In 2008, a twenty-year-old environmental treaty had a dramatic impact upon the care of asthma in the United States. Due to the 1987 ban on chlorofluorocarbons (CFCs), the ozone-depleting propellents once found in hair spray and other aerosol-can products, the inhalers used by millions of asthmatics underwent a mandatory switch to a CFC-free version. Unfortunately, patient education about the switch was scarce, leaving many unaware that they would be receiving the new inhalers. Even more concerning, many physicians were equally uninformed about the switch and how to counsel their patients on use of the new devices, called HFA inhalers.
That impending storm of confusion, as highlighted by a May 2008 New York Times article, inspired a group of University of Chicago Medical Center residents and faculty to launch the Chicago Breathe Project. Modeled upon the Medical Center’s community-based Neighborhood Health Exchange, an effort to raise health literacy on diet, nutrition and heart health in underserved communities, the project focused on asthma education – for patients and medical residents alike. Their two-pronged educational effort was described this month in the Journal of the National Medical Association.
“Reports were saying that patients and physicians are completely unprepared for this transition,” said Valerie Press, instructor in the section of hospital medicine and one of the Chicago Breathe Project founders. “We found that a large majority of the residents really didn’t know much about these HFAs, and also didn’t know a ton about how to teach patients about inhalers in general.”
Community health clinics and respiratory health organizations also reported a need for patient education on the new inhalers, Press said. Minority populations in Chicago suffer at least twice the national hospitalization rate and mortality rate for asthma. More recently, a litany of complaints and questions related to the new inhalers – that the spray was too cold, tasted different, wasn’t working, was working too strongly, or was too expensive – had come in from patients, the organizations reported.
So the Chicago Breathe Project set about educating both groups, and like the Neighborhood Health Exchanges, a team of residents led the educational efforts. With a grant from the American College of Physicians Foundation, the team was able to go to four other Chicago medical centers and teach a workshop to their residency programs, with the added allure of free lunch. Residents learned about the inhaler switch, how to best instruct a patient on inhaler use, and discussed case studies of patients having trouble with the devices. Those surveyed 6 months after the workshops said that they were more likely to assess a patient’s inhaler technique and were more comfortable discussing proper use with their patients.
In the community workshops – held at clinics on the South Side of Chicago and in suburban Cicero – the discussion was much less technical. The events were designed to foster communication with attendees, whether that meant using bilingual residents in the predominantly Spanish-speaking Cicero clinic or making sure all materials and presentations were understandable to people with low health literacy. When the residents opened the floor to questions, it soon became apparent that the education shortage ran deeper than the recent inhaler switch.
“In the workshops, it was highlighted how much confusion there is amongst patients in general about their medications,” said Amber Pincavage, one of the University of Chicago residents who helped lead the events.
“The switch to HFA inhalers was what led us to be somewhat interested in this topic, but it also opened up a whole can of worms,” said Vineet Arora, assistant professor of general internal medicine and another project co-organizer. “Once we started, we realized it wasn’t just the HFA inhalers; people just had a lot of confusion about their asthma.”
But the audience, made up of patients waiting for appointments, school nurses, and mothers of asthmatic children, were “overwhelmingly positive” in their evaluation of the workshops, the authors wrote.
“One woman was so excited – she was having trouble with her son who didn’t want to use the new inhaler and didn’t know what to tell him,” Press said. “But after discovering that she could tell him ‘No, it’s working, it just doesn’t feel the same,’ it was like a lightbulb went off for her.”
As the class of residents that started the Chicago Breathe Project move on to fellowships or chief resident duties, younger residents hope to continue the effort at community clinics and as part of the University of Chicago residency curriculum. To educate residents beyond their local reach, Press and colleagues have filmed videos on proper inhaler use for The Doctor’s Channel and provided a slew of free materials on the Chicago Breathe Project website. By educating providers as well as patients, the team hopes that the workshops will have a long-term and far-ranging impact on asthma education and care as residents disperse to practice medicine around the country.
“Our residents wanted to go out and learn more about the community, so this was another way to help them engage with the community,” Arora said. “I think the other key is that it also helps them with their own patient care. The next time they admit or see an asthma patient in clinic or in their own practice, they’re a little bit more able to use the tools.”