Pharmacist Provided Spirometry Services: A Scoping Review

Purpose

Despite international guidelines' recommendations, spirometry is underutilized in the diagnosis and management of asthma and COPD. Spirometry may be an opportunity for trained pharmacists to meet the needs of patients with suspected or diagnosed lung conditions. The aim of this scoping review is to describe the literature including pharmacist provided spirometry services, specifically to identify: 1) the models of pharmacist provided spirometry services, and additional services commonly offered alongside spirometry, 2) pharmacist training and capability to obtain quality results, and (3) pharmacist, physician, and patient perspectives.

Methods

In September 2020, a comprehensive literature search in PubMed and EMBASE was conducted to identify all relevant literature on the topic of pharmacist provided spirometry services using the search term: "pharmacist or pharmacy" and "spirometry or pulmonary function test or lung function test." Literature was screened using inclusion/exclusion criteria and selected articles were charted and analyzed using the themes above.

Results

A total of 27 records were included. The scoping review found that pharmacist provided spirometry has been conducted around the world in community pharmacies and clinic settings. Community pharmacists may increase access to spirometry screening; the lack of communication with primary care providers and remuneration are barriers that need to be overcome to optimize the utility of the service. Clinic-based services are interprofessional and collaborative, allowing a patient to receive the test, results, diagnosis, and medication changes in one visit. Following comprehensive training, pharmacists felt confident in their ability to perform spirometry and met quality standards at acceptable rates.

Conclusion

Spirometry is an opportunity for pharmacists to improve evidence-based practice for screening and diagnosing lung conditions along with providing comprehensive services to complement testing. Data around provider and patient perspectives is limited and should be further investigated to determine if providers and patients would value and collaborate with pharmacists providing spirometry services.

Pharmacy Education Needs to Address Diagnostic Safety

The American Association of Colleges of Pharmacy, the Accreditation Council for Pharmacy Education, and the Center for the Advancement of Pharmacy Education frame patient safety from the perspective of medication management, which is also the current focus of pharmacy education and training. With the growing appreciation that diagnostic errors represent an urgent and actionable patient safety concern, the National Academy of Medicine has recommended diagnostic safety training for all health care professions. The Society to Improve Diagnosis in Medicine has worked with an interprofessional consensus group to identify a set of 12 key competencies necessary to achieve diagnostic quality and safety that focuses on individual, team-based, and system-related competencies. Much of this already exists in pharmacy education, but pharmacy training programs need to give graduates more guidance on how they contribute to the diagnostic process and the prevention and detection of diagnostic errors. We describe the current state of progress in this regard, and what steps are needed by training programs to provide content and assessment so that graduates achieve the requisite competencies. Governing and advisory bodies need to expand the expectations around patient safety to include diagnostic safety.

Pharmacist-Driven Spirometry Screening to Target High-Risk Patients in a Primary Care Setting

Objectives: The primary objective of this study is to determine the effect of proactive pharmacist identification of high-risk patients eligible for diagnostic spirometry testing on the percentage of appropriate spirometry referrals ordered and the percentage of spirometry tests completed in those that qualify. Methods: This prospective study compares spirometry referrals ordered and tests completed between an intervention site and control site within a federally qualified health center (FQHC) where pharmacists provide spirometry services. At both sites, all patients who had a primary care provider (PCP) appointment and qualified for spirometry screening on the designated intervention dates during a 12-week period were included in this study. At the intervention site, the pharmacist recommended a spirometry screening to the PCP prior to identified high-risk patients' appointments. At both sites, a chart review was completed to determine if referrals were ordered and tests were completed for patients who qualified. Results: The number of patients eligible for diagnostic spirometry testing at the intervention and control sites was 190 (n = 125 vs n = 65, respectively). Among eligible patients, the percentage of referrals ordered was significantly higher at the intervention site (47.2% vs 7.7%, P < .001). Among patients who qualified, completion of spirometry testing was significantly higher in the intervention site (23.2% vs 3.1%, P < .001). Conclusion: Results of this study suggest that pharmacists proactively identifying high-risk patients for spirometry screenings within an FQHC increases appropriate referrals ordered by PCPs and tests completed by high-risk patients. Pharmacists in the primary care setting can aid the PCP in the management of chronic obstructive pulmonary disease through significantly increased spirometry referrals and therapeutic clinical assessments and recommendations. They also can provide face-to-face motivational counseling for smoking cessation, inhaler education, and vaccine recommendations. This population health approach to spirometry testing represents an emerging role for pharmacists and could be adopted in other primary care settings.

Impact of a Pharmacist-driven Spirometry Clinic Service within a Community Family Health Center: A 5-year Retrospective Review

Objective:

This study was designed to describe the impact of a trained pharmacist in performing quality spirometry testing within a community family health center.

Methods:

This was a retrospective, cohort study of 150 physician-referred patients who attended their scheduled spirometry office appointment between November 2008 and December 2013. Information obtained included type of the disease (patients with obstructive or restrictive pulmonary disease), calculated lung age decline due to smoking history, quality of spirometry testing, and percentage of patients requiring pulmonary drug regimen alterations due to spirometry results. Pearson correlation and descriptive statistics were used to address study objectives.

Findings:

Spirometry testing performed by a pharmacist resulted in 87% of tests meeting guidelines for quality. Testing identified patients with reversible airway disease (39%), chronic obstructive pulmonary disease (21%), restrictive (11%), and mixed obstructive/restrictive (11%) lung defect. Patients with abnormal spirometry demonstrated a greater smoking pack-year history and calculated lung age than patients with normal spirometry (29.1 pack-years vs. 17 pack-years; P = 0.024 and 76.3 years vs. 54.6 years; P < 0.001, respectively). A weak correlation was found between a 29.1 smoking pack-year history and forced vital capacity (r = −0.3593, P = 0.018). The pharmacist assisted in modifying pulmonary drug regimens in 69% of patients based on evidence-based guidelines.

Conclusion:

A pharmacist-driven spirometry service was associated with quality testing results, identified respiratory disease abnormalities, and helped modifications of pulmonary drug regimens based on evidence-based guidelines. Future direction of this service may include collaborative practice agreements with physicians to expand services of pharmacists to include spirometry testing.

Evaluation of a pharmacist-managed asthma clinic in an Indian Health Service clinic

OBJECTIVES

To observe whether American Indian and Alaskan Native (AI/AN) patients at the Yakama Indian Health Service seen at the pharmacist-managed asthma clinic improved asthma outcomes.

DESIGN

Retrospective chart review, single group, preintervention and postintervention.

SETTING

Pharmacist-managed asthma clinic at an Indian Health Service ambulatory care clinic.

PATIENTS

Sixty-one AI/AN patients who were seen at least once in the asthma clinic from 2010 to 2014.

INTERVENTION

Pharmacist-provided asthma education and medication management.

MAIN OUTCOME MEASURES

Asthma-related hospitalizations and emergency department or urgent care (ED) visits.

RESULTS

The total number of asthma-related hospitalizations and ED visits between the 12-month periods preceding and following the initial asthma clinic visit were 11 versus 2 hospitalizations (P = 0.02) and 43 versus 25 ED visits (P = 0.02), respectively. Over the same period, asthma-related oral corticosteroid use showed a nonsignificant decrease in the number of prescriptions filled (n = 59, P = 0.08). In contrast, inhaled corticosteroid prescription fills significantly increased (n = 42, P = 0.01).

CONCLUSION

A reduction of asthma-related hospitalizations and ED visits were observed during the course of the intervention. Increased access to formal asthma education and appropriate asthma care benefit the Yakama AI/AN people. A controlled trial is needed to confirm that the intervention causes the intended effect.

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.

Standards of suitability for the management of chronic obstructive respiratory diseases

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) ranks third as cause of mortality and disability-adjusted life years (DALY) worldwide and also in Italy it imposes a huge health, social and economic load. Early symptoms of COPD are often disregarded by patients and physicians, spirometry is underutilized, and the diagnosis is delayed till the disease has reached a distinct severity level. Despite the availability of various guidelines, the behavior of health workers involved in the management of COPD is still rather unlike. These considerations are the reason why in October 2013 AIMAR (Interdisciplinary Scientific Association for Research in Lung Disease) devised and organized a "Third Consensus Conference", aimed at pointing out the standards of suitability for COPD management. In this context three important topics of discussion were identified: early and more widespread diagnosis, management of acute and subacute phases, long-term assistance to chronic patients.

METHODS

The procedure recommended by the Italian Health Superior Institute (ISS) for Consensus Conferences organization was applied. The Conference was structured in three sessions, each dealing with one of the above mentioned topics and including a short update of the subject-matter and presentation, discussion and voting of some statements with a choice ranging from total agreement to total disagreement or no knowledge. The results of voting were eventually recorded in the document, reviewed by an independent jury, that forms the substance of this paper.

RESULTS

The essential role of spirometry, the need for distinguish between different COPD phenotypes, and the obligatoriness to base on the blood gas analysis findings the long-term oxygen therapy, were largely agreed, as well as the need for interventions aimed at decreasing the rate of acute exacerbations. More specific topics like the use of noninvasive ventilation, recognizing the factors affecting outcome and mortality, the choice of pharmacological and non pharmacological treatments in COPD patients led to lively discussing, but they did not always reach the total agreement, probably because of insufficient familiarity with these problems and of diversities in organization and instruments availability. The chronic respiratory assistance was treated with particular regard to smoking cessation, whose implementation is still insufficient. Many doubts rose due to uncertainty, lack of ability and standardization of procedures, insufficient institutional support, and difficulties to realize a network for assistance to chronic patients.

CONCLUSIONS

The results of this Third Consensus Conference revealed some certainties and many doubts and diversities of view also on topics whose importance is well demonstrated in scientific literature. Thus, there is still a long distance to cover before reaching a suitable standardization of COPD management and such situation urges the need for improving not only the health professional's operativeness but also the organizational support by competent institutions. In this context some initiatives organized by AIMAR in cooperation with other respiratory scientific societies and patients' associations are going on.

The AIMAR recommendations for early diagnosis of chronic obstructive respiratory disease based on the WHO/GARD model*

Respiratory diseases in Italy already now represent an emergency (they are the 3(rd) ranking cause of death in the world, and the 2(nd) if Lung cancer is included). In countries similar to our own, they result as the principal cause for a visit to the general practitioner (GP) and the second main cause after injury for recourse to Emergency Care. Their frequency is probably higher than estimated (given that respiratory diseases are currently underdiagnosed). The trend is towards a further increase due to epidemiologic and demographic factors (foremost amongst which are the widespread diffusion of cigarette smoking, the increasing mean age of the general population, immigration, and pollution). Within the more general problem of chronic disease care, chronic respiratory diseases (CRDs) constitute one of the four national priorities in that they represent an important burden for society in terms of mortality, invalidity, and direct healthcare costs. The strategy suggested by the World Health Organization (WHO) is an integrated approach consisting of three goals: inform about health, reduce risk exposure, improve patient care. The three goals are translated into practice in the three areas of prevention (1-primary, 2-secondary, 3-tertiary) as: 1) actions of primary (universal) prevention targeted at the general population with the aim to control the causes of disease, and actions of Predictive Medicine - again addressing the general population but aimed at measuring the individual's risk for disease insurgence; 2) actions of early diagnosis targeted at groups or - more precisely - subgroups identified as at risk; 3) continuous improvement and integration of care and rehabilitation support - destined at the greatest possible number of patients, at all stages of disease severity. In Italy, COPD care is generally still inadequate. Existing guidelines, institutional and non-institutional, are inadequately implemented: the international guidelines are not always adaptable to the Italian context; the document of the Agency for Regional Healthcare Services (AGE.NA.S) is a more suited compendium for consultation, and the recent joint statement on integrated COPD management of the three major Italian scientific Associations in the respiratory area together with the contribution of a Society of General Medicine deals prevalently with some critical issues (appropriateness of diagnosis, pharmacological treatment, rehabilitation, continuing care); also the document "Care Continuity: Chronic Obstructive Pulmonary Disease (COPD)" of the Global Alliance against chronic Respiratory Diseases (GARD)-Italy does not treat in depth the issue of early diagnosis. The present document - produced by the AIMAR (Interdisciplinary Association for Research in Lung Disease) Task Force for early diagnosis of chronic respiratory disease based on the WHO/GARD model and on available evidence and expertise -after a general examination of the main epidemiologic aspects, proposes to integrate the above-mentioned existing documents. In particular: a) it formally indicates on the basis of the available evidence the modalities and the instruments necessary for carrying out secondary prevention at the primary care level (a pro-active,'case-finding'approach; assessment of the individual's level of risk of COPD; use of short questionnaires for an initial screening based on symptoms; use of simple spirometry for the second level of screening); b) it identifies possible ways of including these activities within primary care practice; c) it places early diagnosis within the "systemic", consequential management of chronic respiratory diseases, which will be briefly described with the aid of schemes taken from the Italian and international reference documents.