title: Effectiveness of Interventions to Teach Metered-Dose and Diskus Inhaler Techniques. A Randomized Trial.
abstract: The most effective approach to teaching respiratory inhaler technique is unknown.
  
  
  
  To evaluate the relative effects of two different educational strategies (teach-to-goal instruction vs. brief verbal instruction) in adults hospitalized with asthma or chronic obstructive pulmonary disease.
  
  
  
  We conducted a randomized clinical trial at two urban academic hospitals. Participants received teach-to-goal or brief instruction in the hospital and were followed for 90 days after discharge. Inhaler technique was assessed using standardized checklists; misuse was defined as 75% steps or less correct (≤9 of 12 steps). The primary outcome was metered-dose inhaler misuse 30 days postdischarge. Secondary outcomes included Diskus technique; acute care events at 30 and 90 days; and associations with adherence, health literacy, site, and patient risk (near-fatal event).
  
  
  
  Of 120 participants, 73% were female and 90% were African American. Before education, metered-dose inhaler misuse was similarly common in the teach-to-goal and brief intervention groups (92% vs. 84%, respectively; P = 0.2). Metered-dose inhaler misuse was not significantly less common in the teach-to-goal group than in the brief instruction group at 30 days (54% vs. 70%, respectively; P = 0.11), but it was immediately after education (11% vs. 60%, respectively; P < 0.001) and at 90 days (48% vs. 76%, respectively; P = 0.003). Similar results were found with the Diskus device. Participants did not differ across education groups with regard to rescue metered-dose inhaler use or Diskus device adherence at 30 or 90 days. Acute care events were less common among teach-to-goal participants than brief intervention participants at 30 days (17% vs. 36%, respectively; P = 0.02), but not at 90 days (34% vs. 38%, respectively; P = 0.6). Participants with low health literacy receiving teach-to-goal instruction were less likely than brief instruction participants to report acute care events within 30 days (15% vs. 70%, respectively; P = 0.008). No differences existed by site or patient risk at 30 or 90 days (P > 0.05).
  
  
  
  In adults hospitalized with asthma or chronic obstructive pulmonary disease, in-hospital teach-to-goal instruction in inhaler technique did not reduce inhaler misuse at 30 days, but it was associated with fewer acute care events within 30 days after discharge. Inpatient treatment-to-goal education may be an important first step toward improving self-management and health outcomes for hospitalized patients with asthma or chronic obstructive pulmonary disease, especially among patients with lower levels of health literacy. Clinical trial registered with www.clinicaltrials.gov (NCT01426581).
authors.affiliation: 1 Section of Hospital Medicine, Department of Medicine.
authors.forename: Valerie G
authors.initials: VG
authors.lastname: Press
authors.affiliation: 2 Section of General Internal Medicine, Department of Medicine.
authors.forename: Vineet M
authors.initials: VM
authors.lastname: Arora
authors.affiliation: 3 University of Michigan Medical School, Ann Arbor, Michigan.
authors.forename: Kristin C
authors.initials: KC
authors.lastname: Trela
authors.affiliation: 1 Section of Hospital Medicine, Department of Medicine.
authors.forename: Richa
authors.initials: R
authors.lastname: Adhikari
authors.affiliation: 4 University of Illinois at Chicago College of Medicine, Chicago, Illinois; and.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Zadravecz
authors.affiliation: 5 Department of Public Health Sciences, University of Chicago, Chicago, Illinois.
authors.forename: Chuanhong
authors.initials: C
authors.lastname: Liao
authors.affiliation: 6 Section of Pulmonary and Critical Care Medicine, Department of Medicine, and.
authors.forename: Edward
authors.initials: E
authors.lastname: Naureckas
authors.affiliation: 6 Section of Pulmonary and Critical Care Medicine, Department of Medicine, and.
authors.forename: Steven R
authors.initials: SR
authors.lastname: White
authors.affiliation: 1 Section of Hospital Medicine, Department of Medicine.
authors.forename: David O
authors.initials: DO
authors.lastname: Meltzer
authors.affiliation: 7 Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois.
authors.forename: Jerry A
authors.initials: JA
authors.lastname: Krishnan
mesh_terms: D000280:Administration, Inhalation; D000328:Adult; D001741:Black or African American; D001249:Asthma / Q000188:drug therapy*; D057189:Checklist; D002641:Chicago; D004867:Equipment Design; D019544:Equipment Failure Analysis; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016014:Linear Models; D008297:Male; D036501:Metered Dose Inhalers; D008875:Middle Aged; D010353:Patient Education as Topic; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy*; D019141:Respiratory System Agents / Q000008:administration & dosage*; D018570:Risk Assessment; D012648:Self Care
chemical_list: D019141:Respiratory System Agents
keywords: asthma; chronic obstructive pulmonary disease; patient education as topic; self-care