Effectiveness of Virtual vs In-Person Inhaler Education for Hospitalized Patients With Obstructive Lung Disease: A Randomized Clinical Trial

Abstract

Importance: Many patients who are hospitalized cannot use inhalers correctly, yet education for their use is often not provided. To address the need for an effective intervention feasible for wide-scale implementation, a virtual teach-to-goal intervention was developed to provide tailored patient-directed education using adaptive learning technology.

Objective: To assess whether the virtual teach-to-goal intervention is noninferior to an in-person teach-to-goal intervention for improving inhaler technique.

Design, setting, and participants: An equivalence and noninferiority randomized clinical trial took place from January 13, 2016, through September 20, 2017, with analyses conducted between October 25, 2017, and September 23, 2019. Adult inpatients with asthma or chronic obstructive pulmonary disease (COPD) admitted to general inpatient wards were eligible. Enrolled participants were randomized to virtual (n = 61) or in-person (n = 60) educational interventions. Investigators and research assistants were masked to interventions. Initial enrollment, study assessments, and delivery of the educational intervention occurred in the hospital; participants returned at 30 days for a follow-up research visit.

Interventions: Virtual education was a module delivered via handheld tablet with self-assessment questions before demonstration, narrated video demonstration of the correct technique, and self-assessment questions after demonstration; up to 3 rounds were repeated as needed. In-person education participants received iterative rounds of inhaler technique assessment and education by trained staff.

Main outcomes and measures: Noninferiority testing of whether virtual vs in-person education achieved an equal percentage with correct inhaler technique after education (>9 of 12 steps correct) against an a priori noninferiority limit of -10%; logistic regression models were used to adjust for differences in baseline technique and health literacy.

Results: Among 118 participants (59 in each group), most were black (114 [97%]) and female (76 [64%]), with a mean (SD) age of 54.5 (13.0) years. Correct technique increased similarly before vs after education in virtual (67%; range, 2%-69%) and in-person (66%; range, 17% to 83%) groups, although the difference after intervention exceeded the noninferiority limit (-14%; 95% CI lower bound, -26%). When adjusting for baseline inhaler technique, the difference was equivalent to the noninferiority limit (-10%; 95% CI lower bound, -22%).

Conclusions and relevance: The findings suggest that patient-directed virtual education similarly improved the percentage of participants with correct technique compared with in-person education. Future work should confirm whether virtual teach-to-goal education is noninferior to in-person education and whether it is associated with long-term skills retention, medication adherence, and improved health outcomes.

Trial registration: ClinicalTrials.gov identifier: NCT02611531.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Press reported receiving grants from the National Institutes of Health (NIH), the American Thoracic Society, and the American Lung Association during the conduct of the study and reported receiving personal fees from the American Academy of Allergy, Asthma, and Immunology, RoundGlass, the Society of Hospital Medicine, and Vizient Inc outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Flowchart of Patients Through the Trial

COPD indicates chronic obstructive pulmonary disease; MDI, metered dose inhaler; TTG, teach-to-goal; V-TTG, virtual teach-to-goal. aMay add to more than 1034 persons because of multiple exclusion factors.

Figure 2.. Metered Dose Inhaler Technique Steps Correct Before and After Education

TTG indicates teach-to-goal; V-TTG, virtual teach-to-goal.