A Tablet-Based Multimedia Education Tool Improves Provider and Subject Knowledge of Inhaler Use Techniques

Discussion

This study shows that tablet-based inhaler education improves correct inhaler use technique by providers in the short term regardless of specialty or previous personal or family member inhaler use. There were no differences in inhaler use technique between pulmonologists and primary care providers either before or after viewing the videos, but both groups had better technique after the educational intervention. This tablet-based educational tool also improved inhaler use by patients with COPD, which was durable over several months. Despite better inhaler use technique, subjects' respiratory symptoms did not improve.

Health-care providers and patients are confronted by a myriad of devices for the delivery of respiratory medications, each of which has a unique and complex technique for correct use. For patients to learn how to use their inhalers correctly, education should be provided by health-care providers who are proficient in using inhalers.^3,10,16 Unfortunately, provider inhaler knowledge is often suboptimal and varies by specialty and level of training (pharmacy, respiratory therapy, house staff, and attending physicians).^8,10,17–19 Provider inhaler knowledge is not only important for patient education when initially prescribing inhalers but is critical in the selection of devices that might best suit an individual patient to improve their opportunity for correct use and to identify inhaler technique errors in patients with poorly controlled COPD.^10,20

Incorrect inhaler technique by patients occurs in up to 90% of patients with COPD.^{1,2,5–7,11,21} Correct inhaler technique is critical in the management of COPD because inhaled drug effectiveness requires appropriate delivery to the correct anatomic location for maximal physiologic benefit. Unlike pills or injections, inhaler use requires a complex series of actions to achieve optimal use and medication delivery. Patients with COPD are often older and can have cognitive or memory impairments that contribute to incorrect inhaler technique.⁹ Further, there are multiple different types of inhalers for respiratory medications, and each has a unique delivery technique.²²

Providing patients with inhaler education before initiation of therapy is critical, but written instruction alone is often inadequate.²³ Verbal education with assessment of inhaler technique followed by re-assessment of correct technique at subsequent visits improves inhaler technique.^9,24 Patients who receive inhaler education at regular intervals make fewer mistakes in inhaler technique compared with those who only receive instruction at the time of prescription.²⁵ As previously noted, in our study, there was no improvement in the subjects' clinical symptoms over a long-term follow-up period. Potential reasons for the lack of symptomatic improvement include: (1) receiving inhaler education at one interval instead of frequent evaluations, and (2) the fact that 70% of our subjects were receiving “maximal inhaler therapy” with budesonide/formoterol MDI + tiotropium DPI. These subjects' respiratory symptoms may not be as responsive to inhaled medication but may improve with non-inhaler treatments, such as pulmonary rehabilitation and pursed lip breathing.

Both the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the National Institute for Health and Care Excellence (NICE) recommend inhaler education and device training when a patient is prescribed a new inhaler and during each subsequent patient encounter (http://goldcopd.org/; https://www.nice.org.uk/guidance/cg101; Accessed April 5, 2016). Despite these recommendations, Lavorini et al²¹ found that 25% of subjects did not receive any verbal instruction when prescribed an inhaler. We found that 16 (32%) of our subjects reported never having any inhaler education. A previous survey study of 493 veterans with a diagnosis of COPD showed that 92 (19%) did not recall any inhaler education.¹²

With advancements in information technology, multimedia techniques have been adapted for patient and provider education. The use of tablet-based patient education is effective for patient self-management of chronic diseases and to teach patients physical therapy and pulmonary rehabilitation exercises.^26–28 Potential benefits of multimedia patient inhaler education include individualized information using a wide range of visual and auditory formats that are viewable in diverse settings, personalized inhaler instruction specific for a patient's devices, self-education empowering patients to be more involved in their COPD management, and the ability to review and replay videos when and where repeat education is needed or when questions arise. Videos on tablets or smart phones tend not to be misplaced or discarded, as frequently occurs with paper instructional materials, and deliver information that can easily be shared across a large patient population through internet downloads.²⁹ Savage and Goodyer³⁰ compared inhaler education delivered by either the manufacturer's paper information leaflet or a multimedia touchscreen computer for 105 subjects with asthma who had been prescribed pressurized MDIs. Inhaler technique scores improved by 44% in the multimedia group compared with only 19% in the print-based group (P < .05). We were unable to reproduce these findings because our study design did not include a comparative control group receiving conventional inhaler education (eg, receiving no inhaler education or reading a package insert).

There are a number of strengths to our study. This study evaluates an education tool for both health-care providers and subjects. The same investigator evaluated every health-care provider and subject before and after education to avoid inter-observer variability. Testing health-care providers and subjects at the time of study enrollment limited bias because they had no prior notification of the study, and the investigators had no prior knowledge of their inhaler education. Last, our tablet-based intervention can easily be accomplished in clinical practice.

Our study does also have some limitations. Although predefined inhaler technique checklists were used, evaluating some steps of inhaler device use can be subjective. For example, emptying air out of the lungs followed by a forceful inhalation, are common steps for almost every inhaler but can only be subjectively evaluated. The first author of this manuscript (AMM) served many roles in this study, in particular the assessment of inhaler technique for all subjects and providers. Having an individual rater of inhaler technique can be a source of bias because that person will know whether the subject was pre- or post-inhaler education. In retrospect, the study design could have been stronger by either (1) blinding the assessor to the subject's inhaler education status or (2) having a second rater, therefore enabling reporting of the inter-rater reliability of the assessments. This study was conducted at a single institution, and we cannot exclude any selection bias. The subjects recruited for our study make up a very specific subgroup of patients, veterans with COPD. Thus, the results of the study may differ for civilians in the community with COPD or for groups of patients with other obstructive respiratory disorders. Last, provider knowledge of correct inhaler technique may not translate into the ability to teach patients to use their inhalers correctly.

Another potential limitation is that we did not test respiratory therapists' inhaler technique. They are often primarily responsible for inhaler education in the in-patient, and sometimes in the out-patient, setting. When compared with other providers, respiratory therapists have the highest inhaler knowledge scores and the best inhaler technique.^10,16,31,32 A recent study by Alismail et al³² evaluated the use of inhaler education videos on both written and practical inhaler education tests in 4 groups of providers (respiratory therapists, pharmacists, nurses, and physicians). They found that respiratory therapists have the highest baseline written and practical scores, and their practical scores were the only scores to improve significantly after viewing inhaler education videos. Overall, they found that written and practical scores before and after inhaler education were suboptimal.³² Our tablet-based videos could easily be reviewed by respiratory therapists to confirm or improve their baseline inhaler knowledge, or they could provide the videos to patients as another mode of inhaler education.