Inhaler technique mastery and maintenance in healthcare professionals trained on different devices

ABSTRACT

Objective: Healthcare professionals (HCPs) are required to assess and train patients in the correct use of inhalers but are often unable to demonstrate correct technique themselves. We sought to assess the level of training required for HCPs to master and maintain device mastery when using two different dry powder inhalers (DPIs). Methods: We conducted a randomized, un-blinded, crossover study in undergraduate HCPs who undertook a six-step training procedure (intuitive use, patient information leaflet, instructional video, individual tuition from expert, then two repeats of individual tuition) for the use of Turbuhaler® (an established device) and Spiromax® (a newer device, reportedly easier to use). Device mastery (absence of errors) was evaluated by expert assessors at each training step. Maintenance of mastery was assessed 4 ± 1 week (visit 2) and 8 ± 2 weeks (visit 3) after initial training (visit 1). Results: Of 516 eligible participants, 113 (22%) demonstrated device mastery prior to training on Spiromax® compared with 20 (4%) on Turbuhaler® (p < 0.001). The median number of training steps required to achieve mastery was 2 (interquartile range [IQR] 2–4) for Spiromax® and 3 (IQR 2–4) for Turbuhaler® (p < 0.001). A higher number of participants maintained mastery with Spiromax® compared with Turbuhaler®, at visits 2 and 3 (64% vs 41% and 79% vs 65%, respectively; p < 0.001). Conclusions: There are significant differences in the nature and extent of training required to achieve and maintain mastery for Spiromax® and Turbuhaler® devices. The implications on clinical practice, device education delivery, and patient outcomes require further evaluation.

KEYWORDS:

• Asthma
• clinical trial
• device mastery
• device mastery maintenance
• dry powder inhaler
• handling errors

Declaration of interest

SBA sits on an advisory board for TEVA and has consulted for TEVA, GSK, and Mundipharma. CC and VN were employees of Observational and Pragmatic Research Institute Pte Ltd at the time of the study. Observational and Pragmatic Research Institute Pte Ltd conducted this study and has conducted paid research in respiratory disease on behalf of the following other organizations in the past 5 years: UK National Health Service, British Lung Foundation, Aerocrine, AKL Research and Development Ltd, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, Pfizer, Respiratory Effectiveness Group, Takeda, Teva Pharmaceuticals, Theravance, and Zentiva. HC has no shares in any pharmaceutical company. He has received sponsorship to carry out studies, together with Board Membership, consultant agreements, and honoraria for presentation, from several pharmaceutical companies that market inhaled products. These include Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Innovata Biomed, Meda, Napp Pharmaceuticals, Mundipharma, NorPharma, Norvartis, Orion, Sanofi, Teva, Truddell Medical International, UCB, and Zentiva. Research sponsorship has also been received from grant awarding bodies (EPSRC and MRC). He is the owner of Inhalation Consultancy Ltd. He is also an employee of Observational and Pragmatic Research Institute Pte Ltd, which conducted this study and has conducted paid research in respiratory disease on behalf of the following other organizations in the past 5 years: UK National Health Service, British Lung Foundation, Aerocrine, AKL Research and Development Ltd, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, Pfizer, Respiratory Effectiveness Group, Takeda, Teva Pharmaceuticals, Theravance, and Zentiva. FL received in the last 5 years fees for speaking or honoraria for attending advisory boards from the following pharmaceutical companies: Boehringer Ingelheim, Chiesi, CIPLA, TEVA, AstraZeneca, and Menarini International. VK received over the past 3 years fees for speaking for AstraZeneca, GlaxoSmithKline, and Pfizer. PNRD and/or his department have received unrestricted educational grants from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Mundipharma, Takeda and Teva; consulting and advisory fees from AstraZeneca, Boehringer Ingelheim, Takeda, Chiesi, Zambon, Novartis and Teva. NR has received over the past 3 years (i) fees for speaking, organizing education, participation in advisory boards, or consulting from 3 M, Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, MSD-Chibret, Mundipharma, Novartis, Pfizer, Sandoz, Sanofi, Takeda, Teva, Zambon; (ii) research grants from Novartis, Boehringer Ingelheim and Pfizer. LB has received over the past 3 years fees for speaking, or participation in advisory boards for Aerocrine, Arsonette, Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Mundipharma, Novartis, Sandoz, Sanofi, Takeda, and Teva. CR reports membership on a TEVA scientific advisory board and consulting for TEVA. NZ declares no shares in any pharmaceutical company. However, he is a chief investigator on a grant from GSK Australia for a project on self-management support for patients with COPD. DBP has board membership with Aerocrine, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, and Teva Pharmaceuticals; consultancy with Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Meda, Mundipharma, Napp, Novartis, Pfizer, Teva Pharmaceuticals, and Theravance; grants and unrestricted funding for investigator-initiated studies (conducted through Observational and Pragmatic Research Institute Pte Ltd) from UK National Health Service, British Lung Foundation, Aerocrine, AKL Research and Development Ltd, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, Pfizer, Respiratory Effectiveness Group, Takeda, Teva Pharmaceuticals, Zentiva, and Theravance; payment for lectures/speaking engagements from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Meda, Merck, Mundipharma, Novartis, Pfizer, Skyepharma, Takeda, and Teva Pharmaceuticals; payment for manuscript preparation from Mundipharma and Teva Pharmaceuticals; payment for the development of educational materials from Novartis and Mundipharma; payment for travel/accommodation/meeting expenses from Aerocrine, Boehringer Ingelheim, Mundipharma, Napp, Novartis, Teva Pharmaceuticals, and AstraZeneca; funding for patient enrolment or completion of research from Chiesi, Teva Pharmaceuticals, Zentiva, and Novartis; stock/stock options from AKL Research and Development Ltd, which produces phytopharmaceuticals; owns 74% of the social enterprise Optimum Patient Care Ltd, UK, and 74% of Observational and Pragmatic Research Institute Pte Ltd, Singapore; and is peer reviewer for grant committees of the Medical Research Council, Efficacy and Mechanism Evaluation program, and HTA.

Funding

This investigator-initiated study (IIS) was conducted and part-funded by Research in Real Life Ltd, which is subcontracted by Observational and Pragmatic Research Institute Pte Ltd (OPRI), with institutional support from Teva Pharmaceuticals Europe B.V. Teva Pharmaceuticals Europe B.V. played no role in the design, conduct, and reporting of the study. Alessandra Cifra provided writing support, funded by Observational and Pragmatic Research Institute Pte Ltd.