Effectiveness of an educational intervention about inhalation technique in healthcare professionals in primary care: a cluster randomized trial.

Background: Incorrect inhalation technique (IT) is an important issue for chronic obstructive pulmonary disease (COPD) patients and healthcare professionals. Studies in which counseling is carried out with healthcare professionals beforehand so that they can properly educate their patients are required. The objective of the present trial is to assess the improvement in the performance of the IT in subjects with COPD and prescribed inhaled therapy after the implementation of an educational intervention conducted by their general practitioners. Methods: A cluster randomized clinical trial was conducted. A total of 286 COPD patients received scheduled inhalation therapy from 27 general practices in seven primary care centers. A teach-back educational intervention was implemented for both healthcare professionals and patients. The primary outcome of this study was the performance of the correct inhalation technique. It is considered a good technique if all steps in the inhalation data sheet are correctly performed. The secondary outcomes were assessed using forced spirometry, the basal dyspnea index, the Medical Research Council dyspnea scale, St George's Respiratory Questionnaire (SGRQ), and EuroQoL5D-5L for health-related quality of life. A one-year follow-up was conducted using an intention-to-treat analysis. Results: After the intervention, incorrect IT was observed in 92% of professionals and patients, with rates reaching 50% and 69.2%, respectively. The effectiveness in patients was significant, with a number needed to treat of 2.14 (95% CI 1.79-2.66). Factors related to correct IT in patients included the type of intervention, length of intervention (>25 min), good pulmonary function, age (youngest <=65, oldest >83), and less limitation of activity due to dyspnea. There was no relation with the cluster. Conclusion: This study shows the effectiveness of direct inhaler technique training provided by a trained professional on an appropriate timescale (for example, a specific consultation for medication reviews), aiming to help subjects improve their performance using the teach-back method. This could be an encouraging intervention to improve medication adherence and health promotion in people with COPD. Clinical Trial Registration: clinicaltrials.gov, identifier ISRCTN93725230.

Internet como fuente de datos en investigación cualitativa en ciencias de la salud. Comunidades virtuales de pacientes / Internet as a data source in qualitative research in health sciences. Virtual Patient Communities

Las comunidades virtuales de pacientes en Internet son una fuente de datos potencial para investigaciones cualitativas, permitiendo explorar la perspectiva y vivencia de los pacientes sobre sus problemas de salud. En este artículo analizamos las posibilidades de utilización de estas comunidades virtuales y aportamos una propuesta metodológica. Se parte de una revisión bibliográfica y se realiza una adaptación práctica de la metodología cualitativa siguiendo el esquema: pregunta de investigación-objetivos-hipótesis-muestreo-análisis de hilos de conversación. Se aplican principios de netnografía y ciberhabla. La base de muestreo son lugares web de comunidades virtuales de pacientes, seleccionadas según enfermedad, objetivos y calidad, estableciendo límites temporales. Contenido del análisis de los hilos: tema, número de participantes, secuencias conversacionales, protagonistas, reglas y clima. Se realiza un informe provisional, definitivo tras la devolución a la comunidad virtual para aportaciones. El ciclo se reinicia si no se responden las preguntas de investigación.(AU)

Virtual Patient Communities are a potential data source for qualitative research, allowing to explore the patient perspective and experience about their chronic diseases. In this article we analyse the possibilities of using these virtual patient communities, and we provide a methodological proposal. It starts from a bibliographic review and a practical adaptation to the qualitative methodology is carried out following the scheme: research question-objectives-hypothesis-sampling-analysis of conversation threads. Principles of netnography and netspeak are applied. The sampling frame is websites of virtual patient communities that are selected according to disease, objectives, quality and time limits. Content of the analysis of the threads: theme, number of participants, conversational sequences, protagonists, rules and climate. A provisional report is made, and the definitive report will be make after the return to virtual patient community for their contributions. The cycle restarts if the research questions are not answered.(AU)

The importance of reminders and patient preferences to improve inhaler technique in older adults with COPD.

Objectives: Medication non-adherence in patients with chronic obstructive pulmonary disease is common. The aim is to evaluate the efficacy of two interventions to improve the inhalation technique (IT) in patients with pulmonary disease is common. Also determine optimal IT reminder time and to test the role of preferences in the intervention selection. Method: 726 pulmonary disease in common patients (consecutive sampling) from two trials: 1) TECEPOC-study (patients' preference trial/comprehensive cohort design) 2) TIEPOC-study (randomised controlled trial). Interventions: intervention-A (ad-hoc leaflet with instructions about correct IT according Spanish Respiratory Society), intervention B (intervention A+ individual training by instructors). Four visits were performed (baseline, 3, 6 and 12 months). Data on IT, sociodemographic and clinical characteristics, quality of life and respiratory drugs were recorded. Analysis under intention to treat principle. Multivariate analysis was conducted to measure the potential modifying factors of improvement in the IT along follow-up. Results: 660 patients (90.9%) did not perform a correct IT at baseline 89.75% with Handihaler, 86.95% with Turbuhaler, 84.75% with Accuhaler and 87.35% with pMDI. At 12 months, 221 patients 29.9% performed correctly the IT; a decrease in the slope of the curve (correct IT) was detected at 3 months follow-up. Intervention B was the most effective in both trials compared to control group or intervention A, regardless of preferences: 1) TECEPOC Study (preference trial): Intervention B versus control group, NNT = 3.22 (IC95%, 2.27-5.52); and versus Intervention A, NNT = 3.57 (CI95%, 2.41-6.8). Preferences improved 6.7% in the correct IT without statistical significance. 2) TIEPOC Study (randomized controlled trial): Intervention B versus control group, NNT = 1.74 (IC95%, 1.47-2.17), and versus intervention A, NNT = 3.33 (CI 95%, 2.43-5.55). No differences were measured between Intervention A and control group. Conclusion: Individual training significantly improves IT. Reminders every 3 months are recommended. Preferences do not influence the intervention effectiveness.

Efficacy of the Treatments Used in Multiple Sclerosis: From Meta-analysis to Number Needed to Treat.

The aim of this study was to analyze the efficacy of drugs used in relapsing-remitting multiple sclerosis, first- and second-line drugs, using the number needed to treat (NNT) as a measure of efficacy. METHODS: Data from randomized clinical trials were analyzed for 3 categories of clinical efficacy outcomes: relapse, change in Expanded Disability Status Scale, and number of new lesions in magnetic resonance imaging. Meta-analysis results are expressed as odds ratios. RESULTS: The global odds ratio was 0.41 (95% confidence interval [CI], 0.34-0.49). For analyzed clinical outcomes, the odds ratio was less for second-line drugs (odds ratio, 2.0). For all studied clinical conditions, in the control group, 47 of 100 patients do not get benefits, compared with 25 (95% CI, 18-32 patients) of 100 for the active treatment group. The NNT was 5 patients (95% CI, 4-7 patients). For the proportion of patients free of relapses, in the control group, 56 of 100 patients had a relapse at 2 years, compared with 37 of 100 patients in the treatment group, with an NNT of 6 patients (95% CI, 5-8 patients). CONCLUSIONS: Active treatments produced statistically significant improvements compared with placebo.

Identifying risk in the use of tumor markers to improve patient safety.

BACKGROUND: Tumor markers (TM) are a routine test that are not always used well, and can lead to unnecessary additional tests, which are not without risks for the patients. So, to implement appropriate strategies to improve the adequate use of TM and, therefore, improve patient safety, is required to analyze the use of TM, identifying risks and establishing if there are differences in their use as a function of their utility. METHODS: The study was a descriptive, longitudinal, retrospective and systematic study in the area covered by the University Hospital of Padua. In the follow-up 2-year study, 23,059 analytical requests of TM, corresponding to 14,728 patients, were analyzed. For the level of statistical significance it applies an approximation of the normal law (Z statistic) and χ2-test. RESULTS: Only 9196 requests (39.88%) out of a total of 23,059 on 5080 patients with neoplastic diseases have been classified as adecuate according to current guidelines. The number of requests per patient was variable (1.57±1.35). In patients with neoplastic diseases this increased to 1.80±1.68. The mean of number of TM per request was 2.4±1.73. The analysis showed an association between the number of requests and the type of marker used. CONCLUSIONS: The use of TM is variable, mainly of the follow-up markers, when they are used as screening. This inappropriate use, minimizes their utility favoring erroneous interpretations and increases the risk of damage to the patient. So it is essential to implement safe practices in the use of TM.

Impacto de la aplicación de un protocolo para el uso adecuado y seguro de marcadores tumorales / Impact of the implementation of a protocol for the adequate and safe use of tumor markers

Fundamento y objetivo: Los marcadores tumorales (MT) son pruebas accesibles para la actividad clínica. Su uso inadecuado puede provocar pruebas complementarias innecesarias para confirmar o refutar un resultado positivo. Tras 2 acontecimientos adversos por un uso incorrecto de MT, se implementó un protocolo para el uso adecuado y seguro de estos. El objetivo de este trabajo fue determinar el impacto de la implementación de dicho protocolo. Material y método: Estudio pre-postintervención. Se analizó el uso, durante un año, de peticiones de MT (antígeno carcinoembrionario, CA15.3, CA19.9, CA125) de pacientes no sometidos a revisión oncológica. Se implementó un protocolo, formándose a los facultativos según las recomendaciones del Grupo Europeo de Marcadores Tumorales, limitando su uso al seguimiento de la enfermedad y monitorización de tratamientos. Período estudiado: 2010-2014. Resultados: El número total de peticiones descendió un 50,81%, y el porcentaje de adecuación de los MT aumentó anualmente desde un 31,03 hasta un 77,91%. Conclusiones: La implantación de un protocolo del uso adecuado de MT contribuye a un uso seguro, evitando estudios no indicados y evitando pruebas complementarias innecesarias y lesivas para el paciente (AU)

Background and objetive: Improper clinical use of tumor markers (TM) may cause unnecessary additional studies to confirm or refute a positive result. After observing 2 adverse events due to a wrong use of TM, a protocol for improving their use was implemented. The objective of this study was to determine the impact of the implementation of the protocol. Material and method: This was a pre-postintervention study, where analytical requests of carcinoembryonic antigen, CA15.3, CA19.9 and CA125 were analyzed during one year in patients not undergoing checking of neoplasia. A protocol was implemented and physicians were trained as recommended by the European Group on Tumor Markers, limiting its use to monitor the disease and its treatment. The study period was 2010-2014. Results: The total number of requests dropped 50.81% and the percentage of adequacy of TM increased, each year, from 31.03 to 77.91%. Conclusions: The implementation of a protocol for the proper use of TM contributes to a safer use, avoiding incorrect studies and unnecessary and harmful tests for the patient (AU)

[Impact of the implementation of a protocol for the adequate and safe use of tumor markers]. / Impacto de la aplicación de un protocolo para el uso adecuado y seguro de marcadores tumorales.

BACKGROUND AND OBJECTIVE: Improper clinical use of tumor markers (TM) may cause unnecessary additional studies to confirm or refute a positive result. After observing 2 adverse events due to a wrong use of TM, a protocol for improving their use was implemented. The objective of this study was to determine the impact of the implementation of the protocol. MATERIAL AND METHOD: This was a pre-postintervention study, where analytical requests of carcinoembryonic antigen, CA15.3, CA19.9 and CA125 were analyzed during one year in patients not undergoing checking of neoplasia. A protocol was implemented and physicians were trained as recommended by the European Group on Tumor Markers, limiting its use to monitor the disease and its treatment. The study period was 2010-2014. RESULTS: The total number of requests dropped 50.81% and the percentage of adequacy of TM increased, each year, from 31.03 to 77.91%. CONCLUSIONS: The implementation of a protocol for the proper use of TM contributes to a safer use, avoiding incorrect studies and unnecessary and harmful tests for the patient.