Background -The percentage of patients inhaling their medication effectively varies widely, according to methods of assessment and inhalers used. This study was carried out to assess differences among four types of inhalers using inhalerspecific checklists. Methods -Inhalation technique was evaluated in adult patients with chronic obstructive pulmonary disease (COPD). Inhalers investigated were either metered dose inhalers (MDIs) or the dry powder inhalers Turbohaler (Turbuhaler), Diskhaler, and Rotahaler. Errors were recorded against inhaler-specific checklists. From these, scores were derived by dividing the number of items correctly completed by the total number of items on the checklist and the result was expressed as a percentage. For every inhaler "essential actions" were identified and scores on these key manoeuvres were calculated. The percentage of patients performing all these essential actions correctly was also calculated. Scores were also compared with adjustment for differences in relevant patient characteristics. Results -Important differences among inhalers were found. Of 152 patients with COPD (mean (SD) age 55-1 (8.7) years), those with MDIs performed worst, especially when only essential items were considered. Patients with a Diskhaler did best, although after correction for patient characteristics the differences tended to diminish. Only 60% of patients were able to perform all essential inhaler actions satisfactorily. Of those using the Diskhaler, 96% did so correctly, while the corresponding figure for those using the MDI was only 24%. Inhaled medication plays an important part in the treatment of asthma and chronic obstructive pulmonary disease (COPD). In the Netherlands two types of inhaler are in common use: metered dose inhalers (MDIs) and (in the majority) dry powder inhalers (DPIs). Both have their advantages and disadvantages. MDIs are small, easy to carry, and deliver at least 100 doses, but they require good handlung coordination to achieve the best results.' DPIs, being breath actuated, are unaffected by hand-lung coordination, but patients need an inspiratory flow ofmore than 30 1/minute which might prove difficult to achieve for patients with severe COPD.The percentage of patients inhaling their medication effectively varies from 2% to 85% according to the method of assessment and the type of inhaler.2'-A previous survey of inhalation technique in 123 patients with COPD" revealed that one third failed to use their inhaler effectively, and that inhalerspecific design features contributed significantly to the failure rate. The latter finding is confirmed in a number of other reports. [3][4][5][6][7][8][9][10][11][12][13][14][15] To our knowledge, no comparable study of inhaler technique has considered such patient variables as age, sex, educational achievement, type of health care insurance, duration of disease, previous experience with the inhaler, or instruction in inhalation technique, all ofwhich may influence the efficacy of treatment. In two studies an attempt was m...

Inhaled medication is important in the treatment of chronic obstructive pulmonary disease (COPD). In this paper a comparison of the long-term efficacy of three instruction-models is presented. A total of 152 COPD-patients were randomized into one of four groups: Personal-, video-, group-instruction and a control group. Inhalation technique was assessed by means of checklists, on which essential inhalation manoeuvres were identified. Up to 9 months later, 148 patients returned for follow-up assessment. Prior to instruction 61% of patients in the control group had a perfect score on essential actions, compared to 62, 65 and 53% for those receiving group-, personal- and video-instruction respectively. At follow-up these percentages were 49, 97, 75 and 76%. For group-(35%) and video-instruction (24%) the increase from baseline was significant. Examining the different inhalers under investigation, it is striking, that only 24% of all patients with a Metered Dose Inhaler (MDI) performed all essential checklist items correctly, versus 96% for those using a Diskhaler. The fact that for the MDI this percentage improved to 90% post-instruction, shows that time spent on instruction, is time well spent. We conclude that group instruction seems superior to personal counselling, and equally effective or even better than video instruction. Personal instruction should not be dismissed and a combination with video instruction might prove to be effective as well.

We studied the reproducibility of ultrasonographic screening examination of the hip when read by diagnostic radiographers. In order to determine interobserver variability, 200 ultrasonograms were classified according to Graf’s method by five observers (four radiographers and one radiologist). The kappa values for interobserver variability indicated moderate agreement (kappa 0.47) for the exact Graf classification and substantial agreement (kappa 0.65) for the classification of normal (type I) versus abnormal (type IIa-IV). Agreement was significantly different for normal, immature and abnormal hips. Comparison of the findings in our interobserver study with existing information based on other examinations and treatment revealed that only a small number of infants with mildly dysplastic hips would have been typed as normal by some observers as a result of observer variability. In conclusion, the interobserver agreement on the ultrasound assessment of the hip was good enough for screening purposes. Observer variability did not result in any severe cases being missed.

Self-management of asthma and self-treatment of exacerbations are considered important in the treatment of asthma. For successful self-treatment, medication has to be inhaled correctly, but the percentage of patients inhaling effectively varies widely. As part of a self-management program we checked and corrected inhalation technique. This paper addresses differences among inhalers in relation to patient characteristics and the effect of instruction, 1 year after enrollment. Maneuvers that are essential for adequate inhalation were identified. When errors in inhalation technique were observed, patients were instructed in the correct use of their devices. One year later, inhalation technique was checked again. Only patients who used the same inhaler throughout the entire study period were analyzed. Of the 245 adult asthmatic patients who were enrolled in the self-management program, 166 used the same inhaler throughout the study period. One hundred twenty patients (72%) performed all key items correctly at baseline and this increased to 80% after 1 year. At follow-up, older patients were less likely to demonstrate a perfect inhalation. Patients with a Diskhaler made fewest errors. Adjustment for differences in patient characteristics did not significantly change the results. Because many patients with asthma use their inhaler ineffectively, there is a need to know which inhaler leads to fewest errors. Diskhaler was nominated by this study. When patients are not able to demonstrate adequate inhalation technique in a "tranquil" setting, it is doubtful that they can do so when they experience an exacerbation. Therefore, inhalation instruction should be considered an essential ingredient, not only of self-management programs, but also of asthma patient care in general.

Action research (AR) is increasingly being used to study the improvement of healthcare delivery. Ensuring that all the stakeholders in the AR are willing to take action, however, can be difficult. Especially in healthcare contexts, action plans may challenge the autonomy of the healthcare professionals and the positions of the different stakeholder groups. Does the use of computer simulation techniques within the AR promote action taking by all the stakeholders? We performed an AR experiment with computer simulation in a university hospital's emergency department in the Netherlands. A simulation model was designed that replicated the actual healthcare delivery process in the study setting. Together with representatives from the medical and nursing staff and department management, we used the model to discuss improvement actions. The team designed an improvement scenario that fundamentally rearranged the task division between the physicians and the nurses. The promising projections in the simulation model motivated the team to try the scenario in reality. The implementation was successful, although it generated much concerns and discussion. The new task division successfully improved patient length of stay (LOS) in the ED. The results achieved by the single team turned out to have lasting effects on the other stakeholders in the ED. Our AR experiment with computer simulation promoted action taking by all the stakeholders. Computer simulation within AR is a promising combination for improving healthcare delivery.