P Pa at ti ie en nt t c co om mp pl li ia an nc ce e w wi it th h i in nh ha al le ed d m me ed di ic ca at ti io on n: : D Do oe es s c co om mb bi in ni in ng g b be et ta a--a ag go on ni is st ts s w wi it th h c co or rt ti ic co os st te er ro oi id ds s i im mp pr ro ov ve e c co om mp pl li ia an nc ce e? ? In an open, multicentre, parallel group study 102 asthmatic patients were randomly divided into two groups, either receiving the two drugs in separate Turbuhalers or combined into one Turbuhaler. A twice daily regimen was prescribed and a preweighed metered-dose inhaler (MDI) of salbutamol was provided for rescue use. Compliance was measured using the Turbuhaler Inhalation Computer (TIC), which recorded the time and date of each inhalation over a 12 week period. Forced expiratory volume in one second (FEV 1 ) and forced vital capacity (FVC) measurements were carried out at week 0, 6 and 12.Results from 72 patients were analysed. The average compliance was 60-70%. Treatment was taken as prescribed on 30-40% of the study days, and over-usage occurred on less than 10% of days. Only 15% of patients took the drugs as prescribed for more than 80% of the days.Compliance was no greater in patients using the combined inhalers. Other ways of improving patient self-management need further investigation.

Morbidity and mortality from asthma in the Western world is increasing despite effective prophylactic drugs. Beta agonists are increasingly considered causal; while under-prescribing of inhaled steroids or other anti-inflammatories are accepted as causes for the problems, but the role of non-compliance with inhaled asthma therapy is rarely mentioned. Using a novel electromechanical counter MDI actuations have been recorded in three small (9-11 patients), short (2-3 weeks) studies. When aware compliance with prescribed inhaled steroids was under scrutiny, six patients were fully compliant, two took just 70% of the prescribed regimen, but two did not follow the prescribed regimen at all. When unaware of scrutiny, six out of 11 were compliant but five patients were estimated as taking less than 30-51% of the prescribed dose of inhaled steroid. When asked to monitor rescue bronchodilator usage patients consistently under-recorded. Under-use as well as under prescription of inhaled steroids and under-estimation (8) of beta 2-agonists use may be contributory factors to the present increase in asthma mortality and morbidity. These potential problems of poor compliance need larger scale studies to show how and if behaviour can be altered to improve compliance.

IntroductionWe have been running an Internet and CD-ROM based course in Health Informatics in New Zealand, since July 1998. This paper describes the structure of the course, the technology used and the development process and lessons we have learned. Our target audience is working health care professionals, including primary care and hospital doctors, nurses, and managers. The educational goals of the course include skills in:Using electronic information sources, databases, presentation and analysis tools, electronic communication and collaboration tools.Understanding of the breadth of the field of Health and Medical Informatics (HMI), including basic computing concepts, advantages and disadvantages of the application of IT in HealthCare situations and the concept of professional HealthCare workers as knowledge workers and information users.MethodsThe format of the course is a four semester, part-time course run over the Internet for HealthCare workers throughout New Zealand. Some course material is delivered via CD-ROM; some via the Web and communication takes place over the Internet using synchronous and asynchronous tools. A face-to-face workshop is provided at the start of each semester. At present 45 students are enrolled on the course. Student assessment takes the form of a set of competency tests (one every 3 weeks) covering application of topics covered in the current module. In addition 40% of the student's mark is assigned according to group work (groups are 4-5 students). These projects include a report on a topic of relevance along with web pages and presentations. Marks are also awarded for active participation in the group.ResultsA standard set of questions is provided to each student by the university - the first set of results have been very positive. Feedback forms have been provided and returned at the end of each workshop.ConclusionInternet technology has allowed a higher level of communication between staff and students, and student to student than would be possible with conventional means. Off-the-shelf software can support this process and the barriers to this method of teaching can be breached.