Effects of PACK guide training on the management of asthma and chronic obstructive pulmonary disease by primary care clinicians: a pragmatic cluster randomised controlled trial in Florianópolis, Brazil

Abstract

IntroductionThe Practical Approach to Care Kit (PACK) guide was localised for Brazil, where primary care doctors and nurses were trained to use it.MethodsTwenty-four municipal clinics in Florianópolis were randomly allocated to receive outreach training and the guide, and 24 were allocated to receive only the guide. 6666 adult patients with asthma or chronic obstructive pulmonary disease (COPD) were enrolled, and trial outcomes were measured over 12 months, using electronic medical records. The primary outcomes were composite scores of treatment changes and spirometry, and new asthma and COPD diagnosis rates.ResultsAsthma scores in 2437 intervention group participants were higher (74.8%, 20.4% and 4.8% with scores of 0, 1 and 2, respectively) than in 2633 control group participants (80.0%, 16.8% and 3.2%) (OR for higher score 1.32, 95% CI 1.08 to 1.61, p=0.006). Adjusted for asthma scores recorded in each clinic before training started, the OR was 1.24 (95% CI 1.03 to 1.50, p=0.022). COPD scores in 1371 intervention group participants (77.7%, 17.9% and 4.3% with scores of 0, 1 and 2) did not differ from those in 1181 control group participants (80.5%, 15.8% and 3.7%) (OR 1.21, 95% CI 0.94 to 1.55, p=0.142). Rates of new asthma and COPD diagnoses, and hospital admission, and indicators of investigation, diagnosis and treatment of comorbid cardiovascular disease, diabetes and depression, and tobacco cessation did not differ between trial arms.ConclusionPACK training increased guideline-based treatment and spirometry for asthma but did not affect COPD or comorbid conditions, or diagnosis rates.Trial registration NCT02786030 (https://clinicaltrials.gov/).

Facilitators and obstacles to implementing the practical approach to the care kit/pack Brazil / Facilitadores e obstáculos para implementar a abordagem prática do kit de cuidados/ pacote Brasil

“…The methodology used during the PACK training was highly praised by the interviewees, which confirms what the literature has found 22 regarding the use of active and interactive strategies as facilitators in the implementation of interventions in primary care, when compared to the simple distribution of materials. In addition, our findings corroborate the article published by Bachmann et al (2018) 25 , which demonstrated that health professionals who received the PACK training increased treatment based on guidelines in spirometry for asthma, compared to those who only received the protocol without training. The interviews also pointed to the transferability of the training, as no cultural barriers related to the Brazilian context were reported about a methodology that was originally created in another country.…”

Understanding and controlling asthma in Latin America: A review of recent research informed by the SCAALA programme

“…ProAR has recently focussed efforts on building the capacity of primary health care workers to manage asthma throughout Brazil, in collaboration with other groups. 167 , 168 , 169 Important barriers for asthma control in LA include the neglect of asthma as a public health issue by health authorities. Despite the provision of free asthma medications in many settings, there is no training of primary health care teams to diagnose and treat asthma.…”

“…There is a major unmet need in primary health care to improve capacity to manage asthma adequately in LA. ProAR has recently focussed efforts on building the capacity of primary health care workers to manage asthma throughout Brazil, in collaboration with other groups 167–169 . Important barriers for asthma control in LA include the neglect of asthma as a public health issue by health authorities.…”

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care

“…One study reported the number of patients who had spirometry performed at the GP practice at least once per year (Smidth 2013) and one study reported change in number of spirometry tests per 100 patients a iliated with the GP practice (Due 2014). Four further studies reported outcomes related to spirometry, but were not considered part of our primary outcome: one simulated COPD cases and reported the agreement on case diagnoses between GPs and expert panel judgement (Poels 2008); one used the COPD Physician Practice Assessment Questionnaire for GPs to self-report the percentage of COPD patients in whom they confirmed diagnosis by pulmonary function tests (Uzzaman 2020); one reported the number of patients with a request for spirometry (Bachmann 2019); and one reported the percentage of spirometry testing sessions that were assigned a 'pass' grade (Latzke-Davis 2011).…”

“…Respiratory medications reported included short-acting beta agonists (SABA), long-acting beta agonists (LABA), inhaled corticosteroids (ICS), oral corticosteroids, tiotropium, theophylline, antibiotics and combinations of two or more of these medications. Seven studies reported on individual medications (Fairall 2005;Martens 2006;Soler 2010;Hurlimann 2015;Lou 2015;Morganroth 2016;Bachmann 2019) Cochrane Database of Systematic Reviews medication and non-medication changes" for COPD as an indicator of GP decision-making based on simulated COPD cases (Poels 2008). Timing of the outcome measurement ranged from three months to four years, with a median time frame at 12 months (five studies).…”