Asthma friendly pharmacies: a model to improve communication and collaboration among pharmacists, patients, and healthcare providers

Deploying an asthma dashboard to support quality improvement across a nationally representative sentinel network of 7.6 million people in England

Every year, there are ~100,000 hospital admissions for asthma in the UK, many of which are potentially preventable. Evidence suggests that carefully conceptualised and implemented audit and feedback (A&F) cycles have the potential to improve clinical outcomes for those with chronic conditions. We wanted to investigate the technical feasibility of developing a near-real time asthma dashboard to support A&F interventions for asthma management in primary care. We extracted cross-sectional data on asthma from 756 participating GP practices in the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) database in England comprising 7.6 million registered people. Summary indicators for a GP practice were compared to all participating RCGP RSC practices using practice-level data, for the week 6-12th-Mar-2023. A weekly, automated asthma dashboard with features that can support electronic-A&F cycles that compared key asthma indicators for a GP practice to RCGP RSC could be created ( https://tinyurl.com/3ydtrt85 ): 12-weeks-incidence 0.4% vs 0.4%, annual prevalence 6.1% vs 6.7%, inhaled relievers to preventer 1.2 vs 1.1, self-management plan given 83.4% vs 60.8%, annual reviews 36.8% vs 57.3%, prednisolone prescriptions 2.0% vs 3.2%, influenza vaccination 56.6% vs 55.5%, pneumococcal vaccination ever (aged ≥65 years) 90.2% vs 84.1% and current smokers 14.9% vs 14.8%. Across the RCGP RSC, the rate of hospitalisations was 0.024%; comparative data had to be suppressed for the study practice because of small numbers. We have successfully created an automated near real-time asthma dashboard that can be used to support A&F initiatives to improve asthma care and outcomes in primary care.

Development of a community pharmacy-based intervention for patients with uncontrolled asthma

Background

Objective

Methods

Results

Conclusions

Managing asthma in primary healthcare

Asthma brings considerable challenges for family doctors because of its variety of shapes, different levels of severity, a wide age range, and the fact that in the last decades clinicians are able to offer much better treatment options with a better level of disease control and a higher quality of life. The objectives of the current review article are to provide an up-to-date review by primary care respiratory leaders from different countries of the most significant challenges regarding asthma diagnosis and management, the importance of team work and the problems in recognizing and dealing with difficult-to-manage and severe asthma in primary care. The article provides a short review of the main challenges faced by family physicians and other primary health care professionals in supporting their patients in the management of asthma, such as asthma diagnosis, promoting access to spirometry, the importance of a multiprofessional team for the management of asthma, how to organize an asthma review, the promotion of patient autonomy and shared decision-making, improving the use of inhalers, the importance of the personalized asthma action plan, dealing with difficult-to-manage and severe asthma in primary care and choosing when, where and how to refer patients with severe asthma. The article also discusses the development of an integrated approach to asthma care in the community and the promotion of Asthma Right Care.

Role of community pharmacists in educating asthmatic patients: A multi-centered cross-sectional study in Ethiopia

Background:

Effective asthma management requires a multidisciplinary approach that includes; the physician, the patient, and the patient’s family.

Objectives:

The current study aimed to assess the roles played by community pharmacists toward asthma control together with the barriers hindering their practice and possible strategies to overcome those barriers.

Methods:

A multi-centered cross-sectional study was conducted. Data was collected using a structured, self-administered questionnaire adapted from previously conducted studies and customized to fit with the current study setup. The collected data was cleaned, coded, and entered into Statistical Package for Social Sciences (SPSS) version 21 for analysis. Descriptive analysis of the collected data was conducted and the results were presented using frequency tables and graphs.

Results:

A total of 122 community pharmacy professionals; 63 from Gondar, 26 from Bahir Dar, 15 from Debre Markos, 14 from Woldia, and 4 from Debre birhan participated in the study. About 96 (78.7%) of the participants reported that they teach their patients the basic facts about asthma. More than two-thirds of the participants 85 (69.7%) also reported that they were able to identify and manage the triggering factors of asthma for their patients. Lack of pharmacist time was reported by 78 (63.9%) of the study participants as a major reason for the inadequacy of the counseling service provided.

Conclusion:

It appears evident that there is a need for continuing professional education and pharmacists to receive additional training to improve their ability to go beyond identifying a problem and suggesting therapeutic options.

Improving primary care management of asthma: do we know what really works?

Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel's opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.

Essential Role of Pharmacists in Asthma Care and Management

Asthma, a chronic respiratory disease characterized by chronic airway inflammation, bronchial hyperresponsiveness, and reversible airflow obstruction, poses a substantial economic burden on patients and caregivers alike. Moreover, the heterogeneous nature of the disease and the presence of various phenotypes make the treatment of asthma challenging and nuanced. Despite the availability of several approved pharmacological treatments, approximately half of patients with asthma in the United States experienced exacerbations in 2016, highlighting the need for effective add-on treatments. Furthermore, asthma control remains suboptimal due to low adherence to medications, poor inhaler technique, and several patient-related factors. Importantly, the primary care setting, in which pharmacists play an integral role, represents a critical environment for providing long-term follow-up care for the effective management of chronic diseases, such as asthma. Pharmacists are uniquely positioned to ensure optimal clinical outcomes in patients with asthma since they have the clinical expertise to educate patients on their disease state and the role of asthma medications, provide training on inhalation technique, address patients’ concerns about potential side effects of medications, and improve adherence to therapy. Therefore, in this review article, we discuss the overall role of pharmacists in effective asthma care and management.

A systematic review and meta-analysis of the impact of collaborative practice between community pharmacist and general practitioner on asthma management

Objective: This systematic review aims to investigate the impact of collaborative practice between community pharmacist (CP) and general practitioner (GP) in asthma management. Methods: A systematic search was performed across 10 databases (PubMed, Medline/Ovid, CINAHL, Scopus, Web of Science, Cochrane central register of controlled trials, PsycARTICLES®, Science Direct, Education Resource Information Centre, PRO-Quest), and grey literature using selected MeSH and key words, such as "community pharmacist", "general practitioner", and "medicine use review". The risk of bias of the included studies was assessed by Cochrane risk of bias tool. All studies reporting any of the clinical, humanistic, and economical outcomes using collaborative practice between CPs and GPs in management of asthma, such as CPs conducting medications reviews, patient referrals or providing education and counseling, were included. Results: A total of 23 studies (six RCTs, four C-RCT, three controlled interventions, seven pre-post, and three case control) were included. In total, 11/14 outcomes were concluded in favor of CP-GP collaborative interventions with different magnitude of effect size. Outcomes, such as asthma severity, asthma control, asthma symptoms, PEFR, SABA usage, hospital visit, adherence, and quality of life (QoL) (Asthma Quality-of-Life Questionnaire [AQLQ]; Living with Asthma Questionnaire [LWAQ]) demonstrated a small effect size (d≥0.2), while inhalation technique, ED visit, and asthma knowledge witnessed medium effect sizes (ES) (d≥0.5). In addition to that, inhalation technique yielded large ES (d≥0.8) in RCTs subgroup analysis. However, three outcomes, FEV, corticosteroids usage, and preventer-to-reliever ratio, did not hold significant ES (d<0.2) and, thus, remain inconclusive. The collaboration was shown to be value for money in the economic studies in narrative synthesis, however, the limited number of studies hinder pooling of data in meta-analysis. Conclusion: The findings from this review established a comprehensive evidence base in support of the positive impact of collaborative practice between CP and GP in the management of asthma.

"Being in Control of My Asthma Myself" Patient Experience of Asthma Management: A Qualitative Interpretive Description

Asthma control can be achieved with effective and safe medication use; however, many patients are not controlled. Patients’ perceptions of asthma, asthma treatment, and pharmacist roles can impact patient outcomes. The purpose of this study was to explore patients’ experiences and patient–pharmacist relationships in asthma care. Qualitative Interpretive Description method guided the study. Semi-structured individual interviews were conducted with 11 patients recruited from personal contacts, pharmacies, and asthma clinics. Categories and themes were identified using inductive constant comparison. Themes indicated patients had a personalized common sense approach to asthma management, “go-to” health care provider, and prioritized patient–pharmacist relationships. Patients described their illness experiences and asthma control based on personal markers similar to the common sense model of self-regulation. Patients chose a family physician, asthma specialist, respiratory therapist, or pharmacist as an expert resource for asthma management. Patient perceived pharmacists’ roles as information provider, adviser, or care provider. Pharmacists who develop a collaborative relationship with their asthma patients are better positioned to provide tailored education and self-management support. Inviting patients to share their perspective could increase patient engagement and uptake of personalised asthma action plans to achieve asthma control.

Can we document the practice of dispensing? A systematic review

WHAT IS KNOWN

Documentation is a process indicator utilized to evaluate quality clinical pharmacist services. In this framework, documentation of dispensing, besides supporting patient care, allows evaluation of the impact of counselling.

OBJECTIVE

To identify and assess studies of documentation by pharmacists in the dispensing process.

METHOD

A systematic review was carried out according to the following steps: (i) identification of studies in the following databases: PubMed/Medline, Web of Science, Scopus and Lilacs, using the descriptors 'counselling', 'dispensing', 'community pharmacy services', 'pharmacies' and 'pharmacists' in different combinations; (ii) evaluation of studies, in which the title, abstract and full text of the studies, and the evaluation of the methodological quality of the selected studies were analysed.

RESULTS

In total, 26 articles met the specific criteria. Few studies addressed documentation as part of the dispensing working process (3), and 16 articles reported documentation using non-electronic systems. The main variables documented were patient information, drug therapy problems and clinical interventions. Furthermore, 20 studies showed the effects of documentation in the dispensing process and 23 studies included statistical evidence. Eight articles met between 42% and 75% of the 28 items recommended by the STROBE initiative, and two articles met approximately 60% of the 36 items recommended by the CONSORT initiative.

WHAT IS NEW AND CONCLUSION

Few studies address documentation as part of the dispensing working process. Thus, researchers should be concerned with standardizing documentation and implementing more robust designs and multicenter studies.

How pharmacist-patient communication determines pharmacy loyalty? Modeling relevant factors

BACKGROUND

Portuguese community pharmacies provide pharmaceutical services, such as therapeutic outcomes follow-up, supplemented by relevant point-of-care testing that require continuity of provision to be effective.

OBJECTIVES

To identify factors of technical and communication nature that during a patient interview contribute to patients' loyalty.

METHODS

A cross-sectional descriptive study, with a purposive sample of community pharmacies providing pharmaceutical care, was conducted. Patient interviews were taped and transcribed verbatim. Duration, segments and utterances were identified and time stamped, using a previously validated coding scheme. To identify predictors of loyalty, logistic regression analyses were performed.

RESULTS

From 59 interviews, participants' average age was 65.7 years and 42 (71.2%) were female; 45 (76.3%) interviews were classified as outcomes measurements and 14 (23.7%) as pharmaceutical consultations, with 33.2% of the patients booking a following appointment. The significant items to explain loyalty were associated with lifestyle and psychosocial exchange, age of the patient, and the presence of all interview segments (i.e. a complete consultation).

CONCLUSION

Contrary to common professional beliefs and practice orientation it would appear that pharmacists' technical skills are not the essential factors that promote patients' loyalty needed for continuity of care, at least in the same extent as the social and lifestyle-related content of the exchange. Pharmaceutical care education should focus on relational skills as much as on medication-related competencies.

Timing of emergency department visits for childhood asthma after initial inhaled corticosteroid use

Inhaled corticosteroids can prevent acute exacerbations and emergency visits when used as part of a chronic care plan for long-term control of asthma, but low patient adherence and inadequate provider prescribing (clinical inertia) can limit these benefits. State Medicaid programs are a major source of insurance coverage for low-income children, paying for medications and preventive care, as well as bearing the cost of adverse outcomes for common chronic conditions in childhood, such as asthma. This study measured the incidence and timing of emergency department (ED) visits in the first 90 days after an initial inhaled corticosteroid prescription (ICS-Rx) among 43,156 Medicaid-enrolled children with a diagnosis of asthma in 14 southern states in 2007. One in 5 children (19.6%) with asthma had at least 1 ED visit in the first 90 days after initial ICS-Rx; 10% of these visits occurred within the first 48 hours, and 25% occurred within the first week. Continued ICS-Rx use was associated with lower risk of an ED visit. There were no racial differences in the ED visit rates. Initial ICS-Rx for Medicaid-enrolled children is a warning flag for short-term risk of asthma-related ED visits, whereas continued ICS-Rx use is protective for at least 90 days. Primary care follow-up may be needed within the first 2 days after initial ICS-Rx to prevent adverse outcomes. Medicaid programs could use claims data for surveillance of adherence to guideline-concordant therapy and for sentinel events marking windows of a higher risk for ED visits. Population Health Management 2015;18:54-60.

A pharmacy asthma service achieves a change in patient responses from increased awareness to taking responsibility for their asthma

OBJECTIVES

If novel health services are to be implemented and sustained in practice, the perceptions and views of patients form a critical part of their evaluation. The aims of this study were to explore patient's perceptions and experiences with a pharmacy asthma service and to investigate if there was a change over time.

METHODS

Interviews and focus groups were conducted with patients participating in the asthma service at three time points. Data were transcribed verbatim and thematically analyzed using a framework approach.

KEY FINDINGS

The service led to an enhanced awareness and understanding of asthma, changes in participants' beliefs and attitudes towards asthma management, changes in asthma-related health behaviours and improved self-efficacy. Participants were very positive about the service and the role of the pharmacist in asthma management. There was a shift in participant perceptions and views, from being at an abstract level in those who had completed just one visit of the service to a more experiential level in those who had experienced the entire comprehensive asthma service.

CONCLUSIONS

A sustained experience/multiple visits in a service may lead to more concrete changes in patient perceptions of severity, beliefs, health behaviours and enhanced self-efficacy and control. The study highlights a need for such asthma services in the community.

Considerations and challenges for planning a public health approach to asthma

Addressing asthma from a public health perspective is a relatively new concept for which the literature provides little guidance. A public health approach seeks to decrease the burden of asthma and improve health outcomes at the population level, such as communities, cities, or states, by reaching large numbers of individuals with effective interventions and at reasonable cost. Projects designed to achieve a measureable impact at the population level are fundamentally different from projects or interventions designed to improve outcomes among individuals. This paper uses the experience of the Controlling Asthma in American Cities Project and a review of the relevant literature to explore some of the unique questions and considerations that are implicit when planning large-scale asthma projects intended to improve population outcomes. The paper is intended to inform decision making by local and state government agencies, managed care organizations, health systems, community coalitions, and funders. Analysis of asthma and other chronic disease projects aiming to achieve population-level impact is an area for continued public health research.

Conceptual framework of the Controlling Asthma in American Cities Project

The Controlling Asthma in American Cities Project (CAACP) was designed to improve the control of asthma in inner-city populations of children with a disparate burden of symptoms and adverse outcomes. As with many chronic diseases, asthma is the manifestation of multiple biologic, environmental, and social determinants. In addition to appropriate medical management, individuals with asthma must have logistical, financial, and cultural access to environments that allow avoidance of asthma triggers and encourage good asthma management practices. In recognition of this complexity, the CAACP required the seven project sites to coordinate and synchronize multiple interventions (education, healthcare access, medical management, trigger reduction) at multiple levels (individual, home, school, community, and policy) through the collaboration of relevant groups, institutions, and individuals. This paper describes the "program theory" of the CAACP project-the assumptions about how the project worked, how the components were linked, and what outcomes were anticipated. It relates the subsequent papers in the supplement to the program theory and describes how the papers can inform and guide other community-based interventions, and advance the translation of scientific knowledge to effective interventions in communities of need.