Improving the quality of hospital care provided for asthma out-patients in a country in turmoil: a report from Syria

Yousser Mohammad, Rafea Shaaban, Hiba Alwan Salman, Boushra Nazer Shabraq, Basim Dubaybo


Background: In low resources settings, especially during periods of turmoil, asthma care becomes emergency-oriented, and adherence to international asthma management guidelines such as long-term inhaled corticosteroids (ICS) prescription is limited. The role of education for inhaler technique to guarantee treatment efficacy is neglected and follow up is hampered by war-related displacement. In Syria, asthma care is not included in primary care, and frequently, internal medicine general hospital outpatient clinics are the first contact. The main objective of our study was to evaluate the adequacy of prescription of controller medications (ICS/LABA) by residents on initial contact with patients, and the effect of regular onsite personalized supervision and coaching by a trainer pulmonologist on improving their practice. The second objective was to evaluate the efficacy of mobile training for inhaler technique, and asthma mobile follow up.
Methods: We developed an audit form to assess initial prescription of ICS/LABA by residents. Filled forms were reviewed by a trainer pulmonologist for compliance with international guidelines. When discrepancies were noted, onsite training was provided. Auditing of new presenting asthma patients is continual to evaluate improvement of initial prescription by the same residents. In parallel, video-mobile education of patients for inhaler technique, and mobile interviewing follow up were tested.
Results: Implementation of these strategies resulted in improved adherence of residents to ICS dosing guidelines (P=0.002), optimal inhaler technique by patients, and efficacy of mobile follow up.
Conclusions: WHO programs for CRD in developing countries, especially in regions of conflict and war, should include auditing of care by residents with onsite coaching by trainer pulmonologists, and mobile education for technology of inhaler and patient follow up.