Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence.

STUDY OBJECTIVES: To evaluate whether direct feedback discussion on inhaled steroid use might influence subsequent adherence with this therapy. DESIGN AND SETTING: A 10-week, single-blind, randomized trial in asthma patients. Inclusion criteria included forced expiratory volume in 1 second <80%, one or more markers for low socioeconomic status, and the use of inhaled steroids. Inhaled steroid and beta-agonist use were electronically monitored. All patients received standard asthma care. The treatment group received direct clinician-to-patient feedback discussion on their inhaled steroid and beta-agonist use on all subsequent visits, whereas this information was withheld during the study period in the control group. MEASURES: 1) Mean weekly inhaled steroid adherence [(number of actuations/prescribed number of actuations) x 100]; 2) number of days with overuse of inhaled steroids; 3) 24-hour and nighttime albuterol use; 4) included forced expiratory volume in 1 second; and 5) Asthma Quality of Life Questionnaire total score. RESULTS: Ten treatment and nine control patients completed the study. Mean weekly inhaled steroid adherence over the first week was not significantly different in the treatment and control groups: 61 +/- 9% versus 51 +/- 5%, respectively. However, by the second week, adherence increased to 81 +/- 7% in the treatment group, whereas it decreased to 47 +/- 7% in the control group (P = 0.003). Adherence remained above 70% in the treatment group for the entire trial, but continued to decrease in the control group. Overuse of inhaled steroids was low in both groups. There were no group differences in any of the asthma outcomes. CONCLUSIONS: Direct clinician-to-patient feedback discussion on inhaled steroid use using electronic printouts did improve adherence in the short-term in asthma patients at high-risk for poor adherence.

The utility of chest radiographs following percutaneous dilatational tracheostomy.

OBJECTIVE: To determine the usefulness of performing routine postprocedure chest radiographs (CXRs) following percutaneous dilatational tracheostomy (PDT) under bronchoscopic visualization. DESIGN: Retrospective, chart review. SETTING: Medical-surgical ICU of a teaching hospital. METHODS: Sixty patients who underwent PDT under bronchoscopic visualization, for persistent ventilator dependence, in our medical-surgical ICU were studied. We noted the occurrence of any perioperative complications, physician anticipation of postoperative complications, and postprocedure CXR findings. We compared postprocedure CXRs with the last preprocedure CXR. Immediate postoperative complication was defined as a clinical worsening, hemodynamic instability, or a new radiographic finding such as atelectasis, paratracheal placement, pneumothorax, and pneumomediastinum. We determined whether the postprocedure CXRs led to any change in patient management. OBSERVATION: Two patients (3.3%) had postoperative complications detected on their CXRs, one with a pneumomediastinum and the other with a tension pneumothorax. Both procedures were noted to be difficult, with a high physician anticipation of complication. In the remaining 58 patients (96.7%), no postoperative complications were detected on the postprocedure CXRs that necessitated any change in patient management. CONCLUSION: We concluded that routine CXR following PDT that had been performed under bronchoscopic visualization is unnecessary in the absence of clinical deterioration or the anticipation of postoperative complications.