Asthma disease management-Australian pharmacists' interventions improve patients' asthma knowledge and this is sustained

The role of community pharmacists as oral health advisors in the management of oral effects of asthma medications: an exploratory survey

OBJECTIVES

To investigate community pharmacists' attitudes, confidence, practice, knowledge, and barriers towards the management of oral side effects of asthma medications.

METHODS

A paper-based questionnaire was developed from previous research, trialled, and validated. Convenience sampling through web search was used to identify pharmacy practices across Cairns, Queensland, Australia. Practices were contacted by email and phone before hand-delivering and collecting questionnaires.

KEY FINDINGS

Thirty eight community pharmacist responses were descriptively analysed. Community pharmacists surveyed within the Cairns region feel that it is within their role to help manage the side effects of asthma medications. Many feel this is best conveyed during inhaler dispensing and instruction. Current advice is more prompted rather than preventative. Pharmacists routinely advise patients of mouth-rinsing following inhaler use, however the link to preventing side effects is not clearly communicated. Pharmacists are confident in recognizing and managing common side effects such as oral thrush and dry mouth, but fewer are aware of dental decay and gingivitis. Many identify a lack of guidelines as the largest barrier to providing preventive oral health advice.

CONCLUSIONS

Cairns community pharmacists already self-perceive their role in the management of oral side effects of asthma medications. Advice given to patients is practical but does not clearly convey the causative associations between asthma medications and their potential oral side effects. Patient education is prompted more by enquiry rather than a preventative approach. The development of standardized practice protocols and integration within undergraduate degrees or continuing education may benefit the community-pharmacist delivered care.

A qualitative study on asthma management experiences of Turkish community pharmacists

INTRODUCTION

Asthma is seen in more than 4 million people in Turkey. Numerous studies have shown the beneficial effects of pharmacist interventions on medication adherence and therapeutic outcomes. The aim of this study was to gain insight into the current situation by examining the experiences of Turkish community pharmacists in relation to the counseling and referral of asthma patients, the responsibilities of pharmacists and the recommendations made by pharmacists to improve asthma management.

METHODS

In this qualitative study, the constructivist-interpretivist paradigm was adopted. To conduct qualitative interviews, a semi-structured interview guide was devised to gather insights from the pharmacists. The interviews were coded verbatim. Subsequently, various themes and sub-themes were developed based on the aim and objectives of the study.

RESULTS

A total of 14 pharmacists engaged in semi-structured interviews conducted between June and August 2023. The wealth of information gathered during these interviews facilitated a meticulous thematic analysis, yielding four overarching themes: 1) Patient-related difficulties, 2) Communication with physicians, 3) Desired traits and responsibilities of pharmacists, 4) Pharmacists' expectations. Pharmacists placed significant emphasis on their challenges in allocating time to patients, primarily due to high workloads and limited collaboration with physicians.

CONCLUSION

Considering the workload and time limitations faced by pharmacists, a collaborative model involving pharmacists and physicians is seen as essential. Enhancing the collaboration between pharmacists and physicians, especially for chronic diseases, holds the potential to enhance public health outcomes while alleviating the workload of pharmacists.

Insights into British Columbian Hospital Pharmacists Perspectives on the Discharge Process

Background: Transitions of care represent a vulnerable time for patients where unintended therapeutic changes are common and inadequate communication of information frequently results in medication errors. Pharmacists have a large impact on the success of patients during these care transitions; however, their role and experiences are largely absent from the literature. Objectives: The purpose of this study was to gain a greater understanding of British Columbian hospital pharmacists' perceptions of the hospital discharge process and their role in it. Methods: A qualitative study utilizing focus groups and key informant interviews of British Columbian hospital pharmacists was conducted from April to May 2021. Questions asked during interviews were developed following a detailed literature search and included questions regarding the use of frequently studied interventions. Interview sessions were transcribed and then thematically analyzed using both NVivo software and manual coding. Results: Three focus groups with a total of 20 participants and one key informant interview were conducted. Six themes were identified through data analysis: (1) overall perspectives; (2) important roles of pharmacists in discharges; (3) patient education; (4) barriers to optimal discharges; (5) solutions to current barriers; and (6) prioritization. Conclusions and Relevance: Pharmacists play a vital role in patient discharges but due to limited resources and inadequate staffing models, they are often unable to be optimally involved. Understanding the thoughts and perceptions of pharmacists on the discharge process can help us better allocate limited resources to ensure patients receive optimal care.

Improving Asthma Management: Patient–Pharmacist Partnership Program in Enhancing Therapy Adherence

Community pharmacist interventions can assist in improving adherence in patients with asthma. The objective of the study was to assess the feasibility of patient-centered counseling using the developed asthma-specific tools to identify barriers to adherence and identify their preliminary effect on adherence barrier score and asthma control. Adult patients with persistent asthma were invited to participate in a 3-month pre–post intervention study involving community pharmacist-provided patient-centered counseling. Bivariate analyses were conducted to determine whether there were changes in outcomes from the pre to post period. Of 36 recruited patients, 17 completed both pre and post surveys. At baseline, patients had a mean ACT score of 15.1 ± 3.5, with 94% having uncontrolled asthma, and an average of 4.2 ± 2.5 reported barriers. The following barriers were most common: not having an Asthma Action Plan (52.9%), use of inhaler more or less often than prescribed (47.1%) and forgetfulness (41.2%). The ACT score increased by 2.7 ± 5.4, which was not statistically significant; however, it might be clinically significant. Two barrier scores improved as a result of the intervention. Preliminary evidence on the feasibility of identifying and addressing patient-specific barriers to adherence delivered by pharmacists showed that it has the potential to resolve barriers and improve asthma outcomes.

A Targeted Approach to Improve Asthma Control Using Community Pharmacists

Background: Building on lessons learnt from evidence-based community pharmacy asthma management models, a streamlined and technology supported Pharmacy Asthma Service (PAS) was developed to promote the integration of the service into routine practice.

Objective: This study investigates the efficacy of the PAS in improving asthma symptom control and other health outcomes.

Methods: A two-arm pragmatic cluster randomized controlled trial was implemented in 95 pharmacies across three Australian States. Participants were adults with poorly controlled asthma as per the Asthma Control Questionnaire (ACQ), with or without allergic rhinitis. Patients within the PAS arm engaged in four consultations with the pharmacist over a 12-month period. An evidence-based algorithm guided pharmacies, via a trial specific software, to deliver a series of interventions targeting three issues underpinning uncontrolled asthma (medication use and adherence, inhaler technique, and allergic rhinitis management) to patient clinical asthma status and patient need. Comparator arm patients received a minimal intervention likened to usual practice involving referral of eligible patients to the GP and two follow-up consultations with their pharmacist to collect comparative data.

Results: In total, 143 of 221 PAS patients (65%) and 111 of 160 comparator patients (69%) completed the trial. Improvements in asthma control were achieved in both the PAS (mean difference (MD) in ACQ from baseline = −1.10, p <.0001) and comparator (MD in ACQ from baseline = −0.94, p <.0001) arms at the trial end; however, there were no significant differences between the two arms (MD = −0.16, 95% CI −0.41 to 0.08, p = 0.19). Patients’ quality of life in the PAS arm improved significantly when compared with the comparator arm (MD in Impact of Asthma on Quality-of-Life Questionnaire (IAQLQ) = −0.52, 95% CI −0.89 to −0.14, p = 0.0079).

Conclusion: Despite the PAS achieving a greater improvement in patients’ quality of life, the pharmacist-led service and usual practice arm produced comparable improvements in asthma control. These results ask us to reflect on current standards of usual care, as it appears the standard of asthma care in usual practice has evolved beyond what is reported in the literature.

The lived experience of adherence to asthma medication in young adults (18-34 years)

BACKGROUND

Adherence to asthma medications is commonly poor and is the primary cause for anticipated worsening health outcomes for patients with asthma. Worldwide, qualitative investigations that examine the adherence of young adults (18-34 years) to their asthma medication are limited.

METHOD

This study used a phenomenological research approach to explicate the experience of asthma medication adherence as described by young adults. Data were collected using semi-structured in-depth video interviews conducted with participants aged between 18 and 34 years to elicit their lived experience with adherence to asthma medication. Data from the interviews were transcribed and analyzed using the Edward and Welch (1) extension of Colaizzi's approach to phenomenology.

RESULTS

Results yielded four main themes related to the phenomenon of adherence that emerged from the analysis. The themes were: Having a plan; Having knowledge about your medication and asthma triggers; Being responsible with asthma medication; and Health belief.

CONCLUSION

According to the findings, for young people adhering to asthma medication is a process that depends on four vital aspects: (A) plan, (B) knowledge, (C) responsibility, and (D) belief. If young adults with asthma received individualized written asthma plans and have adequate knowledge about this plan, developing the correct health belief is likely to result. Hence, this can lead to a greater responsibility to manage their asthma to the recommended adherence level.

Impact of educational intervention by community pharmacists on asthma clinical outcomes, quality of life and medication adherence: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Community pharmacists can play an important role in controlling chronic diseases. This study aimed to evaluate the effects of pharmacists' educational interventions in the community pharmacy settings on asthma control and severity, quality of life (QOL) and medication adherence.

METHODS

Databases PubMed, Scopus and Web of Science were searched for evidence regarding asthma severity and control, QOL, and medication adherence after pharmacists' interventions in community pharmacy settings. Twenty-one studies were eligible for qualitative and quantitative analysis. Indices and questionnaires were used in the studies, such as Asthma-related quality of life (IAQLQ), Asthma Control Test (ACT), Perceived Control of Asthma Questionnaire (PCAQ), inhaler technique (IT), Asthma Control Questionnaire (ACQ), 36-Item Short Form survey (SF-36) and peak expiratory flow rate (PEFR). The outcomes were extracted, pooled and analysed as percentages, means, standard deviations and errors, and 95% confidence intervals (CIs).

RESULTS AND DISCUSSION

Community pharmacists in all studies educated and followed up the asthmatic patients, addressing the outcome measures. Pharmacists underwent training courses of at least a day. Standardized mean differences for the indices were pooled as follows: IAQLQ -0.241 (95% CI, -0.362 to -0.121), ACT 0.14 (95% CI, 0.02 to 0.27), PCAQ -0.15 (95% CI, -0.28 to 0.01), IT 0.79 (95% CI, 0.05 to 1.54), ACQ -0.50 (95% CI, -0.69 to -0.30), SF-36 0.39 (95% CI, 0.16 to 0.62), PEFR 0.13 (95% CI, 0.01 to 0.26) and asthma symptoms score -0.34 (95% CI, -0.49 to -0.18).

WHAT IS NEW AND CONCLUSION

Pharmacists' educational interventions in community pharmacy settings could significantly improve asthma severity and control, QOL and medication adherence.

Medication Therapy Management for Texas MediCAID Patients With Asthma and Chronic Obstructive Pulmonary Disease-A Pilot Study

BACKGROUND

Pharmacists can play an important role in providing medication therapy management (MTM) services, which focus on appropriate medication use. This pilot study aimed to describe pharmacists' MTM service provision, results/outcomes of pharmacists' recommendations and resolution/acceptance rate among patients with high-risk asthma and/or chronic obstructive pulmonary disease (COPD).

METHODS

This was a prospective descriptive study of MTM services provided by community pharmacists to Texas Medicaid patients (5-63 years) with "high risk" asthma or COPD. Patients received in-person and telephone consultations that included medication review, asthma control test assessment, and education on adherence and proper medication/device use. Data extracted from MTM software was used to describe: reasons for MTM services, type of pharmacists' interventions, outcomes of pharmacists' recommendations and acceptance rate.

RESULTS

Twenty-eight pharmacists provided 139 MTM interventions with 63 patients (2.2 interventions per patient). The most frequent intervention reason was complex drug therapy (53.2%), underuse of medication (8.6%), need for drug therapy (8.6%), new or changed prescription therapy (6.5%), and administration technique (5.0%). The resolution rate was 77.7%. Patient and prescriber, respectively, refused recommendation in 12% and 6% of the interventions. Outcomes included comprehensive medication review (46.7%), improved adherence (6.5%), therapeutic success (6.5%), improved administration technique (5.0%), and initiation of new therapy (5.0%).

CONCLUSION

Through the provision of MTM, pharmacists were able to identify and intervene with medication-related problems. These interventions are instrumental in helping patients better manage their asthma/COPD. The high resolution rate was encouraging. Larger scale studies are needed to assess clinical and economic outcomes.

Sleep health management in community pharmacy: Where are we and where should we be heading?

BACKGROUND

Poor sleep health is now recognised as a significant risk factor for chronic diseases and is associated with considerable comorbidity and mortality. Community pharmacists are primary care clinicians with an integral role in sleep health promotion and chronic sleep disorder management; however, it is unclear to what extent this is currently being undertaken or what the perspectives of Australian community pharmacists regarding their role in sleep health are.

OBJECTIVES

To explore community pharmacists' current sleep health practice and perspectives on the potential future of sleep health care in community pharmacy.

METHODS

Qualitative semi-structured interviews were carried out with a maximally varied, convenience-based purposive sample of community pharmacists. Interviews were audio-recorded, transcribed verbatim and subjected to, in sequence; an inductive analysis followed by a deductive approach where the inductively derived thematic structure was used as a framework.

RESULTS

Twenty-five community pharmacists from two Australian states were interviewed. Insomnia and obstructive sleep apnea (OSA) were the most frequently encountered sleep disorders in community pharmacy presentations. Four key themes were derived from the data: 1) Preparedness, 2) Approach, 3) Capabilities and 4) What needs to change? All participants reported that their sleep health knowledge was insufficient and emphasized the need for more education and training. Although some were engaged in providing OSA services, none of the participants offered services for insomnia or other sleep disorders. Time/task pressures, low health system/health care professional sleep health recognition/awareness and the lack of standardised pharmacy-specific sleep health management guidelines were commonly cited barriers for sleep health service provision.

CONCLUSION

Community pharmacists commonly manage day-to-day sleep health; however, most expressed a need for increased sleep health recognition/awareness by the health system, targeted education/training for pharmacists and support for the future provision of community pharmacy-delivered sleep health services. With the appropriate implementation strategies, community pharmacists could utilise their availability and accessibility to improve the future of primary care sleep health management.

Smartphone App for monitoring Asthma in children and adolescents

PURPOSE

The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them.

METHODS

The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights).

RESULTS

The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application.

CONCLUSIONS

Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.

Effect of a Multidimensional Pharmaceutical Care Intervention on Inhalation Technique in Patients with Asthma and COPD

Background

Inhalation therapy is the main treatment for asthma and chronic obstructive pulmonary disease (COPD) patients. Owing to the poor inhaler technique in using inhalers, we assessed the effect of a multidimensional pharmaceutical care on inhalation technique in patients with asthma and COPD.

Materials and Methods

A 3-month controlled parallel-group study was undertaken in asthma and COPD patients using dry powder inhalers (DPIs). Patients in the intervention group received multidimensional pharmaceutical care, including establishment of a special dispensing window, face-to-face demonstration and education, brochure education, videos education, online consultation and education, and follow-up reeducation. Patients in the control group received usual pharmaceutical care. The inhaler technique score, correctness of inhaler usage, beliefs about medicines questionnaire (BMQ) score, asthma control test (ACT), and COPD assessment test (CAT) were measured pre- and postintervention. Quality of life improvement evaluated according to score changes of ACT in asthma and CAT in COPD and patient satisfaction were measured postintervention.

Results

259 patients finished the study with 133 in the intervention group and 126 in the control group. Compared to preintervention and control group postintervention, the inhaler technique score, correctness of inhaler usage, and ACT score significantly increased in the intervention group postintervention, while the BMQ score and CAT score decreased significantly (P < 0.05). Significant improvements in quality of life and patient satisfaction were found (P < 0.05).

Conclusion

This study showed the multidimensional pharmaceutical care for asthma and COPD patients were effective in improving inhalation technique. By providing pharmaceutical care, pharmacists might help asthma and COPD patients to acquire better quality of life.

A Role for Primary Care Pharmacists in the Management of Inflammatory Bowel Disease? Lessons from Chronic Disease: A Systematic Review

Background and aims: Chronic disease, particularly inflammatory bowel disease (IBD), requires a multifaceted approach to managing patients, but it is apparent that primary care pharmacists are being underutilized. To demonstrate the benefits of pharmacist interventions in primary care, a systematic review was conducted of interventions in asthma and type 2 diabetes where pharmacists have a defined role in chronic disease management. We also explored potential opportunities for primary care pharmacists to deliver tailored care to patients with inflammatory bowel disease. Methods: The search strategy retrieved original research articles from seven databases; eligible articles were assessed for inclusion. Quality appraisal was performed independently by two reviewers. Results: Thirty-seven included studies were grouped into four categories of interventions: education/counseling (43%), medication management (34%), monitoring/follow-up (17%), and screening/risk prevention (6%). Education plus counseling was reported as the main intervention delivered by pharmacists. Three measurable outcomes were identified: clinical, humanistic (e.g., quality of life), and economic. Clinical outcomes (63%) were reported more commonly than humanistic (26%) and economic (11%) outcomes. Pharmacist interventions led to statistically significant improvements in control of disease, severity, and medication adherence, as well as improvements in overall patient satisfaction, quality of life among patients with asthma and type 2 diabetes. Conclusion: As one of the most accessible sources of primary health care, pharmacists are well-placed to minimize the impact of chronic diseases on patients and communities. Evidence suggests there are opportunities for primary care pharmacists to play a more active role in the management of chronic diseases such as IBD.

Medication Adherence in a Community Population with Uncontrolled Asthma

It is well documented that the use of medications in asthma and allergic rhinitis is often suboptimal, and consequently, patients remain symptomatic. This study aimed to determine the extent and type of medication-related issues contributing to poor asthma control by profiling medication management in those most at risk—a population with clinically uncontrolled asthma. Participants (n = 363) were recruited from Australian community pharmacies, and a dispensed medication history report for the previous 12 months was collected to examine medication adherence and factors affecting adherence. Information was also collected regarding participant asthma control and asthma/allergic rhinitis (if applicable) management. The participants’ mean asthma control score was 2.49 (± 0.89 SD, IQR = 1.20) (score ≥ 1.5 indicative of poorly controlled asthma), and 72% were either non-adherent or yet to initiate preventer therapy. Almost half had been prescribed high doses of inhaled corticosteroid and 24% reported use of oral corticosteroids. Only 22% of participants with concomitant allergic rhinitis were using first line treatment. A logistic regression model highlighted that participant health care concession status and hospital admissions were associated with better adherence. Suboptimal medication management is evident in this at-risk population.

Perspectives of general practitioners about a collaborative asthma care model in primary care

INTRODUCTION

Asthma affects 2.7 million people in Australia and is predominantly managed by general practitioners (GPs) within primary care. Despite national focus on this condition, asthma control in the population is suboptimal, with many preventable hospitalizations. In the light of robust evidence supporting the role of pharmacists in the management of chronic diseases including asthma, the Australian Medical Association (AMA) proposed a General Practice Pharmacist (GPP) model in 2015. In this proposal, a non-dispensing pharmacist, co-located within the primary care setting and collaborating with GPs and allied health professionals, can make a positive impact on patients' health and minimize costs due to medication misadventure. The aim of this study was to obtain the views of GPs regarding the GPP model for better management of asthma in a qualitative study.

METHODS

Semi-structured interviews were conducted with 23 GPs, audio-recorded, transcribed verbatim, and later analyzed for emergent themes. The GPs support the idea of a GPP as time and task pressures restrict them in adhering to asthma management guidelines.

RESULTS

Support from another health professional in such a pressured environment can positively impact patient's health. Funding, clear role delineation within general practice, training of pharmacists working as GPPs, and effective communication systems were described as the potential catalysts for the success of the model.

CONCLUSION

Sustainable funding and the willingness of practice owners/managers were described as the barriers. The GPs agreed that pharmacists can make a positive difference in patient's asthma management once the barriers were effectively addressed.

A Scoping Review of International Barriers to Asthma Medication Adherence Mapped to the Theoretical Domains Framework

BACKGROUND

Internationally, adult asthma medication adherence rates are low. Studies characterizing variations in barriers by country are lacking.

OBJECTIVE

To conduct a scoping review to characterize international variations in barriers to asthma medication adherence among adults.

METHODS

MEDLINE, EMBASE, Web of Science (WOS), and CINAHL were searched from inception to February 2017. English-language studies employing qualitative methods (eg, focus groups, interviews) were selected to assess adult patient- and/or caregiver-reported barriers to asthma medication adherence. Two investigators independently identified, extracted data, and collected study characteristics, methodologic approach, and barriers. Barriers were mapped using the Theoretical Domains Framework and findings categorized according to participants' country of residence, countries' gross national income, and the presence of universal health care (World Health Organization definitions).

RESULTS

Among 2942 unique abstracts, we reviewed 809 full texts. Among these, we identified 47 studies, conducted in 12 countries, meeting eligibility. Studies included a total of 2614 subjects, predominately female (67%), with the mean age of 19.1 to 70 years. Most commonly reported barriers were beliefs about consequences (eg, medications not needed for asthma control, N = 29, 61.7%) and knowledge (eg, not knowing when to take medication, N = 27, 57.4%); least common was goals (eg, asthma not a priority, N = 1, 2.1%). In 27 studies conducted in countries classified as high income (HIC) with universal health care (UHC), the most reported barrier was participants' beliefs about consequences (N = 17, 63.3%). However, environmental context and resources (N = 12, 66.7%) were more common in HIC without UHC.

CONCLUSION

International adherence barriers are diverse and may vary with a country's sociopolitical context. Future adherence interventions should account for trends.

Pharmacists experience of and perspectives about recruiting patients into a community pharmacy asthma service trial

BACKGROUND

Research trials testing the impact of community pharmacy services require adequate and appropriate recruitment of patients by participating pharmacists, however, this step presents an ongoing challenge.

OBJECTIVE

To identify factors affecting recruitment of patients in community pharmacies participating in a multi-center trial of a pharmacy asthma service in Australia (Pharmacy Trial Program - Asthma and Rhinitis Control (PTP-ARC).

METHODS

The PTP-ARC protocol required identification and recruitment of seven eligible asthma patients per pharmacy. Pharmacists responsible for sites that failed to recruit or retain any patients into the PTP-ARC trial participated in a semi-structured telephone interview about their experiences with these elements of the trial. The interviews were recorded, transcribed and coded using QSR International's NVivo 11 software. The analysis was conducted with reference to the COM-B framework (Capability, Opportunity, Motivation).

RESULTS

Pharmacists from 47 of 50 eligible pharmacies were interviewed. Seventeen factors were isolated and mapped to the COM-B framework. Psychological capability (recruitment hesitancy, research literacy and health literacy), physical capability (technological barriers, staffing issues and pharmacy busyness), physical opportunity (patient busyness, trial timing, study protocol, support and location), social opportunity (health literacy and supportive milieu), reflective motivation (incentive for participation, simplification) and automatic motivation (patient attitudes and pharmacist-felt experience) were factors affecting pharmacists' participation. Challenges identified included: issues with the software, unfamiliarity with research procedures generally (and specifically with the PTP-ARC protocols), the patients' lack of interest and pharmacists' lack of time.

CONCLUSIONS

To the best of our knowledge, this is the first study to focus on issues affecting patient recruitment into a pharmacy health services (asthma) trial in real time. To propel evidence-based trials towards practice implementation, user-friendly software, pharmacists' training on research and patient-engagement and adequate remuneration to address pharmacist time issues need to be key foci for health services design and implementation research.

Pharmacists' experience of asthma management in culturally and linguistically diverse (CALD) patients

BACKGROUND

In Australia, one of the world's significantly multicultural nations, asthma is one of the most common chronic conditions. A significant level of health disparities have been observed in many countries with a culturally and linguistically diverse demography. Previous studies have identified that language and culture affect health care provision, this is why culturally competent care is crucial when managing chronic conditions in diverse populations.

OBJECTIVE

The purpose of this study was to explore Australian community pharmacists' experience and perspective about providing care for CALD people with asthma.

METHODS

Qualitative semi-structured interviews were used as the method of choice to fulfil the study objective. Participants were recruited purposively from suburbs of relative diversity in two Australian cities: Melbourne and Sydney. Interviews with consenting pharmacist were conducted using an interview guide. Verbatim transcripts of interviews were then thematically analysed.

RESULTS

Thirty-two interviews resulted in five emergent themes 1) Pharmacists' attitudes towards CALD patients and Cultural Competence; 2) Barriers and facilitators; 3) Clinical issues; 4) Cultural barriers; 5) Workarounds. It was evident that language and to a smaller extent, cultural barriers were experienced regularly by pharmacists managing CALD patients; pharmacists had mostly adapted with a range of methods to work around these barriers. Although pharmacists had a positive attitude, there seemed to be a need for enhanced cultural competence skills; reflections from pharmacists supported the need for further training and pharmacy specific resources.

CONCLUSIONS

There is a significant gap in cultural awareness among Australian pharmacists. Future direction suggests obligatory training in cultural competence for health professionals in order to be able to provide cultural proficient care.

Does clinic-based education have a sustainable impact on asthma patient awareness?

Introduction: Asthma patient education is an essential component of asthma management, just as inhaler treatment adherence and inhaler technique education. These issues face challenges in the developed world communities and the literature demonstrates data of various validity supporting the need for educational activities. However, communities with poor health-care facilities and low socioeconomic status have seen little or no effort to tackle this challenging area of research. Methods: This interventional study aims to impact on sustained asthma awareness with clinic-based asthma patient education. The quasi-experiment recruited asthma patients from achest clinic within apoor healthcare system at desperate economic and political times. The educational intervention consisted of an educational video, posters and leaflets, in addition to the doctor’s clinic encounter and inhaler technique education by clinic nurse. Results: 24 patients of the initially recruited 87 patients were re-assessed 4 to 12 weeks later, on the impact of the educational activity on certain asthma awareness parameters. Patients’ awareness of their diagnosis of asthma did not improve despite the educational activity with p= 0.141. However, there was asignificant improvement with the awareness of patients for the need of long-term inhalers (p = < 0.0001), adherence to inhaler treatment (p = < 0.0001) and correct use of inhaler (p = < 0.021). Discussion & Conclusion: The study supports the feasibility and efficacy of asthma patient education in poor health-care circumstances at basic levels of asthma knowledge, adherence and inhaler technique. This interventional study is unique in the circumstances it was carried out under. Limitations include the large number of dropouts.

Assessment of Educational Inhaler Technique Interventions Among Community Pharmacists: A Systematic Review

Objective

Community pharmacists are the last point of contact before patients are provided with an inhaled asthma device and are expected to adequately educate and train patients on its use. Evidence has shown that pharmacists lack the knowledge and skills required to appropriately counsel patients on these devices. The aim of this systematic review was to focus on evaluating the effects of educational interventions on community pharmacists knowledge of inhaler technique.

Methods

A literature search was conducted using the databases Pubmed and Embase with no applied time restrictions. The databases were searched from inception to December 2018. Articles were eligible for inclusion if they reported outcomes evaluating the improvement in pharmacists knowledge of inhaler technique after an educational intervention and provided details of the intervention. Pharmacists working in settings other than community pharmacies and inhaler devices used for conditions other than asthma were excluded.

Results

Five studies met the eligibility criteria. Workshops and one-on-one instruction were the main educational strategies used in these studies to augment the pharmacists knowledge of asthma inhaler devices. A checklist was utilized by all studies to evaluate the pharmacists improvement of inhaler technique after an educational intervention. All studies showed an improvement in inhaler technique of pharmacists post-intervention.

Conclusion

Studies identified in this systematic review have shown that an educational intervention produced positive outcomes related to the pharmacists knowledge on the steps involved in using asthma inhaler devices. However, the study findings focused on short-term retention of knowledge of inhaler technique and did not address the application of these results in clinical practice.

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.

Efficacy of an Education Session by Pharmacists for Patients With Asthma: Protocol and Design of a Randomized Controlled Trial

Background

Asthma is a chronic disease that requires indefinite long-term therapy. Many approaches have been developed to enable people with asthma to live as normally as possible. In medication therapy management, pharmacists could play important roles in supporting the everyday life of asthmatic patients, such as by providing education therapy management to ensure that patients achieve optimal therapeutic outcomes. A good collaboration between health care practitioners and patients will produce a better system in terms of therapeutic management, which will lead to health care cost savings related to emergency visits. Although the Government has made various efforts to manage asthma in Indonesia, without commitment and support from both patients and health care professionals, the expected outcomes cannot be achieved.

Objective

This study aims to evaluate the effectiveness of an educational intervention provided by pharmacists compared with that of usual care.

Methods

A randomized controlled trial comparing usual care with an education session by pharmacists is underway. The intervention comprises a one-on-one education session of 60 minutes with a pharmacist comprising information regarding (1) asthma medication that has been used; (2) how to use asthma medication devices correctly; (3) asthma symptoms and how to prevent exacerbation of asthma; and (4) how to manage asthma triggers and environmental control measures. The primary outcome measure is change in asthma control, as measured using the Asthma Control Questionnaire. Secondary outcomes include changes in Asthma Quality of Life Questionnaire score, lung function, asthma-related health visits, days off from work or study, and oral corticosteroid use. Research assistants who are masked to the group allocation will collect outcome data at the baseline and every month for a 3-month period. Informed consent will be sought at enrollment and intention-to-treat analysis will be performed.

Results

This study was funded in January 2017 and ethical approval was obtained in June 2017. The enrollment was started in August 2017, and about 72 participants have been enrolled. First results are expected to be submitted for publication in 2019.

Conclusions

This is the first study to evaluate the effectiveness of a pharmacist-guided asthma education session compared with that of usual care in Indonesia. If it is proven effective, this intervention program could improve asthma self-management by patients, which may reduce risks of poorly controlled asthma. This intervention could also be implemented in addition to the current usual care for patients with asthma.

Trial Registration

Thai Clinical Trials Registry TCTR20171219001; http://www.clinicaltrials.in.th/index.php? tp =regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3068 (Archived by WebCite at http://www.webcitation.org/73Ci5eKtv)

International Registered Report Identifier (IRRID)

DERR1-10.2196/10210

Video education versus face-to-face education on inhaler technique for patients with well-controlled or partly-controlled asthma: A phase IV, open-label, non-inferiority, multicenter, randomized, controlled trial

BACKGROUND

Education on inhaler technique is critical for effective asthma treatment. However, traditionally used face-to-face education is time-consuming, costly, and often laborious. The current study evaluated the efficacy of a newly developed video-based inhaler technique education method.

METHODS

A total of 184 subjects with well-controlled or partly-controlled asthma were enrolled from 12 hospitals in South Korea from 30 November 2015 to 01 June 2016. Subjects were randomly divided into two groups in a 1:1 ratio; a control group that received face-to-face education, and a study group that received video education. All subjects received fluticasone propionate plus salmeterol xinafoate (Fluterol® 250/50 inhalation capsules) for 12 weeks. The primary outcome measure was forced expiratory volume in the 1st second (FEV1) at 12 weeks. The secondary outcome measures were change in FEV1 at 4 weeks, change in asthma control test (ACT) score, and changes in various inhaler technique parameters. These measures were assessed with a non-inferiority margin of 10% between the control group and the study group.

RESULTS

FEV1 was significantly improved at 12 weeks in the control group and the study group. After adjustment, FEV1 improvement was not significantly inferior in the study group compared to the control group. The secondary outcome measures, including change in FEV1 at 4 weeks, ACT score, and various parameters pertaining to inhaler technique and satisfaction at 4 and 12 weeks did not differ significantly in the two groups. In subgroup analysis of elderly subjects and subjects with well-controlled asthma, FEV1 was significantly improved at 12 weeks in the study group but not the control group.

CONCLUSION

The newly developed video education technique investigated functioned as a suitable substitute for face-to-face education on inhaler technique (dry powder inhalation capsule) in patients with stable asthma, particularly in elderly patients and patients with well-controlled asthma.

Assessing the knowledge to practice gap: The asthma practices of community pharmacists

Background

Community pharmacists are well positioned to identify patients with poorly controlled asthma and trained to optimize asthma therapy. Yet, over 90% of patients with asthma live with uncontrolled disease. We sought to understand the current state of asthma management in practice in Alberta and explore the potential use of the Chat, Check and Chart (CCC) model to enhance pharmacists' care for patients with asthma.

Methods

An 18-question survey was used to examine pharmacists' monitoring of asthma control and prior use of the CCC tools. Descriptive statistics were used to characterize the response rate, sample demographics, asthma management and CCC use. Survey validity and reliability were established.

Results

One hundred randomly selected pharmacists completed the online survey with a 40% (100/250) response rate. A third of responding pharmacists reported talking to most patients about asthma symptoms and medication, with a greater focus on talking with patients on new prescriptions over those with ongoing therapies. Fewer than 1 in 10 pharmacists routinely talked to most patients about asthma action plans (AAPs). The majority of pharmacists (76%) were familiar with the CCC model, and 83% of those reported that the CCC model influenced their practice anywhere from somewhat (45%) to a great deal (38%). Both scales had good reliability, and factor analysis provided support for scale validity.

Conclusions

There was considerable variability in pharmacists' activities in monitoring asthma. Pharmacists rarely used AAPs. The CCC model had a high level of self-reported familiarity, use and influence among pharmacists.

Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views

Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: (1) partnership between patient and health care professional; (2) issues around medication; (3) education about asthma and its management; (4) health beliefs; (5) self-management interventions; (6) co-morbidities (7) mood disorders and anxiety; (8) social support; (9) non-pharmacological methods; (10) access to healthcare; (11) professional factors. From this, perceived barriers and facilitators were identified at the level of individuals with asthma (and carers), and health-care professionals. Future work addressing the concerns and beliefs of adults, adolescents and children (and carers) with asthma, effective communication and partnership, tailored support and education (including for ethnic minorities and at risk groups), and telehealthcare may improve how self-management is recommended by professionals and used by patients. Ultimately, this may achieve better outcomes for people with asthma.

The operation of a Research and Development (R&D) program and its significance for practice change in community pharmacy

Background

Community pharmacy practice in Australia is changing and Research and Development (R&D) in community pharmacy plays an important role in contributing to the changes. A range of Cognitive Pharmacy Services (CPS) were developed from R&D programs, yet their implementation has been minimal indicating slow practice change within community pharmacy. Given the vital role of R&D, little is known about the operation and the extent to which it has been effective in supporting practice change in community pharmacy.

Methods

In depth, semi-structured interviews were conducted with 27 key stakeholders in the pharmacy and healthcare system in Australia. All interviews were audio-recorded, transcribed ad verbatim and analysed using an inductive approach.

Results

Participants perceived that the R&D program has played an important role in the advent of CPS. Furthermore, they considered that evidence generated by the R&D projects is a critical influence on policy formulation, funding and implementation of CPS into practice. However, policy decisions and subsequent implementation are also influenced by other factors associated with context and facilitation which in turn foster or inhibit effective Knowledge Translation (KT) in the community pharmacy sector.

Conclusion

While R&D programs have been viewed as essential for supporting changes in community pharmacy practice through development and funding of CPS, the overall impact has been small, as contemporary practice continues to be predominantly a dispensing model. Given the complexity and dynamic nature of the community pharmacy system, stakeholders must take into account the inter-relationship between context, evidence and facilitation for successful KT in community pharmacy practice.

The effectiveness of clinical pharmacist's intervention in improving asthma care in children and adolescents: Randomized controlled study in Jordan

OBJECTIVE

To evaluate the effectiveness of clinical pharmacist's intervention on achieving better asthma control, quality of life and other clinical parameters.

METHODS

A prospective randomized controlled study in north Jordan was conducted. Pediatric patients with asthma (aged 7-18 years old) were included and randomly allocated into two groups, intervention and control. Both groups were interviewed at the first visit and followed up twice by phone (at 3 and 6 months). Education was provided to patients and their caregivers in the intervention group only.

RESULTS

Of 206 eligible patients recruited and randomized to our study, 178 patients completed the study (48.3% intervention versus 51.7% control). There were no significant differences in all baseline data between both groups. We identified significant differences in the improvement of asthma control (p<0.001) and consequently pediatric and caregiver quality of life (p<0.001) between both groups at the end of study. Significant differences were also detected in other clinical parameters (p<0.05).

CONCLUSION

Implementation of clinical pharmacy service can positively influence asthma control, pediatric and caregiver's quality of life, and other clinical parameters.

PRACTICE IMPLICATIONS

To maintain a good asthma status, education of pediatric patients and their caregivers should be part of routine assessment during clinic visit.

Review of community pharmacy services: what is being performed, and where are the opportunities for improvement?

Objective

The aim of this review was to assess pharmacist and pharmacy services being provided and identify opportunities to improve patient satisfaction.

Methods

Studies published between January 2006 and July 2016 examining patient satisfaction with pharmacy and pharmacist services, which were written in English, were identified in PubMed. Studies were excluded if they only looked at pharmacy student-provided services.

Key findings

A total of 50 studies were ultimately included in the review. Of these studies, 28 examined services traditionally provided by community pharmacists such as dispensing and counseling, while 16 examined a new in-person service being offered by a pharmacy, and the remaining six involved a new technology-assisted service. While study findings were generally positive for patient satisfaction of pharmacy services, several opportunities were identified for pharmacies to improve.

Conclusion

Overall, patient satisfaction is high across pharmacy services; however, this satisfaction is related to prior patient exposure to services and their level of expectation. Pharmacists have multiple opportunities to improve the services they provide, and there are additional services pharmacists may consider offering to expand their role within the health care system.

Opportunities to develop the professional role of community pharmacists in the care of patients with asthma: a cross-sectional study

There are many indications in Australia and globally that asthma management is suboptimal. Ideally, patients need to proactively self-manage the condition with the support of health professionals. Community pharmacists are a highly accessible resource for patients but currently provide inconsistent services. General practitioners also face many barriers to the provision of chronic disease management for asthma patients. The aim of this research was to characterise patients with asthma who present to community pharmacy. The objective was to identify opportunities to develop the role of pharmacists in the context of the primary healthcare setting and in view of the needs of the patients they routinely encounter. The results of a comprehensive survey of 248 patients recruited from community pharmacies indicated there was discordance between patient perceptions of asthma control and actual asthma control. Almost half the patients surveyed had poorly controlled asthma, whereas almost three quarters perceived their asthma to be well or completely controlled. Fewer than 20% of patients were utilising written asthma action plans, and issues around quality use of medicines were identified. The significance of the incongruent perceptions regarding asthma control is that patients are unlikely to proactively seek intervention and support from healthcare professionals. Community pharmacists provide a significant opportunity to address these issues by direct intervention. There is scope to investigate pharmacists preparing written asthma action plans for patients, using software to monitor medication adherence and prescribe on-going medication. To maximise the potential of pharmacists, barriers to practice need to be identified and addressed.

The role of the pharmacy in the management of bronchial asthma: A literature-based evaluation

OBJECTIVE

Pharmacists play a relevant role in the real-life management of asthma because they are a first-line referral for patients. In fact, the role of pharmacies has been underlined and evidenced also in guidelines. Nonetheless, the true effect of pharmacy-based management of asthma has been assessed in only a few studies. We review the available literature on asthma management in a territorial pharmacy setting.

DATA SOURCES

The literature was searched for the keywords pharmacy, bronchial asthma, control, and management.

STUDY SELECTIONS

The available studies were subdivided into observational and interventional and described.

RESULTS

Seven observational studies and 14 interventional trials were found, involving approximately 20,000 individuals. Most of those studies were performed in Europe and Australia. A high proportion of patients had poorly controlled asthma in the observational studies. The active involvement of pharmacists, in the interventional trials, consistently led to an improvement of the quality of life, a better inhalation technique, and a reduction of exacerbations.

CONCLUSION

The literature analysis confirms the relevance of the role of pharmacists in the real-life management of bronchial asthma and underlines the need for a more specific training for those health care professionals.

Communication during counseling sessions about inhaled corticosteroids at the community pharmacy

BACKGROUND

Pharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist-patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist-patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions.

METHODS

Patients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider-patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting.

RESULTS

A total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians.

CONCLUSION

Pharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients.

Drug-related problems and pharmacist interventions in a cohort of patients with asthma and chronic obstructive pulmonary disease

BACKGROUND

Asthma and chronic obstructive pulmonary disease are preventable and treatable chronic airway diseases with high incidence and prevalence. Pharmacists and clinical pharmacy based pharmaceutical care services have positive impact on therapy outcomes.

OBJECTIVE

The aim of this study is to describe drug related problems in a cohort of patients with asthma and chronic obstructive pulmonary disease and to assess interventions provided by the pharmacist to address these problems in a community pharmacy.

METHOD

Study population consisted of patients with asthma and chronic obstructive pulmonary disease older than 18 years who visited the study pharmacy during the pre-determined six-month period. The patients whose disease control states were "not fully controlled" were included in our study for further steps. On the first interview, present and potential drug related problems were addressed, interventions were provided. Follow-up interviews were held one month and two months later than the first interview.

RESULTS

For the 44 patients with asthma, 59 drug-related problems and 134 causes for these problems were identified. Eighty-four interventions were made to resolve the problems; and 54.2% of the problems were resolved. For the 37 patients with chronic obstructive pulmonary disease, 60 drug-related problems and 128 causes for these problems were identified. Ninety-five interventions were made to resolve the problems; and 63.3% of the problems were resolved.

CONCLUSION

Pharmacists taking part in therapy and management of asthma and chronic obstructive pulmonary disease can help patients be more educated about their disease and medications; and improve disease control and therapy outcomes.

Effectiveness of Various Methods of Teaching Proper Inhaler Technique

OBJECTIVE

To compare the effectiveness of 4 different instructional interventions in training proper inhaler technique.

DESIGN

Randomized, noncrossover trial.

SETTING

Health fair and indigent clinic.

PARTICIPANTS

Inhaler-naive adult volunteers who spoke and read English.

INTERVENTIONS

Subjects were assigned to complete the following: (1) read a metered dose inhaler (MDI) package insert pamphlet, (2) watch a Centers for Disease Control and Prevention (CDC) video demonstrating MDI technique, (3) watch a YouTube video demonstrating MDI technique, or (4) receive direct instruction of MDI technique from a pharmacist.

PRIMARY OUTCOME

Inhaler use competency (completion of all 7 prespecified critical steps).

RESULTS

Of the 72 subjects, 21 (29.2%) demonstrated competent inhaler technique. A statistically significant difference between pharmacist direct instruction and the remaining interventions, both combined ( P < .0001) and individually ( P ≤ .03), was evident. No statistically significant difference was detected among the remaining 3 intervention groups. Critical steps most frequently omitted or improperly performed were exhaling before inhalation and holding of breath after inhalation.

CONCLUSION

A 2-minute pharmacist counseling session is more effective than other interventions in successfully educating patients on proper inhaler technique. Pharmacists can play a pivotal role in reducing the implications of improper inhaler use.

Beliefs about inhaled corticosteroids: Comparison of community pharmacists, pharmacy technicians and patients with asthma

OBJECTIVES

To compare pharmacists' and pharmacy technicians' perceptions of patients' beliefs regarding inhaled corticosteroids (ICS) with those of patients and to compare the ICS beliefs of pharmacists and technicians with those of patients with asthma.

METHODS

1269 community pharmacies were approached to fill out an online questionnaire; 1952 patients were sent a questionnaire by post. Beliefs (i.e., necessity and concerns) regarding ICS were measured using (an adapted version of) the Beliefs about Medicines Questionnaire (BMQ-specific). Pharmacists and technicians were instructed to fill out the BMQ for themselves, and to fill it out in the way they thought most of their patients would complete it.

RESULTS

136 pharmacists, 90 pharmacy technicians and 161 patients with asthma completed the questionnaire. Pharmacists and technicians thought patients had more concerns about ICS than patients themselves reported (p < 0.0001). They also thought that patients had stronger beliefs in their personal need for ICS than patients reported (p < 0.01). Pharmacists reported lower levels of concerns than patients (p < 0.05) and both providers attributed a higher level of necessity to ICS than patients did (p < 0.0001).

CONCLUSION

Pharmacists and technicians overestimate the personal need for treatment as well as the concerns patients with asthma have regarding ICS. They also have, to some extent, stronger positive beliefs about ICS than patients. If pharmacists and technicians expect that patients share their positive views about ICS, they might be less likely to elicit and address patients' doubts and concerns about ICS, which might be relevant for effective ICS treatment and subsequent patient outcomes.

A snapshot of pharmacist attitudes and behaviors surrounding the management of pediatric asthma

OBJECTIVE

The aim of this study is to identify the current status of pediatric asthma management in the Australian community pharmacy setting from the pharmacists' perspective. This research will allow us to identify training needs of community pharmacists.

METHOD

Pharmacists were recruited from the Sydney metropolitan region and asked to complete a self-reported questionnaire that elucidated information on four general domains relating to pediatric asthma management within community pharmacy. All data collected were analysed descriptively. Bivariate Pearson correlations were performed to determine whether interrelationships existed between specific domains.

RESULTS

All 77 pharmacists completed the questionnaire. Thirty-two percent had not completed any asthma related CPD in the past year and only 25% of pharmacists reported using the national asthma guidelines in practice. Just over half of the pharmacists (54%) reported that they provide device technique demonstrations for new inhaled medicines, and 35% of pharmacists reported that they check for written asthma self-management plan possession. Although 65% of pharmacists reported confidence in communication skills, most pharmacists were not confident in setting short-/long-term goals with the patient and carer for managing asthma at home. Pharmacists believed that they are just as effective as doctors in providing asthma counseling and education. Lack of time was identified as a significant barrier.

CONCLUSION

We have identified a gap between guideline recommended practices and the self-reported practices of community pharmacists. Pharmacists need more appropriate continuing education programs that can translate into improved pediatric asthma self-management practices and thus improved asthma outcomes in children. This may require an alternative approach.

The reliability and utility of spirometry performed on people with asthma in community pharmacies

OBJECTIVE

To investigate the reliability and the utility of spirometry generated by community pharmacists participating in two large asthma intervention trials of 892 people.

METHODS

The Pharmacy Asthma Care Program (PACP) and the Pharmacy Asthma Management Service (PAMS) involved up to four visits to the pharmacy over 6 months for counseling and goal setting. Pharmacists performed spirometry according to ATS/ERS guidelines to inform management. The proportion of A-E, F quality tests, as per EasyOne QC grades, were recorded. Lung function results between visits and for participants referred/not referred to their general practitioner on the basis of spirometry were compared.

RESULTS

Complete data from 2593 spirometry sessions were recorded, 68.5% of spirometry sessions achieved three acceptable tests with between-test repeatability of 150 ml or less (A or B quality), 96% of spirometry sessions included at least one test that met ATS/ERS acceptability criteria. About 39.1% of participants had FEV1/FVC values below the lower limit of normal (LNN), indicating a respiratory obstruction. As a result of the service, there was a significant increase in FEV1 and FEV1/FVC and asthma control. Lung function values were significantly poorer for participants referred to their general practitioner, compared with those not referred, on the basis of spirometry.

CONCLUSIONS

Community pharmacists are able to reliably achieve spirometry results meeting ATS/ERS guidelines in people with asthma. Significant improvements in airway obstruction were demonstrated with the pharmacy services. Pharmacists interpreted lung function results to identify airway obstruction for referral, making this a useful technique for review of people with asthma in the community.

Chronic disease management programmes for adults with asthma

BACKGROUND

The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education.

OBJECTIVES

To evaluate the effectiveness of chronic disease management programmes for adults with asthma.

SEARCH METHODS

Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months.

DATA COLLECTION AND ANALYSIS

After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs).

MAIN RESULTS

A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes.

AUTHORS' CONCLUSIONS

There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

A review of countries' pharmacist-patient communication legal requirements on prescription medications and alignment with practice: Comparison of Nordic countries

BACKGROUND

Pharmacist-patient communication around prescription medications can optimize treatment outcomes. Society's expectations of pharmacist-patient communication around medications can be expressed in legislation, economic incentives, and authority control. In this study, the Nordic countries of Denmark, Finland, Iceland, Norway and Sweden provide the legislative examples and can be used as a platform to discuss how society's expectations, professional visions, and practice are aligning.

OBJECTIVE

The overall aim of this study was to describe society's expectations of pharmacist-patient communication around medications as expressed by the state in Nordic legislation, economic incentives and authority control. Additionally, this study describes how the states govern Nordic pharmacists in different pharmacy systems.

METHOD

A legal review was performed using online legislative databases. Regulating authorities were contacted to gather supplementary information. Thereafter, a qualitative document analysis was conducted.

RESULTS

The Nordic countries regulate staff-patient communication by using broad laws. The legislation's main focus during dispensing is information on the use of medications, but also generic substitution and pricing. Pharmacies should have internal routines for this in place. Pharmacists' obligation to keep a journal on advice given during dispensing is ambiguously regulated. The economic incentives for communication on prescription medication during dispensing are included in the general pharmacy mark-up. Today's authority control focuses on the pharmacy management and appears to primarily evaluate structure indicators of communication, for example, if there is a routine method of counseling available.

CONCLUSION

Various countries throughout the world differ in their requirements for pharmacy staff to communicate on the use of medicines during dispensing. The Nordic countries all require such communication, which aligns with professional visions. Regardless of the pharmacy system, the states let the employer and pharmacy professions carry out it in practice with apparently little state involvement, thus showing trust in the profession and employers. However, since Nordic communication studies show deviation from the legislation, there are reasons to reevaluate and discuss the legislation, the economic incentives and the control system.

Physician-pharmacist collaborative management of asthma in primary care

OBJECTIVE

To determine if asthma control improves in patients who receive physician-pharmacist collaborative management (PPCM) during visits to primary care medical offices.

DESIGN

Prospective pre-post study of patients who received the intervention in primary care offices for 9 months. The primary outcome was the sum of asthma-related emergency department (ED) visits and hospitalizations at 9 months before, 9 months during, and 9 months after the intervention. Events were analyzed using linear mixed-effects regression. Secondary analysis was conducted for patients with uncontrolled asthma (Asthma Control Test [ACT] less than 20). Additional secondary outcomes included the ACT, the Asthma Quality of Life Questionnaire by Marks (AQLQ-M) scores, and medication changes.

INTERVENTION

Pharmacists provided patients with an asthma self-management plan and education and made pharmacotherapy recommendations to physicians when appropriate.

RESULTS

Of 126 patients, the number of emergency department (ED) visits and/or hospitalizations decreased 30% during the intervention (p=0.052) and then returned to preenrollment levels after the intervention was discontinued (p=0.83). Secondary analysis of patients with uncontrolled asthma at baseline (ACT less than 20), showed 37 ED visits and hospitalizations before the intervention, 21 during the intervention, and 33 after the intervention was discontinued (p=0.019). ACT and AQLQ-M scores improved during the intervention (ACT mean absolute increase of 2.11, AQLQ-M mean absolute decrease of 4.86, p<0.0001) and sustained a stable effect after discontinuation of the intervention. Inhaled corticosteroid use increased during the intervention (p=0.024).

CONCLUSIONS

The PPCM care model reduced asthma-related ED visits and hospitalizations and improved asthma control and quality of life. However, the primary outcome was not statistically significant for all patients. There was a significant reduction in ED visits and hospitalizations during the intervention for patients with uncontrolled asthma at baseline. Our findings support the need for further studies to investigate asthma outcomes achievable with the PPCM model.

PACE: Pharmacists use the power of communication in paediatric asthma

BACKGROUND

Paediatric asthma is a public health burden in Australia despite the availability of national asthma guidelines. Community pharmacy interventions focusing on paediatric asthma are scarce. Practitioner Asthma Communication and Education (PACE) is an evidence-based program, developed in the USA for general practice physicians, aimed at addressing the issues of poor clinician-patient communication in the management of paediatric asthma. This program has been shown to improve paediatric asthma management practices of general practitioners in the USA and Australia. The development of a PACE program for community pharmacists will fill a void in the current armamentarium for pharmacist-patient care.

OBJECTIVES

To adapt the educational program, PACE, to the community pharmacy setting. To test the feasibility of the new program for pharmacy and to explore its potential impact on pharmacists' communication skills and asthma related practices.

SETTING

Community pharmacies located within the Sydney metropolitan.

METHOD

The PACE framework was reviewed by the research team and amended in order to ensure its relevance within the pharmacy context, thereby developing PACE for Pharmacy. Forty-four pharmacists were recruited and trained in small groups in the PACE for Pharmacy workshops. Pharmacists' satisfaction and acceptability of the workshops, confidence in using communication strategies pre- and post-workshop and self-reported behaviour change post workshop were evaluated.

MAIN OUTCOME MEASURE

Pharmacist self-reported changes in communication and teaching behaviours during a paediatric asthma consultation.

RESULTS

All 44 pharmacists attended both workshops, completed pre- and post-workshop questionnaires and provided feedback on the workshops (100 % retention). The participants reported a high level of satisfaction and valued the interactive nature of the workshops. Following the PACE for Pharmacy program, pharmacists reported significantly higher levels in using the communication strategies, confidence in their application and their helpfulness. Pharmacists checked for written asthma self-management plan possession and inhaler device technique more regularly, and provided verbal instructions more frequently to paediatric asthma patients/carers at the initiation of a new medication.

CONCLUSION

This study provides preliminary evidence that the PACE program can be translated into community pharmacy. PACE for Pharmacy positively affected self-reported communication and education behaviours of pharmacists. The high response rate shows that pharmacists are eager to expand on their clinical role in primary healthcare.

Asthma management and inhalation techniques among community pharmacists in 2009: a comparison with the 1999 survey

OBJECTIVE

In a 1999 survey, community pharmacists from the Alsace region of France had a reasonably good knowledge of asthma treatment and prevention, but their skill in the use of asthma inhalation devices left room for improvement. Since then, health authorities have encouraged the involvement of community pharmacists in patient care and education in order to improve asthma control. The aim of this study was to assess the change in the knowledge of asthma management and inhaler technique skills of community pharmacists in the same geographic area after a 10-year interval.

METHODS

In 2009, 86 randomly selected community pharmacists from the Alsace region answered a standardized questionnaire about their theoretical knowledge of and practical attitude toward asthma management and inhaled delivery systems, following which their skills in the use of four inhalation devices (pressurized metered-dose inhaler (pMDI) with/without a spacer, breath-actuated pMDI and dry powder inhaler (DPI)) were evaluated.

RESULTS

Very few pharmacists were required to manage an acute asthma exacerbation at the pharmacy, but all responded well by administering a short-acting inhaled β2-agonist. Theoretical knowledge of asthma management (criteria of severity of asthma exacerbation, guidelines and drugs triggering asthma exacerbations) was still average. Compared with 1999, they were twice as confident in demonstrating inhaler use, and their skills in using the pMDI, breath-actuated pMDI and DPI had improved significantly (p < 0.001).

CONCLUSIONS

Since 1999, pharmacists' skill in the use of inhalers has improved, but theoretical knowledge of asthma management is still average, pointing to the importance of continuing pharmaceutical education.

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.

How do people with asthma use Internet sites containing patient experiences?

OBJECTIVE

To understand how people engage with websites containing patient authored accounts of health and illness. To examine how people with asthma navigate their way through this information and make use of the patient experiences they find.

METHODS

Twenty-nine patients with diagnoses ranging from mild to severe asthma were shown a range of websites, some containing patient experiences, and selected two sites to explore further. They discussed their choices in a series of focus groups and interviews.

RESULTS

Participants were influenced initially by the design quality of the sites and were subsequently drawn to websites containing patient experiences but only when contributions were from similar people offering 'relevant stories'. The experiences reminded participants of the serious nature of the disease, provided new insights into the condition and an opportunity to reflect upon the role of the disease in their lives.

CONCLUSION

For people with asthma websites containing other patients' personal experiences can serve as a useful information resource, refresh their knowledge and ensure their health behaviours are appropriate and up-to-date.

PRACTICE IMPLICATIONS

Health professionals should consider referring asthma patients to appropriate websites whilst being aware that online experiences are most engaging when they resonate with the participants own situation.

The role of community pharmacists in screening and subsequent management of chronic respiratory diseases: a systematic review

OBJECTIVE

The purpose of this review was to evaluate the role of community pharmacists in provision of screening with/without subsequent management of undiagnosed chronic obstructive pulmonary disease (COPD) and uncontrolled asthma.

METHODS

An extensive literature search using four databases (ie. Medline, PubMed, International Pharmaceutical Abstracts (IPA) and Scopus) with search terms pharmacy, screening, asthma or COPD was conducted. Searches were limited to the years 2003-2013, those in English and those reporting research with humans. Data retrieval, analysis and result presentation employed a scoping review method.

RESULTS

Seventeen articles met the inclusion/exclusion criteria, of which fifteen studies were based on people with asthma and two were based on people with COPD. Only seven asthma studies and one COPD study involved screening followed by subsequent management. More than half of the people screened were found to be poorly controlled and up to 62% of people were identified at high risk for COPD by community pharmacists. The studies varied in the method and type of asthma control assessment/screening, the type of intervention provided and the outcomes measured. The limitations of the reviewed studies included varying definitions of asthma control, different study methodologies, and the lack of long-term follow-up. While many different methods were used for risk assessment and management services by the pharmacists, all the studies demonstrated that community pharmacists were capable of identifying people with poorly controlled asthma and undiagnosed COPD and providing them with suitable interventions.

CONCLUSIONS

The literature review identified that community pharmacists can play an effective role in screening of people with poorly controlled asthma and undiagnosed COPD along with delivering management interventions. However, there is very little literature available on screening for these chronic respiratory conditions. Future research should focus on development of patient care delivery model incorporating a screening protocol followed by targeted management interventions delivered by the community pharmacist.

The contribution of goal specificity to goal achievement in collaborative goal setting for the management of asthma

BACKGROUND

Goal setting was investigated as part of an implementation trial of an asthma management service (PAMS) conducted in 96 Australian community pharmacies. Patients and pharmacists identified asthma-related issues of concern to the patient and collaboratively set goals to address these. Although goal setting is commonly integrated into disease state management interventions, the nature of goals, and their contribution to goal attainment and health outcomes are not well understood.

OBJECTIVES

To identify and describe: 1) goals set collaboratively between adult patients with asthma and their pharmacist, 2) goal specificity and goal achievement, and 3) describe the relationships between specificity, achievement, asthma control and asthma-related quality of life.

METHODS

Measures of goal specificity, and goal achievement were developed and applied to patient data records. Goals set were thematically analyzed into goal domains. Proportions of goals set, goals achieved and their specificity were calculated. Correlational and regression analyses were undertaken to determine the relationships between goal specificity, goal achievement, asthma control and asthma-related quality of life.

RESULTS

Data were drawn from 498 patient records. Findings showed that patients set a wide range and number of asthma-related goals (N = 1787) and the majority (93%) were either achieved or being working toward by the end of the study. Goal achievement was positively associated with specific and moderately specific goals, but not non-specific goals. However, on closer inspection, an inconsistent pattern of relationships emerged as a function of goal domain. Findings also showed that goal setting was associated with end-of-study asthma control but not to asthma-related quality of life.

CONCLUSIONS

Pharmacists can help patients to set achievable and specific asthma management goals, and these have the potential to directly impact health outcomes such as asthma control. Goal specificity appears to be an important feature in the achievement of goals, but other factors may also play a role.

Patient preferences for community pharmacy asthma services: a discrete choice experiment

BACKGROUND

Specialized community pharmacy services, involving the provision of disease state management and care by pharmacists, have been developed and trialled and have demonstrated very good health outcomes. Most of these services have been developed from a healthcare professional perspective. However, for the future uptake and long-term sustainability of these services as well as for better and sustained health outcomes for patients, it is vital to gain an understanding of patients' preferences. We can then structure healthcare services to match these preferences and needs rather than around clinical viewpoints alone.

OBJECTIVE

The aim of this study was to elicit patient preferences for pharmacy-based specialized asthma services using a discrete choice experiment and to explore the value/importance that patients place on the different attributes of the asthma service. The existence of preference heterogeneity in the population was also investigated.

METHODS

The study was conducted with asthma patients who had recently experienced a specialized asthma management service at their pharmacy in New South Wales, Australia. Pharmacists delivering the asthma service mailed out the discrete choice questionnaires to participating patients at the end of 6 months of service provision. A latent class (LC) model was used to investigate each patient's strength of preference and preference heterogeneity for several key attributes related to asthma service provision: frequency of visits, access to pharmacist, interaction with pharmacy staff, availability of a private area for consultation, provision of lung function testing, type and depth of advice provision, number of days with asthma symptoms and cost of service.

RESULTS

Eighty useable questionnaires (of 170 questionnaires sent out) were received (response rate 47.1%). The study identified various key elements of asthma services important to patients. Further, the LC analysis revealed three classes with differing patient preferences for levels of asthma service provision. Patients in the Minimalistic Model class valued provision of lung function testing and preferred more frequent service visits. Cost of service had a negative effect on service preference for patients in this class. Patients in the Partial Model class mainly derived utility from the provision of lung function testing and comprehensive advice at the pharmacy and also wanted more frequent service visits. The Holistic Model class patients considered all attributes of the service to be important when making a choice. While the majority of the service attributes had a positive effect on preference for patients in this class, cost of service and days with symptoms of asthma had a negative effect on service preference. These patients also preferred fewer service visits.

CONCLUSION

The study identified various key attributes that are important to patients with respect to community pharmacy-based asthma services. The results also demonstrate the existence of preference heterogeneity in the population. Asthma service providers need to take these findings into consideration in the design and development of future service models so as to increase their uptake and ensure their long-term sustainability.

Practice change in community pharmacy: using change-management principles when implementing a pharmacy asthma management service in NSW, Australia

OBJECTIVE

This study aimed to investigate the application of a research-based change-management tool, the Pharmacy Change Readiness Wheel (PCRW), in practice, and the impact it had on the implementation of an asthma service (Pharmacy Asthma Management Service or PAMS).

METHODS

All pharmacists implementing the PAMS in the state of New South Wales, Australia, were provided training using a custom-designed module explaining change readiness as it applied to the PAMS. This training and a self-administered PCRW checklist were completed before PAMS implementation. Following PAMS service delivery, semi-structured phone interviews were conducted with the pharmacists and any additional staff involved regarding their experiences of change management. Interviews were transcribed verbatim and content analysed.

KEY FINDINGS

Thirty seven of the forty five pharmacies who delivered PAMS returned the PCRW checklist (82% response rate) and participants from 29 pharmacies were interviewed (29 pharmacists and six additional staff). Perception of readiness for change before service delivery was remarkably high. From the interviews conducted after service delivery it was evident that systematic management of the practice change using theoretical concepts had not really been undertaken and that many challenges were faced in the implementation of practice change (PAMS). The results of the content analysis from the interviews revealed that factors external or internal to the pharmacy or those related to the individual pharmacist could affect implementation of practice change.

CONCLUSION

Change is not as straightforward as it may appear and is a multi-step process over time. Pharmacists were unaware of this. A change-management framework should be applied to specific services with enough flexibility so that pharmacists can individualise them for their pharmacies.