The problem, of course, is how to provide that level of patient education within the time constraints of a busy family practice. We recommend these time-efficient solutions:
Enlist the help of other clinicians. While it is important that someone in your office be well trained and able to instruct patients in the proper use of inhalers, that individual need not be you. The National Institutes of Health recommends that the “principal clinician” introduce key educational messages, which can be reinforced and expanded on by other members of the health care team.1
After you advise patients that it is crucial for them to be trained in and adhere to proper inhaler technique, another health care professional—often a clinic nurse or pharmacist who has had special training—can provide the hands-on education. Studies have shown that when pharmacists who are competent in asthma management, including inhaler technique, work with physicians to optimize the education and overall management of patients with asthma, better outcomes often result, including a reduction in both emergency department visits and hospitalizations.1,39,40
Use videos to demonstrate correct technique. Videos are an effective teaching tool,9 and many of them are device-specific. National Jewish Health, which is world renowned for its asthma care, has a set of instructional videos posted on You-Tube and accessible from its Web site (http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos). In addition to videos that demonstrate the use of an MDI alone and an MDI plus a valved holding chamber, the site has links to 6 DPI videos, each covering a different device.
Use intermittent observation. After the patient views the appropriate video, you or a member of your staff will still need to observe the patient’s inhaler technique to ensure correct use. Ideally, this should occur at every visit.1,37 When that’s not possible, use intermittent observation, starting with the first 2 or 3 visits after the introduction of inhalation therapy and then switching to periodic observation to ensure that the patient is maintaining good technique.
In determining how often observation is necessary, keep in mind that simply asking patients whether they are having inhaler problems is not sufficient.1 Patients tend to say they have little or no trouble when, in fact, most struggle, at times, with the devices. What’s more, good technique tends to decrease over time, and repetitive education is important.
To motivate patients, try this communication technique
Motivational interviewing, a technique that has been used to help patients battle obesity, quit smoking, and control hypertension,41-43 among other health problems, can help you identify inhaler problems that need to be addressed. It involves the use of open-ended questions (eg, “What worries you most about your asthma?”), affirmations (“You’ve done a great job testing your peak flow level every morning”), reflective listening (“You’re tired of taking medicine every day”), and summary statements (“You know you should take your medicine every day but you’re having trouble remembering it. Is that right?”).
A pilot study44 showed that when this technique was incorporated into an asthma education session, patient motivation increased. The ratio of perceived advantages vs disadvantages of taking asthma medication correctly improved, as well. Another study45 found that when motivational interviewing was used during home visits to inner-city African American adolescents for asthma care, the patients’ motivation, readiness to adhere to treatment, and asthma-related quality of life improved, although self-reported adherence to asthma medication did not. Further studies involving patients with asthma are under way (www.clinicaltrials.gov/ct2/results?term=asthma).
It is important to note that the use of motivational interviewing does not require a lengthy visit. One study found that on average, visits in which primary care physicians used this communication technique lasted less than 10 minutes.46
CORRESPONDENCE Timothy H. Self, PharmD, University of Tennessee Health Science Center, 881 Madison Avenue, Room 235, Memphis, TN 38163; [email protected]