WA News News & Reports Inhaler Back to Basics
Inhaler Back to Basics
Written by Dr Rob McEvoy
Friday, 26 August 2016

The National Asthma Council (NAC) – a Melbourne NFP group comprised of allergists, GPs, pharmacists, and nurses in the know – recently sent a media release urging health professionals to check their patients’ inhaler technique. Why? Because their research showed up to 90% of patients incorrectly use their inhalers for asthma or COPD. Moreover, amongst the 75% of patients who reported their inhaler technique over the last 2-3 years was OK, only 10% were correct when checked.
201609-Asthma-inhaler-use-infographicTo combat the problem of poor inhaler technique NAC has put this info on their website and launched updated versions of its information paper for health professionals and demonstration videos on inhaler technique for people with asthma or COPD.
While few would argue that correcting the inhaler technique of any patient who really needs it could improve lung function, quality of life and asthma control, there are some unanswered questions.
Does the 90% “incorrect technique” really refer to those who need the treatment? Maybe there are too many people on inhalers who don’t really need them?
One of the key contributors to the NAC information Assoc/Prof Helen Reddel commented. (Helen is an Australian respiratory physician with expertise in inhaler technique and helps oversee the Australian Asthma Handbook.) She said that amongst those studied the evidence was strong (but mentioned one study in which 1,664 patients averaging age 62 years were referred to a chest clinic!). “In these studies there is a strong association between poor technique and poor health outcomes, and as asthma control improves after fixing inhaler technique, it is a reasonable assumption that most of the patients needed the inhalers.”
Fair enough for patients associated with hospitals or needing regular treatment. But she didn’t really answer either of our questions which are likely to refer to patients confined to primary care. Metered dose inhalers (MDIs) are available over the counter these days so it is important for the primary care doctor to know this.  
These doctors may also want to know if amongst the reported 90% incorrect technique there are faults in technique that have major influences on treatment efficacy? NAC says “poor asthma symptom control is often due to incorrect inhaler technique” but how often?
According to NAC literature, about 1 in 10 people are said to have asthma and only 45% of these are “poorly controlled” yet can we assume these people use up most of the estimated $1.2bn spent per annum on asthma healthcare?
Dr Reddel points out, “Half of the costs of asthma in Australia are from medications for all patients. See data from AIHW: www.aihw.gov.au/asthma/expenditure/. We commissioned a wider report on the cost of asthma last year, which is available at www.nationalasthma.org.au”
Are current NAC efforts well directed and aimed at decreasing asthma deaths and asthma/COPD hospitalisations for exacerbations? NAC says “incorrect inhaler technique increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD”.
There are commercial interests behind asthma treatments and planners wish to avoid (expensive) hospitalisations. One can see how poor inhaler technique will be a popular ‘angle’ amongst those looking to save money (i.e. less unnecessary scripts and hospitalisations). However, faulty technique reflects poorly on the prescribing doctors, whether specialists or GPs, so the onus is on bodies like the NAC to ensure their efforts are correctly targeted.
There are 10 different devices featured in the information paper and videos – a daunting task for any doctor to get their head around and anecdotally different devices would be prone to different errors. The updated information includes checklists on each of the 10 respiratory devices available.
Advice is to always check (by viewing) the inhaler technique before considering dose escalation or add-on therapy. Health professionals are advised to brush up themselves before handing out advice.
NAC suggests one-on-one training in correct inhaler technique, where necessary. To ensure the proper technique continues into the future, reminders are likely needed as most people need reminding within three years.
Target groups are as you might expect - young children, older adults, people already SOB and people using more than one type of inhaler.
National asthma week is the first week in September. See www.nationalasthma.org.au/living-with-asthma/resources/health-professionals

While communication is one thing, investigation of notifications is another. We believe good doctors want the bad ones weeded out but they don’t want to be part of a witch hunt or get buried in lawyers, politics or paperwork.

The national Medical Board can respond to a complaint or act on the advice of the WA Medical Board to establish an assessment panel to either examine the health or performance and professional standards of a doctor. Health consumers are represented on panels along with medical practitioners.

The Medical Board and AHPRA have undisclosed lists of doctors who are approved by them as panellists and probably as expert witnesses. Many of these people, we believe, were ‘grandfathered’ across when National Law first came in (2010). Their impartiality is as unknown as they are. Then we have expected biases of the legal assessors, chosen by AHPRA, possibly thrown into the mix.

Is there a problem, Houston?

It is important this is sorted to everyone’s satisfaction as 42% of doctors in our survey thought panellists could lack impartiality to a serious extent.

In fact, only one quarter of doctors we surveyed (n=195) were happy with the impartiality shown by AHPRA or the Medical Board in processing a complaint (with 36% unhappy and 39% undecided). Nearly all of those who were unhappy said they were concerned that unfairness will be seriously damaging to someone. Investigation is a very confronting experience.

If someone is being investigated by a panel, either the panel or the person being investigated can opt for a more out-in-the-open State Administrative Tribunal (SAT) judicial hearing – the panel usually refers because it feels the evidence before it constitutes more serious professional misconduct.

What Fair Doctors Want

Talking to doctors, they appear to want an apolitical system of investigation that is fair and timely. They want to be treated reasonably. Unlike the legal profession, their work is mostly built around trust and honesty. They do not want a return to the ‘good old days’ where those with a political bent in the medical profession could influence what the Medical Board did.

While this is a very difficult area for us to investigate, with arguments and counter-arguments at every step, we cannot understand why the Medical Board would turn to arguably the most political organisation, the AMA, for its counsel (the national Board Chair met earlier this year with “senior leaders from AHPRA and representatives of the AMA” to workshop doctor complaints).

Why? Our e-Poll responses raise a question mark over the AMA’s involvement (and we don’t think AMA members have been polled on this issue.)

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