Effectiveness of an Educational Intervention on Inhaler Technique Proficiency in Chronic Obstructive Pulmonary Disease: A Single-Center Quality Improvement Study

Round 1

Reviewer 1 Report

this study is aimed at evaluating the effectiveness of a teaching intervention on improving the inhalatory technique in patients with stable COPD

the methodology is very clearly described except for the questionnaire aimed at documenting epidemiological and clinical characteristics which is not clear in content and purpose

the correctness of the inhalatory techinque is not quantified before and after the intervention

the effectiveness of the intervention is not also clearly defined. does it refer only to the improvment of the inhalatory technique or do you expect a broader effect including that on disease burden?

the comparative discussion is not exactly the most adequate for the purpose of your study as the cited references refer to the correctness of inhalatory technique in absence of a training session ("ad hoc correctness")

since your draft has significant merits I would try to add in discussion papers examining teaching interventions if available if not I would point out that the already cited data with quite low levels of correctness support the need for a training intervenion of the type described and analysed

also I would try to change the title so it better reflects the content of the draft ie the focus on the patient  Patient reported acceptability and impact of a training ..... (or perhaps you have a more insipired idea) 

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

 This small and preliminary study is clear, well written and correctly performed. It is of some interest, although, as recognized by the authors, it  has important limitations,   and overall adds little to what is already known.    

Author Response

see attachment

Author Response File: Author Response.pdf

Reviewer 3 Report

The authors of this paper aim to determine if demonstration of correct inhaler technique, can improve the ability of COPD patients to properly use their inhaler. In addition, whether the use of a flyer was helpful in achieving this. Authors suggest that their educational intervention was successful in improving patient inhaler use. This was a small local study with short term outcomes.

General Comments:

There is good rationale for the study, however it was not executed as well as it could have. The number of patients were fine for a pilot study, however the biggest issue was the lack of a control arm. It is almost impossible to say with any certainty the real effects of the educational intervention without being able to compare it to a control.

 

Methods:

·         Authors don’t give any information as to what was included in the therapy diary/what exactly the patients were expected to keep track of or how often they were supposed to use it.

·         Supplementary material ( as well as Fig 2) were not in English

·         How did the authors pick 2 weeks to be the follow-up timepoint? And why didn’t they have more visits, even for a short term study?

·         There is no baseline assessment of what the patients’ inhaler technique was before the intervention, so we can’t objectively say there was any improvement compared to before the teaching session.

·         As mentioned before, the lack of a control arm is a serious flaw of the study, simply referring to the literature for comparison is not a viable alternative here.

Results

·        About 60% of patients were 70+ years old, did incorrect use have any correlation to their age?

·        Authors have determined that at least step 6 of the flyer was difficult for patients to understand, do they have suggestions of how they would improve this?

·        There needs to be consistency in the questions included in the questionnaire at each visit, e.g evaluation of the flyer should be asked the same way in both questionnaires.

·        What was the significance of asking  (in questionnaire at visit 2) if the last page (preparation of Respimat) had been shown to the patient?

Discussion and Conclusions:

·        Line 134: “Everyone knows that…..” This should be written differently, E.g it is well established that….

 

·        The authors have correctly stated that their study has multiple limitations, however I don’t believe this is justified by the local improvement of the study, because you can’t reliably prove improvement.

·        Line 152-154: This is an overstatement of results considering you have nothing to really compare it to.

Author Response

see attachment

Author Response File: Author Response.pdf

Reviewer 4 Report

1.       I have a complaint about inclusion criteria: why the cut-off in the study was as low as 18 years, in the study of COPD patients, which by definition are older than 40 years, except some rare conditions?

2.       Visit 2 at 14 days is too short to evaluate the effect, as most prevoius reserches showed that after 3 months memory and abilities for proper inhaler technicques wained and is necessary to repeat the training with an inhaler.

Advantage is that some of listed limititation authors stated by themselves, and that they are aware of, together with the small sample. An inhalers techicque is a crucial topic for the daily practice or many physicians, pulmologist as well as general pracititioners, because of that I support publishing of this article.

Author Response

see attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Thank you for addressing my comment/questions. While authors resolved the question of controls, the authors response also highlighted that there are several other studies that have investigated the same/similar aims; investigating educational/training intervention as a means to improve inhaler technique in chronic airways disease (COPD and asthma). How is your study different to the literature, and what does your study add to the existing body of knowledge?

 

Point 2: Authors misread my question, which was in reference to the therapy diary attached to the flyer, not the flyer itself. What were the patients supposed to record in the diary?

Point 3: It may be the case that the original flyer was in Italian as the patients were Italian, however this is an English journal, so an English version of the flyer needs to be attached so readers can also understand it.