repeated up to a further two times until correct technique was observed. Incorrect steps from the first assessment were highlighted on the Inhaler Technique Label (as shown in Fig. 2).

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Fig. 2. Novel Inhaler Technique Labels. At each visit, the Inhaler Technique Label was highlighted with any steps which the patient performed incorrectly at initial assessment. A colour photograph of the inhaler labels, with highlighting of problem steps, is available on the journal website.

Package for Social Science (SPSS) version 12, with p values of 0.05 considered statistically significant. For continuous variables, the difference between Active and Control groups after 3 and 6 months was evaluated by one-way ANCOVA, controlling for baseline. Comparisons between groups were performed by Independent sample T test, Wilcoxon signed-rank test, Mann–Whitney U-test and Chi-square test. 3. Results 3.1. Pharmacists Sixteen pharmacists were randomized to the Active group, and 15 to the Control group. At baseline, correct inhaler technique (score 9/9) was demonstrated by only 13 and 6% of pharmacists on Turbuhaler and Diskus respectively, with no significant difference between randomization groups. After the workshop, all Active group pharmacists achieved correct technique on both devices. Three pharmacists (1 Active, 2 Control) withdrew before recruiting any patients, and 15 Active and 12 Control pharmacists completed the study.

3.2. Patients’ inhaler technique score One hundred sixteen patients were enrolled, and 97 (43 Turbuhaler, 54 Diskus) returned for Visit 2 after the run-in period. Patients had been using their controller medication for an average of 2–3 years, and at baseline, 74% reported that they believed that they were using their inhaler correctly. However, on objective testing, only 10% of patients demonstrated correct technique. Mean (S.D.) Inhaler Technique Score at baseline was 5.5 (1.5) for Turbuhaler users and 5.9 (1.7) for Diskus users (maximum score 9). There was no significant difference between the pharmacists’ and the investigator’s scoring of patients’ inhaler technique. Mean Inhaler Technique Score improved significantly from baseline to 6 months for both Active and Control groups (Fig. 3A and B), but the magnitude of improvement was significantly greater for Active than Control patients (for both inhalers combined, change in score was 2.8  1.6 (mean  S.D.) cf. 0.9  1.4, p < 0.001). There was a small decrease in score in the Active group between 3 and 6 months, when no education was received by the patients; the inhaler technique of Control group

Fig. 3. Inhaler Technique Score. Change in patients’ Inhaler Technique Score (out of 9) for Turbuhaler (left panel) and Diskus (right panel). Graphs show mean and 95% confidence intervals. Active group is shown in black and Control group in gray.


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patients was not assessed at 3 months in order to avoid drawing their attention to inhaler technique.

‘‘. . . I loved the stickers; it made my patients feel happy and satisfied, especially when I did not highlight any steps, that way they felt the progress with every visit.’’

3.3. Feasibility of the inhaler technique intervention The intervention, in terms of the time taken, was highly feasible. At the first intervention visit (Visit 2), the inhaler technique component (assessment, education, and highlighting of the Inhaler Technique Label) took 5.0  2 min (median  IQR), with a median of 3  1 assessment/education cycles. At subsequent visits, the inhaler technique intervention took 2  2 min (1 month), 1  1 min (2 months), and 1  0 min (3 months), with no significant difference between Turbuhaler and Diskus. At 6 months, more Turbuhaler users required education than Diskus users (50% cf. 21%, p = 0.07), and hence the inhaler technique intervention took longer (2.5  2.0 cf. 1.0  0.0 min respectively; p = 0.018). 3.4. Qualitative feedback about inhaler technique education and study tools The majority of Active pharmacists volunteered that the educational intervention was ‘‘effective’’ and ‘‘valuable’’, and that it also had a positive impact on their relationship with their patients. Nine pharmacists commented that they retained copies of the Inhaler Technique Checklists and used them to educate non-study patients about inhaler technique. Representative comments from pharmacists were: ‘‘. . . My patients struggled with reading the Product Information leaflets [packaged with medications] because of language problems; I think I underestimated how much that was affecting their asthma management and their inhaler technique . . . it can make a big difference.’’ ‘‘. . . I am now much more confident talking to customers about how to use their TH [Turbuhaler], ACC [Diskus], and PFM [peak flow meter]. One of the really good aspects of the trial was getting to know a few customers well and building ‘special’ relationships with them. I think one of the other advantages is that people perceive us now as being caring pharmacists, interested in their health outcomes.’’ ‘‘. . . This study was most beneficial, and the staff has picked up the extra standard of care, it is really simple, once you know what to do.’’ Active group pharmacists volunteered many enthusiastic comments about the Inhaler Technique Labels themselves, such as: ‘‘. . . The stickers were a simple yet effective way of reminding my patients of how to use their inhalers correctly, and of the steps they need to take extra care of.’’ ‘‘. . . I think the labels made my patients feel unique, and it helped them to remember at all times how their Seretide [Advair] should be used.’’

Spontaneous comments about the Inhaler Technique Labels from patients, documented by the pharmacists, included: ‘‘. . . It really helped, especially that I was using different types of inhalers, which can be confusing sometimes.’’ ‘‘. . . It reminded me of my mistakes later on, so I became conscious not to do them again.’’ ‘‘. . . It always reminded me of what the pharmacist told me at the pharmacy. . .’’ ‘‘. . . It made me feel special, like, this is my puffer, not just a puffer. . .’’ There were some negative comments about study paperwork from both Active and Control pharmacists, and from patients, about the difficulty of completing the three 2-week study diaries. One pharmacist suggested that we should also provide checklists enhanced with symbols or photographs, to assist with elderly patients or those with language difficulties or visual impairment. 3.5. Asthma-related outcomes At baseline, asthma severity was classified according to national guidelines [29] as mild in 10%, moderate in 34% and severe in 56% of patients. Mean reliever use was 1.7  1.4 puffs/day. In the Active group, asthma severity was significantly reduced at 2 months ( p = 0.001), 3 months ( p < 0.001) and 6 months ( p = 0.015) compared with the Control group (Fig. 4A and B). By 3 months, only 8% of Active group patients were classified as having severe asthma compared with 22% of Control group patients ( p = 0.037). There was a trend towards lower reliever use over time in the Active group, which was not significantly different to the Control group when adjusted for baseline. Post hoc analysis demonstrated a significant correlation between improvement in Inhaler Technique Score and improvement in both PEF variability (r = 0.31, p = 0.008) and asthma-related quality of life (r = 0.37, p = 0.001). No clinically important adverse events were reported during the study. 4. Discussion and conclusions 4.1. Discussion This study demonstrated that a simple educational intervention by pharmacists about inhaler technique, which could be taught in a brief workshop, was feasible for delivery in community pharmacies. The findings reinforce the need for repeat assessment and education at each visit. A novel component of the educational intervention was the use of

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Fig. 4. Change in asthma severity. Figure shows Active group (upper panel) and Control group (lower panel), with both inhaler types combined. Asthma severity was significantly better in the Active group at 2 months ( p = 0.001), 3 months ( p < 0.001) and 6 months ( p = 0.015). Asthma severity was assessed by a modification of the criteria in the Asthma Management Handbook [29]. See text for details.

Inhaler Technique Labels, which were personalized at every visit for the patient’s current inhaler skills, and provided dailycustomized instruction between pharmacy-based educational sessions. Inhaler Technique Checklists have often been used to collect objective data about inhaler technique during clinical trials [11,21], but this study was unique by also incorporating them into the ‘‘show-and-tell’’ education and into novel ‘‘Inhaler Technique Labels’’ (Fig. 2) which were attached to the inhalers. The inhaler labels themselves provided a simple visual aid, acting both as a daily reminder of correct technique, and as visit-by-visit evidence of progress. In most previous studies of inhaler technique education, the intervention has been delivered only at the study site [32]. However, interval education alone may not be sufficient to change behavior in patients with chronic illness. A few studies have provided take-home materials such as written instructions [20], video instructions [33,34], or checklists [34], but patients must remember and choose to use such supplementary material for it to provide any benefit. In fact, people with asthma report that medication leaflets are not useful, often throwing them away [35]. By contrast, the Inhaler Technique Labels used in the present study were attached to the device, and would be seen every time that it was used. Highlighting of each patient’s most problematic steps may have encouraged patients to take extra care with these steps when using their inhaler devices. This may have served to resolve an important, recently identified problem with use of inhaler devices. Immediately after education, patients may be able to demonstrate the effective use of their inhalers (‘‘competence’’), but they may subsequently choose to use them in a different – suboptimal – manner (‘‘contrivance’’) [25]. This may be due to patients’ low motivation to change their behavior [1]. For example, the instruction to ‘‘breathe in


forcefully and deeply’’ may mean that patients need to change their customary breathing pattern when taking inhaled medication. The use of labels on the devices provided a mechanism by which patients could repeatedly check and selfcorrect their technique between visits. This could have reinforced, at every use, the importance of using the inhaler correctly, leading to a gradual change in behavior and maintenance of correct technique. The cost of this approach is minimal, compared with strategies such as store-and-forward digital videos of patients using their inhalers [36]. Highlighting a patient’s problem steps at each visit may also have emphasized the individualized nature of the education. This was suggested by qualitative feedback from pharmacists and patients, encapsulated in the comment ‘‘It made me feel special, like, this is my puffer, not just a puffer . . .’’. In cardiopulmonary rehabilitation, customization of videotaped educational material is more effective than standardized videotapes [37]. In the present study, pharmacists reported that patients were encouraged at follow-up visits by seeing a reduction in the number of highlighted steps (‘‘. . . that way they felt the progress with every visit’’). This may also have avoided the boredom which would accompany repeated administration of the same educational routine. Although we know that inhaler technique education must be repeated in order to sustain correct inhaler technique [23,24], patients may not perceive this need [7,38]. In an earlier study, we found that patients whose randomized intervention consisted of the pharmacist merely reading through the inhaler instructions were less likely to return for subsequent visits than those who had received a hands-on demonstration [39]. Although the educational strategy, and particularly the labels, drew enthusiastic comments from the majority of pharmacists and patients, this feedback was not collected prospectively, which may have resulted in bias. The specific contribution of the Inhaler Technique Labels themselves to the study outcomes cannot be assessed from the present study, and should be evaluated directly in further studies in larger populations. Further work is also needed to establish the utility of Inhaler Technique Labels for patient populations with special needs (e.g. those with problems of literacy or visual impairment). The study used a cluster design, with pharmacists randomized to learn the Active or Control education, then recruiting patients to whom they delivered that education. Providing a suitable control activity is always a challenge for non-pharmacological studies [40]. In this study, we blinded pharmacists and patients by teaching both groups how to educate patients in correct peak flow meter technique. This not only ensured accurate data collection, but also provided a plausible ‘‘sham’’ intervention for the Control group. This is the first study to report the effect of inhaler technique education alone, on objective asthma outcomes. One previous randomized controlled study reported subjective improvements in dyspnea in patients with COPD or asthma after inhaler technique instruction from a practice assistant, but no objective measures were recorded [41]. Studies of complex pharmacybased interventions, which incorporated inhaler technique as


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one aspect of extensive asthma education packages, have improved clinical and humanistic asthma outcomes [42–45], but these studies required up to two days of pharmacist training and over 30 min per patient visit [45]. In contrast, the present inhaler technique intervention took an average of only 2.5 min per visit, which is short enough to be feasible during routine dispensing procedures. In the Active group, the magnitude of improvement in asthma-related outcomes was similar to differences which are considered as clinically important in conventional clinical trials. The observed (albeit smaller) improvements in the Control group may have been due to increased contact with the pharmacists, or the provision of general asthma information. The study confirmed previous observations of the need for repetition of education in order to maintain correct inhaler technique long-term [23,24]. Such repetition is feasible in typical pharmacy practice, as patients have more frequent contact with pharmacists than with prescribing clinicians. Although pharmacists are expected to advise patients about how to use other medications such as antibiotics, few pharmacists actually assess their patients’ inhaler technique or provide education about inhaler technique [46,47]. This represents a lost opportunity, given the known deleterious consequences of poor inhaler technique [5,6,8,48]. 4.2. Conclusions This study demonstrated that a brief educational intervention about inhaler technique, delivered by community pharmacists, was feasible within routine dispensing practice, and was effective for improving both inhaler technique and asthma outcomes, although repeated education was required in order to avoid loss of skills. Such education represents an inexpensive way of improving asthma control in the community. The use of personalized Inhaler Technique Labels as educational tools was integral to the design of this study. Although their specific contribution to the beneficial outcomes cannot be established from the present study, the labels drew enthusiastic comments from both patients and pharmacists. It is plausible that, for patients with chronic illness, reminders which would automatically be seen each time a desired behavior was attempted would be more effective than instructions given only at interval visits. 4.3. Practice implications Patients are mostly unaware that their inhaler technique is faulty, and are therefore unlikely to seek out education from a health care professional. Pharmacists, like other health care professionals, should undergo specific assessment and instruction in inhaler technique. Brief training modules and simple educational tools, such as Inhaler Technique Labels, can provide a low-cost and sustainable way of improving asthma outcomes, using community pharmacists as educators. Optimal inhaler technique education, including a physical demonstration by the patient, confirmation by the pharmacist that

correct technique has been achieved, and application of an Inhaler Technique Label, can be carried out in a few minutes, and is therefore feasible for inclusion in normal dispensing practice. If the results of this proof-of-concept study are confirmed in broader populations, health policy should be changed to include inhaler technique education as a routine part of the dispensing of inhaled asthma medications. 4.4. Confidentiality I confirm that all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story. Acknowledgements This study was funded by the Faculty of Pharmacy, University of Sydney. HR was funded by the Asthma Foundation of NSW. Placebo inhalers were provided by AstraZeneca and GlaxoSmithKline. IB, SB and CA have no conflicts of interest to declare. HR is a member of national Advisory Boards for AstraZeneca and GlaxoSmithKline, and her employer, the Woolcock Institute of Medical Research, has received research funding, consultancy payments and travel grants from AstraZeneca, GlaxoSmithKline and BoehringerIngelheim. References [1] Bender BG. Overcoming barriers to nonadherence in asthma treatment. J Allergy Clin Immunol 2002;109:S554–9. [2] Goldney RD, Ruffin R, Fisher LJ, Wilson DH. Asthma symptoms associated with depression and lower quality of life: a population survey. Med J Aust 2003;178:437–41. [3] Sawyer SM, Fardy HJ. Bridging the gap between doctors’ and patients’ expectations of asthma management. J Asthma 2003;40:131–8. [4] Chopra N, Oprescu N, Fask A, Oppenheimer J. Does introduction of new ‘‘easy to use’’ inhalational devices improve medical personnel’s knowledge of their proper use? Ann Allergy Asthma Immunol 2002;88:395– 400. [5] Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19:246–51. [6] McFadden Jr ER. Improper patient techniques with metered dose inhalers: clinical consequences and solutions to misuse. J Allergy Clin Immunol 1995;96:278–83. [7] Osman L. How do patients’ views about medication affect their selfmanagement in asthma? Patient Educ Counselling 1997;32:S43–9. [8] Fink JB. Inhalers in asthma management: is demonstration the key to compliance? Respir Care 2005;50:598–600. [9] Global Initiative for Asthma. Global strategy for asthma management and prevention; 2006 [cited August 2007]. Available from: http://www.ginasthma.com. [10] Melani AS, Zanchetta D, Barbato N, Sestini P, Cinti C, Canessa PA, Aiolfi S, Neri M. Inhalation technique and variables associated with misuse of conventional metered-dose inhalers and newer dry powder inhalers in experienced adults. Ann Allergy Asthma Immunol 2004;93:439–46. [11] van der Palen J, Klein JJ, Schildkamp AM. Comparison of a new multidose powder inhaler (Diskus/Accuhaler) and the Turbuhaler regarding preference and ease of use. J Asthma 1998;35:147–52. [12] Hanania NA, Wittman R, Kesten S, Chapman KR. Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers,

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