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

Process evaluation of a pharmacist-led intervention aimed at deprescribing and appropriate use of cardiometabolic medication among adult people with type 2 diabetes

BACKGROUND

A quasi-experimental study investigated a pharmacist-led intervention aimed at deprescribing and medication management among adult patients with type 2 diabetes at risk of hypoglycaemia.

OBJECTIVE

This study aimed to evaluate the process of implementing the intervention consisting of a tailored clinical medication review (CMR) supported by a training and a toolbox.

METHODS

Mixed-methods study based on the Grant framework, including the domains "recruitment," "delivery of intervention" and "response" of pharmacists and patients. Data collected were administrative logs, semi-structured observations of patient consultations (n = 8), interviews with pharmacists (n = 16) and patient-reported experience measure (PREM) questionnaires (n = 66).

RESULTS

Tailored CMRs were conducted largely as intended for 90 patients from 14 pharmacies. Although patient selection based on a medication-derived hypoglycaemia risk score was considered useful, pharmacists experienced barriers to proposing deprescribing in patients with recent medication changes, without current hypoglycaemic events, or treated by medical specialists. The training and toolbox were evaluated positively by the pharmacists. Overall, patients were satisfied with the CMR.

CONCLUSION

Pharmacists and patients valued the CMR focusing on deprescribing and medication management. To optimize implementation and effectiveness of the intervention, improvements can be made to the patient selection, pharmacist training and the collaboration between healthcare professionals.

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.

A mixed methods analysis of community pharmacists' perspectives on delivering COPD screening service to guide future implementation

BACKGROUND

Studies have shown that COPD screening by community pharmacists is effective, but it is unknown if it can be successfully implemented in Australian pharmacies.

OBJECTIVE

We aimed to investigate the pharmacist-perceived barriers and facilitators to the implementation of a community pharmacy-based COPD screening service guided by implementation science methodology.

METHODS

Trained pharmacists participated in a 6 month longitudinal study designed and based on implementation science frameworks. Pharmacists completed feedback questionnaires pre-and post-study and participated in semi-structured telephone interviews about their experience of implementing the service, the training provided, their views on patient recruitment, their interactions with health professionals and patients, and their future recommendations for such a service. Interviews were recorded and transcribed verbatim, analysed thematically, and questionnaire and interview data were triangulated.

RESULTS

Of 20 pharmacists providing questionnaire data, 15 pharmacists (male 53%; age 39.8 ± 8.6yrs, rural 47%) participated in an interview. Questionnaire data revealed that pharmacists engaged positively with the service and reported that it was very useful for patients and for the profession. In-depth qualitative analysis revealed 6 main implementation themes: 1. Patient recruitment (pharmacists lacked patient recruitment skills), 2. Adaptation and entrepreneurship (protocol adaptation increased patient engagement), 3. Training and resource needs (face-to-face training was preferred for skill-based learning), 4. Lack of GP involvement (sub-optimal GP-pharmacist collaboration), 5. Factors related to the operation or full implementation phase (high professional satisfaction, need for remuneration) and 6. Suggestions for refining the screening service (raise public awareness about the service, provide service remuneration, use electronic methods to improve GP referral uptake). A number of effective adaptations to the service were reported by pharmacists, such as advertising, recruitment practices, patient inclusion criteria and inter-professional communication with GPs which would be beneficial to implementation.

CONCLUSION

This mixed methods study identified a number of key facilitators to service implementation and challenges such as difficulty with patient recruitment, low public awareness of pharmacy-based clinical services, remuneration, and sub-optimal GP-pharmacist collaboration. Working with stakeholders to identify and resolve challenges and to optimise the fit of the service for individual settings may lead to increasingly successful implementation of pharmacy-based service models.

Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management

Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the 'luxury' of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient's make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient's making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.

The effect of counseling on willingness to use a hypothetical medication and perceptions of medication safety

BACKGROUND

Poor medication adherence is an ongoing issue, and contributes to increased hospitalizations and healthcare costs. Although most adverse effects are rare, the perceived risk of adverse effects may contribute to low adherence rates.

OBJECTIVES

The objective of this study was to determine how adverse effect likelihood and pharmacist counseling on adverse effect prevention affects individuals': (1) willingness to use a hypothetical medication and (2) perceptions of medication safety.

METHODS

This study used a 3 × 3 experimental design. Participants (n = 601) viewed a hypothetical scenario asking them to imagine being prescribed an anti-asthma medication that could cause fungal infections of the throat. Participants were randomized to 1 of 9 scenarios that differed on: probability of developing an infection (5%, 20%, no probability mentioned) and whether they were told how to reduce the risk of infection (no prevention strategy discussed, prevention strategy discussed, prevention strategy discussed with explanation for how it works). Participants were recruited through Amazon Mechanical Turk.

RESULTS

Participants were less willing to take the medication (F = 12.86, p < 0.0001) and considered it less safe (F = 13.11, p < 0.0001) when the probability of fungal infection was presented as 20% compared to 5% or when no probability information was given. Participants were more willing to take the medication (F = 11.78, p < 0.0001) and considered it safer (F = 11.17, p < 0.0001) when a prevention strategy was given. Finally, there was a non-statistically significant interaction between the probability and prevention strategy information such that provision of prevention information reduced the effect of variation in the probability of infection on both willingness to use the medication and perceived medication safety.

CONCLUSIONS

Optimal risk communication involves more than informing patients about possible adverse effects. Pharmacists could potentially improve patient acceptance of therapeutic recommendations, and allay medication safety concerns, by counseling about strategies patients can implement to reduce the perceived risk of adverse effects.

Exploring factors associated with asthma-related emergency department visits among adults: A path analysis approach

BACKGROUND

Asthma is an expensive chronic lung disease that affects 7% of U.S. adults and results in as many as 1.8 million emergency department (ED) visits each year. Pharmacists play an important role in managing asthma, including assessing control and monitoring disease progression, educating the patient about the disease and associated treatments, and ensuring safe and cost-effective medication use. However, comprehensive studies that account for the complex relationships between factors impacting asthma-related ED visits are lacking in the adult asthma population.

OBJECTIVE

To explore the complex relationships between asthma control, medication use, co-morbid conditions, minority status, environment and asthma-related ED visits using a path analysis approach.

METHODS AND MATERIALS

Data for this study were obtained from the 2012 Behavioral Risk Factor Surveillance System's Asthma Call Back Survey. Current asthmatics 18 and older were included in the sample. Path analysis was used to evaluate the direct effects of the independent variables on asthma-related ED visits, as well as the indirect effects mediated through asthma control, health status, and daily use of inhaled corticosteroids.

RESULTS

Having controlled asthma (β = -0.153, p < 0.01) and good health status (β = -0.133, p < 0.01) were associated with significantly fewer ED visits. Good health status was associated with daily use of inhaled corticosteroids, which in turn was associated with better asthma control. Hispanic ED use was mediated by asthma control (β = -0.067, p < 0.05), while African American ED use was mediated by health status (β = 0.050, p < 0.05).

CONCLUSION

These findings suggest that there may be race/ethnicity specific factors that may be targeted to reduce asthma-related ED visits in minority populations.

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.

Physician agreement regarding the expansion of pharmacist professional activities in the management of patients with asthma

BACKGROUND

Asthma control remains suboptimal in Canada. Expansion of pharmacist's professional activities offers the opportunity to improve the interdisciplinary management of patients with asthma.

OBJECTIVE

The aim of this study was to determine the level of agreement of physicians regarding the expansion of pharmacists' professional activities in the management of asthma patients.

METHODS

We conducted a survey of randomly selected Quebec physicians in family medicine, paediatrics and emergency medicine. A 102-item questionnaire, including 10 questions regarding pharmacist's expanded professional activities, was sent using the Tailored Design Method. Questions were answered on a 6-point Likert-like scale (0 - strong disagreement to 5 - strong agreement).

RESULTS

With a 56% response rate, 421 (250 family medicine, 115 paediatric and 56 emergency medicine) physicians participated; the median years of practice (25%, 75%) was 13 (5-21) years and 69% of respondents were women. Physicians were in favour of the expansion of pharmacist's professional activities with strong endorsement rates (rating of ≥4 on a maximum of 5) exceeding 60% for all but three activities: suggesting a written action plan to the physician (55%), adjusting the dose of prescribed asthma medication to achieve a therapeutic target (52%) and offering spirometry testing in pharmacies (45%). Emergency physicians, physicians with fewer years of practice, and those with a favourable perception of an interprofessional approach were associated with higher endorsement of these activities.

CONCLUSION

Physicians are favourable to the expansion of pharmacist activities in the management of patients with asthma. More complex activities were less frequently endorsed. The characteristics of strong intenders have been identified.

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.

Patients' reasons for accepting a free community pharmacy asthma service

BACKGROUND

Challenges in recruiting patients at the pharmacy counter for cognitive services have been observed, hampering development in this area. To overcome this barrier, insight into the patient perspective is crucial to understanding their lack of appreciation of the services. However, very few studies have been conducted so far to explore why patients accept or decline offers of cognitive services at the pharmacy counter.

OBJECTIVE

To explore patients' reasons for accepting a particular cognitive service (the Inhaler Technique Assessment Service) a service intended to detect inhalation technique errors. The service is reimbursed by the Danish state and takes approximately 10 min. Setting Ten community pharmacies located in different regions of Denmark, including the center and suburbs of Copenhagen.

METHOD

Two types of interviews were conducted: long and short semi-structured interviews with 24 patients suffering mainly from asthma and COPD. Researchers from Copenhagen University conducted 11 long interviews and pharmacy internship students from Copenhagen University carried out 13 short interviews. The interviews were analyzed using descriptive analysis.

MAIN OUTCOME MEASURE

Patients' perceived needs of an inhalation counseling service as well as their motivation for accepting the service, including their accounts of how the service was orally offered by staff.

RESULTS

The majority of participants were used to using inhaler devices. The participants felt, for several reasons, little need of an inhaler service and seldom noticed the precise way the service was offered. Patients did not seem to accept the service expecting personal benefits. First timers appeared to accept the service to learn how to use the device correctly, whereas experienced users appeared to accept the ITAS to be helpful to staff or to learn more about health issues in general or were convinced by individual employees who showed a special interest in the participant receiving the service. Privacy problems were felt by several participants.

CONCLUSION

The patients felt little need for the inhaler counseling service. Patients however accepted the service for various reasons of which the feeling how staff showing an interest in helping them seemed especially convincing.

An exploration of clinical interventions provided by pharmacists within a complex asthma service

BACKGROUND

Pharmacists in Australia are accessible health care professionals, and their provision of clinical pharmacy interventions in a range of areas has been proven to improve patient outcomes. Individual clinical pharmacy interventions in the area of asthma management have been very successful. An understanding of the nature of these interventions will inform future pharmacy services. What we do not know is when pharmacists provide a complex asthma service, what elements of that service (interventions) they choose to deliver.

OBJECTIVE

To explore the scope and frequency of asthma-related clinical interventions provided by pharmacists to patients in an evidence-based complex asthma service.

METHODS

Pharmacists from 4 states/territories of Australia were trained in asthma management. People with asthma had 3 or 4 visits to the pharmacy. Guided by a structured patient file, the pharmacist assessed the patient's asthma and management and provided interventions where and when considered appropriate, based on their clinical decision making skills. The interventions were recorded in a checklist in the patient file. They were then analysed descriptively and thematically.

RESULTS

Pharmacists provided 22,909 clinical pharmacy interventions over the service to 570 patients (398 of whom completed the service). The most frequently delivered interventions were in the themes 'Education on asthma', 'Addressing trigger factors', 'Medications - safe and effective use' and 'Explore patient perspectives'. The patients had a high and ongoing need for interventions. Pharmacists selected interventions based on their assessment of perceived need then revisited and reinforced these interventions.

CONCLUSION

Pharmacists identified a number of areas in which patients required interventions to assist with their asthma management. Many of these were perceived to require continuing reinforcement over the duration of the service. Pharmacists were able to use their clinical judgement to assess patients and provide clinical pharmacy interventions across a range of asthma management needs.