Effects of PACK training on the management of asthma and chronic obstructive pulmonary disease by primary care clinicians during two years of implementation in Florianópolis, Brazil: extended follow-up after a pragmatic cluster randomised controlled trial with a stepped wedge design

Abstract

Background: Training primary care doctors and nurses to use Practical Approach to Care Kit (PACK) improved management of asthma and chronic obstructive pulmonary disease (COPD) in a previous randomised trial. The present study examined the training effects including a second year of follow-up with expanded coverage of repeated training sessions. Methods: Using a stepped wedge cluster randomised trial design, 48 clinics were randomly allocated either to Sequence A: i) no intervention, ii) no intervention, iii) intervention, or Sequence B: i) no intervention, ii) intervention, iii) intervention, during three 12 month periods. Primary outcomes were change in treatment, and spirometry ordering. Effects of any exposure to the training, and of exposure to the first and second years of training, were estimated with mixed effect logistic regression models. Results: Any exposure to training was associated with increased changes in treatment (Odds Ratio adjusted for calendar time (OR) 1.29, 95% confidence interval (CI) 1.02–1.64) and more spirometry ordering (OR 1.55, (1.22-1.97)) in asthma patients, and with more spirometry ordering (OR 1.50, (1.15-1.96)) in COPD patients. Change in asthma treatment was more likely during the first and second year of exposure to training compared with no exposure (ORs 1.43, (1.09–1.87); 1.91, (1.21–3.02)), respectively. Spirometry was more likely during the first and second year of exposure in asthma patients, (ORs 1.76, (1.17–1.93); 2.05 95% (1.32–3.19)), and in COPD patients (ORs 1.57 (1.18–2.10)); 1.71 (1.08–2.70)). Conclusion: Extended follow-up suggested that PACK training continued to be effective in improving chronic respiratory care, and that effective intervention delivery was sustainable for two years