Interventions to improve inhaler technique for people with asthma.

BACKGROUND: Asthma is a common chronic disease worldwide. Inhalers are often prescribed to help control asthma symptoms, improve quality of life and reduce the risk of exacerbations or flare-ups. However, evidence suggests that many people with asthma do not use their inhaler correctly. It is therefore important to evaluate whether interventions aimed specifically at improving technique are effective and safe, and whether use of these interventions translates into improved clinical outcomes. OBJECTIVES: To assess the impact of interventions to improve inhaler technique on clinical outcomes and safety in adults and children with asthma. SEARCH METHODS: We searched the Cochrane Airways Trials Register, which contains records compiled from multiple electronic and handsearched resources. We also searched trial registries and reference lists of primary studies. We conducted the most recent search on 23 November 2016. SELECTION CRITERIA: We included studies comparing a group of adults or children with asthma receiving an inhaler technique intervention versus a group receiving a control or alternative intervention. We included parallel and cluster-randomised trials of any duration conducted in any setting, and planned to include only the first phase of any cross-over trials identified. We included studies reported as full-text articles, those published as abstracts only and unpublished data. DATA COLLECTION AND ANALYSIS: Two review authors screened the search results for eligible studies. We extracted outcome data, assessed risk of bias in duplicate and resolved discrepancies by involving another review author. We grouped studies making similar comparisons by consensus (e.g. all those comparing enhanced inhaler technique education vs usual care) and conducted meta-analyses only if treatments, participants and the underlying clinical question were similar enough for pooling to make sense. We analysed dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences, all with random-effects models. We described skewed data narratively. We graded the results and presented evidence in 'Summary of findings' tables for each comparison. Primary outcomes were inhaler technique, asthma control and exacerbations requiring at least oral corticosteroids (OCS). MAIN RESULTS: This review includes 29 parallel randomised controlled trials (RCTs) (n = 2210), although not all reported relevant or useable data. All participants had asthma, and follow-up ranged from 2 to 26 weeks. Most studies were at low or unclear risk of selection and attrition biases and at high risk for biases associated with blinding. We considered most of the evidence to be of low quality owing to these biases and to imprecision in the estimates of effect.We classified studies into three comparisons: enhanced face-to-face training session(s), multi-media-delivered inhaler training (e.g. DVD, computer app or game) and technique feedback devices. Differences between interventions, populations and outcome measures limited quantitative analyses, particularly for exacerbations, adverse events, unscheduled visits to a healthcare provider and absenteeism from work or school.Enhanced inhaler technique education and multi-media training improved technique in most studies immediately after the intervention and at follow-up, although the variety of checklists used meant that this was difficult to assess reliably. For both adults and children, how and when inhaler technique was assessed appeared to affect whether inhaler technique improved and by how much.Analyses of the numbers of people who demonstrated correct or 'good enough' technique were generally more useful than checklist scores. Adult studies of enhanced education showed benefit when this metric was used at 2 to 26 weeks' follow-up (odds ratio (OR) 5.00, 95% confidence interval (CI) 1.83 to 13.65; 258 participants; three studies; 31 per 100 with correct technique in the control group compared with 69 (95% CI 45 to 86) in the education group; moderate-quality evidence). A similar result was seen in studies looking at feedback devices at four weeks' follow-up (OR 4.80, 95% CI 1.87 to 12.33; 97 participants; one study; 51 per 100 with correct technique in the control group compared with 83 (95% CI 66 to 93) in the feedback group; low-quality evidence). However, the benefit of multi-media training for adults even immediately after the intervention was uncertain (OR 2.15, 95% CI 0.84 to 5.50; 164 participants; two studies; I² = 49%; 30 per 100 in the control group with correct technique compared with 47 (95% CI 26 to 70) in the multi-media group; moderate-quality evidence). Evidence tended to be less clear for children, usually because results were based on fewer and smaller studies.Some studies did not report exacerbations in a way that allowed meta-analysis; others provided inconclusive results. Inhaler technique interventions provided some benefit for asthma control and quality of life but generally did not lead to consistent or important clinical benefits for adults or children. Confidence intervals included no difference or did not reach a threshold that could be considered clinically important. Responder analyses sometimes showed improvement among more people in the intervention groups, even though the mean difference between groups was small. We found no evidence about harms. AUTHORS' CONCLUSIONS: Although interventions to improve inhaler technique may work in some circumstances, the variety of interventions and measurement methods used hampered our ability to perform meta-analyses and led to low to moderate confidence in our findings. Most included studies did not report important improvement in clinical outcomes. Guidelines consistently recommend that clinicians check regularly the inhaler technique of their patients; what is not clear is how clinicians can most effectively intervene if they find a patient's technique to be inadequate, and whether such interventions will have a discernible impact on clinical outcomes

A Predictive Machine Learning Tool for Asthma Exacerbations: Results from a 12-Week, Open-Label Study Using an Electronic Multi-Dose Dry Powder Inhaler with Integrated Sensors

Purpose: Machine learning models informed by sensor data inputs have the potential to provide individualized predictions of asthma deterioration. This study aimed to determine if data from an integrated digital inhaler could be used to develop a machine learning model capable of predicting impending exacerbations. Patients and Methods: Adult patients with poorly controlled asthma were enrolled in a 12-week, open-label study using ProAir® Digihaler®, an electronic multi-dose dry powder inhaler (eMDPI) with integrated sensors, as reliever medication (albuterol, 90 µg/dose; 1-2 inhalations every 4 hours, as needed). Throughout the study, the eMDPI recorded inhaler use, peak inspiratory flow (PIF), inhalation volume, inhalation duration, and time to PIF. A model predictive of impending exacerbations was generated by applying machine learning techniques to data downloaded from the inhalers, together with clinical and demographic information. The generated model was evaluated by receiver operating characteristic area under curve (ROC AUC) analysis. Results: Of 360 patients included in the predictive analysis, 64 experienced a total of 78 exacerbations. Increased albuterol use preceded exacerbations; the mean number of inhalations in the 24-hours preceding an exacerbation was 7.3 (standard deviation 17.3). The machine learning model, using gradient-boosting trees with data from the eMDPI and baseline patient characteristics, predicted an impending exacerbation over the following 5 days with an ROC AUC of 0.83 (95% confidence interval: 0.77-0.90). The feature of the model with the highest weight was the mean number of daily inhalations during the 4 days prior to the day the prediction was made. Conclusion: A machine learning model to predict impending asthma exacerbations using data from the eMDPI was successfully developed. This approach may support a shift from reactive care to proactive, preventative, and personalized management of chronic respiratory diseases

Use of the Smartphone Camera to Monitor Adherence to Inhaled Therapy

Self-management strategies can lead to improved health outcomes, fewer unscheduled treatments, and improved disease control. Compliance with inhaled control drugs is essential to achieve good clinical outcomes in patients with chronic respiratory diseases. However, compliance assessments suffer from the difficulty of achieving a high degree of trustworthiness, as patients often self-report high compliance rates and are considered unreliable. This thesis aims to enable reliable adhesion measurement by developing a mobile application module to objectively verify inhalation usage using image snapshots of the inhalation counter. To achieve this, a mobile application module featuring pre and post processing techniques and a default machine learning framework was built, for inhaler and dosage counter numbers detection. In addition, in an effort to improve the app’s capabilities of text recognition on a worst-performing inhaler, a machine learning model was trained on an inhaler image dataset. Some of the features worked on during this project were incorporated on the current version of the app InspirerMundi, a medication management mobile application, planned to be made available at the PlayStore by the end of 2021. The proposed approach was validated through a series of different inhaler image datasets. The carried-out tests with the default machine learning configuration showed correct detection of dosage counters for 70% of inhaler registration events and 93% for three commonly used inhalers in Portugal. On the other hand, the trained model had an average accuracy of 88 % in recognizing the digits on the dose counter of one of the worst-performing inhaler models. These results show the potential to explore mobile and embedded capabilities to gain additional evidence for inhaler compliance. These systems can help bridge the gap between patients and healthcare professionals. By empowering patients with disease selfmanagement and drug adherence tools and providing additional relevant data, these systems pave the way for informed disease management decisions

Pharmacy Leadership and Management module: An evaluation of the student experience and its perceived usefulness for future employment

Background: Pharmacy Leadership and Management is a 12-day, final-year synoptic experiential learning simulation. Student teams of six run a primary care-based pharmacy business and are presented with approximately 180 scenarios and over 400 medicines-based exercises. This module is based on the successful model created by the GIMMICS consortia of universities. Aims: To evaluate the acceptability and perceived usefulness to students and their future employment. Method: An online 82-item questionnaire was sent to all 221 students on the module comprising open and closed questions about their module experiences. Two reminders were sent. Analysis consisted of frequency counts and percentages. Results: Sixty-five percent of students completed the survey (n=143). Ninety-two percent said the module challenged them (n=132/143). Eighty-nine percent said it made them more confident talking to patients (n=127/143); 84% reported that their team-working skills improved as the module progressed (n=110/131). Eighty nine percent of students stated that they thought the module consolidated their learning across the degree (n=117/131). Despite the nature of the module, over half felt that the business skills would not be useful to their future career (55%, n=71/131). Conclusion: This new module has assisted students to develop themselves by challenging them and assisting to consolidate their team-working skills. Despite the importance of understanding business and management, students still appear to lack appreciation of this topic, perhaps due to lack of practice exposure in the course. This is the first year the module has run and we will be following up with the now recent graduates to evaluate the module impact on the next stages of their career

Pharmacy Leadership and Management: A new high fidelity simulation to prepare students for their future practise

Objective: To design and deliver a synoptic experiential learning experience drawing on leadership and management skills coupled with clinical problem solving in a high fidelity simulation. Our vision is to produce world leading pharmacists by providing them with diverse opportunities to demonstrate and expand their knowledge, skills and behaviours and prepare them for the changing healthcare landscape of the future. Design: Pharmacy Leadership and Management (PLM) is based on the successful GIMMICS consortia blueprint. Development was informed by stakeholder events with local and national health commissioners, professionals, experts, patients and academic staff. Teams of six final-year students run their own primary care-based pharmacy business competing against four others over four blocks of three days through the year. Simulated patients and academics deliver approximately 180 acute scenarios over the module to each team, comprising face-to-face, telephone and email queries. Teams also have longer term challenges including development new services and tendering for contracts. The curriculum covers all areas of practice including communication with patients and professionals, business and people development, medicines supply, clinical practice, governance and patient safety and health promotion and public health. Assessment: Assessment uses a multi-format approach of OSCE for skills, reflective portfolio for longer term and attitudinal attributes and an online assessment for knowledge based elements. Conclusion: In this paper, we will present the development of this educational experience and describe our implementation and operationalisation of this highly complex module

Using performance and leadership mentors to support students during a simulated pharmacy business module

Objective: To design and deliver a synoptic experiential learning experience drawing on leadership and management skills coupled with clinical problem solving in a high fidelity simulation. To provide undergraduates with a mentor employed to support and coach groups and individuals to learn, practise and develop their leadership and team working skills. Design: Pharmacy Leadership and Management (PLM) is a module which provides an experiential learning simulation drawing on leadership and management skills coupled with clinical problem solving. Teams of six students run their own primary care based pharmacy business competing against each other, based on a successful model currently run by the GIMMICS consortia of universities across Europe. Working with the university graduate school, a job description and person specification was developed. Mentors were appointed, using a robust application and interview process. A bespoke leadership and management training programme was co-developed between the Pharmacy and Graduate schools. The mentors supported student-led group sessions, coaching them to reflect on performance, develop solutions and change initiatives. The performance mentors were able to monitor the progress of their clients and stimulate interventions to improve their performance. Assessment: Students are required to reflect on their team working and its development during the simulation via their reflective portfolios. Conclusion: In this paper, we will present the development of the mentors and the impact they had on student learning. Qualitative interviews are currently being conducted to determine the impact of the mentor role on recent graduates and their development as future leaders

The Stakeholder Experience of a large scale final year undergraduate social community research project

Objective: In 2014 The School of Pharmacy at the University of Nottingham needed to deliver individual research methods supervision by a small number of academic staff to a large number of final year students. There are limited opportunities for students to gain patient facing experience on this course. The learning initiative was designed to meet these needs. Design: Dissertation students were offered a unique opportunity to participate in a large scale community pharmacy research project. Eighty-two students collected standardised data from patients across 36 pharmacies in the Greater Nottingham area. Local data collection supervision was provided by the local community pharmacists at the data collection sites. Academic supervision was provided to students using a hub and spoke model with ‘hub’ supervision provided by two members of staff offering broad methodological support to the cohort. This was further supported by local supervisors providing individualised ‘spoke’ support to students. Students were able to examine and report on their local results. The data generated overall provides a mass dataset for further examination by academics. An independent evaluation of stakeholder experience was undertaken. Assessment: Students were assessed by a poster presentation and written report summarising one segment of local analysis. Conclusion: Academics saw the hub and spoke model of supervision as innovative and a positive and efficient use of their time. All participating stakeholders feel that students benefit from the timely development of their transferable skills for their professional career; skills cited as requirements for pharmacy education by the GPhC (2011)

A cognitive model of medical record coding: implications for understanding inter-rater agreement.

This study evaluated the level of agreement between clinicians (experts) and non-clinicians (lay persons) when answering questions and selecting supporting text from ambulatory care encounter notes. The study hypothesized that 1) clinicians would agree more often than non-clinicians across all documents and 2) agreement would be higher for both groups when subjects were asked to find explicit text in documents than when the subjects were asked to draw inferences from the text. The study was designed to shed light on the causes of disagreement among coders of clinical documents

“Knowing how” is not enough: a mixed methods exploration of inhaler technique maintenance in patients with asthma

Incorrect inhaler technique maintenance is a persistent problem amongst asthma patients, contributing to poor asthma control. Why inhaler technique deteriorates, even in the absence of identifiable barriers, is unknown. Gaining insight into this problem was the driver behind this thesis. The first study in this thesis identified that patients who were more likely to maintain correct inhaler technique were more likely to: 1) be using a DPI instead of pMDI, 2) have better baseline asthma control, and 3) have higher baseline motivation to practice correct technique [X2 (N=125,3)=16.22, p=0.001]. For the first time, the important role that patient psychosocial factors may play in inhaler technique maintenance was shown. The second study in this thesis provided further insight into relationships between patient psychosocial and behavioural factors in the context of inhaler technique maintenance. Influential factors on patient motivation to maintain correct inhaler technique included: the motivation to engage in asthma management; the motivation to self-manage via a preventative-medication based approach; self-management self-efficacy; and health care professionals’ input. Ensuring optimal inhaler technique maintenance may lie in more holistic approaches to inhaler technique interventions that address, not only physical skill related barriers, but also patient psychosocial barriers in technique maintenance