Role of the pharmacist in improving inhaler technique and asthma management in rural areas in Jordan

Transforming respiratory diseases management: a CMO-based hospital pharmaceutical care model

Introduction

Respiratory diseases encompass a diverse range of conditions that significantly impact global morbidity and mortality. While common diseases like asthma and COPD exhibit moderate symptoms, less prevalent conditions such as pulmonary hypertension and cystic fibrosis profoundly affect quality of life and mortality. The prevalence of these diseases has surged by approximately 40% over the past 3 decades. Despite advancements in pharmacotherapy, challenges in drug administration, adherence, and adverse effects persist. This study aimed to develop and perform an interim validation of a Capacity-Motivation-Opportunity (CMO) model tailored for respiratory outpatients to enhance pharmaceutical care, which is the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient's quality of life, and overall wellbeing.

Methodology

This cross-sectional, multicenter study was conducted from March 2022 to March 2023. It comprised four phases: 1) forming an expert panel of 15 hospital pharmacists, 2) selecting respiratory pathologies based on prevalence and severity, 3) developing the CMO model's pillars, and 4) integrating and conducting an interim validation of the model. The Capacity pillar focused on patient stratification and personalized care; the Motivation pillar aligned therapeutic goals through motivational interviewing; and the Opportunity pillar promoted the use of information and communication technologies (ICTs) for telemedicine.

Results

The model included eight respiratory diseases based on expert assessment. For the Capacity pillar, 22 variables were defined for patient stratification, leading to three priority levels for personalized pharmaceutical care. In a preliminary test involving 201 patients across six hospitals, the stratification tool effectively classified patients according to their needs. The Motivation pillar adapted motivational interviewing techniques to support patient adherence and behavior change. The Opportunity pillar established teleconsultation protocols and ICT tools to enhance patient monitoring and care coordination.

Conclusion

The CMO model, tailored for respiratory patients, provides a comprehensive framework for improving pharmaceutical care. By focusing on patient-centered care, aligning therapeutic goals, and leveraging technology, this model addresses the multifaceted needs of individuals with respiratory conditions. Future studies are necessary to validate this model in other healthcare systems and ensure its broad applicability.

Expert consensus on oral corticosteroids stewardship for the treatment of severe asthma in the Middle East and Africa

In the Middle East and Africa (MEA) region, overuse of oral corticosteroids (OCS) for asthma management, both as burst and maintenance therapy, poses a significant challenge. Gaps in knowledge regarding the need to taper OCS in patients with severe asthma and the use of OCS in comorbid conditions have been noted. OCS stewardship can help attain optimal and effective OCS tapering along with reducing OCS overuse and over-reliance. In this paper, we discuss current practices regarding the use of OCS in asthma, globally and in the MEA region. Expert recommendations for achieving OCS stewardship in the MEA region have also been presented. Regional experts recommend increasing awareness among patients about the consequences of OCS overuse, engaging community pharmacists, and educating primary healthcare professionals about the benefits of prompt appropriate referral. Innovative local referral tools like ReferID can be utilized to refer patients with asthma to specialist care. The experts also endorse a multidisciplinary team approach and accelerating access to newer medicines like biologics to implement OCS stewardship and optimize asthma care in the MEA region.

Patient experiences of their current asthma care and their views toward providing support for patients with asthma in community pharmacy: A Qualitative study

Background

An estimated 300 million people live with asthma globally. In England, a significant percentage live with poorly controlled asthma symptoms. Community pharmacists might be able to play a role in filling gaps in asthma care as they have the expertise and are in regular contact with patients with long term conditions. This study described patients' experiences of the management of their asthma in the general physician (GP) practice and community pharmacy settings and explored patients' views on providing support for them in community pharmacy.

Method

This is a descriptive qualitative study. Thirteen adult asthma patients were recruited from a GP practice in the Northwest of England. Semi-structured qualitative interviews were conducted face-to-face or by telephone. The interviews were recorded, transcribed and analysed using a thematic analysis approach. Ethics approval was obtained before the study commenced and all participants gave informed written consent to participate.

Results

We identified challenges in the current asthma care provided to patients with asthma including lack of continuity of care, inability to book an appointment and other experienced differences in the quality of asthma care provided to them and/or access to annual asthma reviews across different GP practices. Additionally, there is lack of awareness of services provided in community pharmacy. These challenges along with having comorbidities alongside asthma may negatively affect asthma patients' engagement with their asthma appointments and their behaviour toward their asthma.

Conclusions

Patients showed trust in community pharmacists same as other HCPs to support them with their asthma care. Patients thought that being provided with regular asthma care including reviews in community pharmacy might be a suitable approach to respond to patients' needs and preferences in terms of their asthma management because of ease of access to community pharmacy. Pharmacists could be involved in the provision of community pharmacy-based asthma interventions that involve more than inhaler technique education. Further research should focus on developing structured approaches for asthma patient education that can be implemented consistently in the context of community pharmacy in England.

Correlation of vitamin D receptor genotypes, specific IgE levels and other variables with asthma control in children

INTRODUCTION

Asthma is a common condition affecting millions of children globally. The main goal of this study is to assess factors related to asthma management, particularly atopy level and the impact of genetic variants of the vitamin D receptor (VDR) gene.

METHODS

Asthmatic children were enrolled in an outpatient respiratory clinic. Information on patients' medication adherence, medical and medication factors, and sociodemographic were gathered. Spirometry FEV1% and FVC% measurements, and the asthma control test were used to evaluate the severity of asthma, and genotyping of the VDR gene and radioallergosorbent test (RAST) were conducted. Regression analyses were conducted to evaluate variables associated with asthma control and spirometry measures.

RESULTS

A total of 313 participants (67.4% males) were recruited in the current study. The mean age was 9.37 (±3.45) years. The mean score for adherence was 4.26 (±2.52), and only 46% of the participants had controlled asthma. Forward conditional stepwise binary regression showed that low and moderate Inhaled corticosteroids (ICS) dose (OR= 0.42 (95% CI 0.20-0.90), p = 0.026; OR = 0.371 (95% CI 0.2-0.72), p = 0.003, respectively) decreased the odds of being in the controlled asthma group, while higher inhaler score (OR = 2.75 (95% CI 2.17-3.49, p < 0.001)) increased the odds of being in the controlled asthma group. However, results found no association between VDR genotype and asthma control, spirometry values or hospitalization due to asthma.

CONCLUSIONS

The results indicated that many of the asthma patients had poorly controlled asthma. Factors that were associated with poor asthma control included poor inhaler technique.

Optimization of Inhalation Technique Knowledge in the Pharmacies of Matosinhos Municipality, Portugal: An Intervention Project

INTRODUCTION

The therapeutic approach to the most common respiratory diseases, asthma and chronic obstructive pulmonary disease (COPD), involves the use of inhalation devices. Its use is essential, but incorrect use is frequent, and learning and reviewing the technique is necessary for the adequate management of these diseases.

OBJECTIVE

This study aims to increase the knowledge of health professionals from pharmacies in the municipality of Matosinhos, Portugal, about the correct inhalation technique.

METHODS

The project developed from May 2022 to June 2023 was based on a training session for pharmacy professionals that took place after professionals completed a questionnaire and after evaluating each participant's inhalation technique by the authors using a checklist. Both were reapplied three months after the first evaluation.

RESULTS

Fifteen pharmacies in Matosinhos, Portugal, were invited, of which eight agreed to participate, with a total of 16 health professionals (30.8% of professionals in these pharmacies). We found that professionals questioned and taught users more times about the inhalation technique and that a greater number of professionals considered they knew how to correctly perform the inhalation technique in the second assessment. It was also possible to verify statistically significant differences (p<0.001) between the mean of correct steps in the inhalation technique between the first and second assessments. There was also an improvement in the qualitative analysis of errors in the inhalation technique. In the first assessment, the inhalation devices with the lowest percentage of correct steps were Forspiro® and Respimat®. In the second evaluation, the Diskus® and Ellipta® devices obtained 100% correct steps, with the K-haler® being the device with the lowest percentage.

CONCLUSIONS

This study confirms the effectiveness of continuous training for health professionals and the importance of multidisciplinary cooperation in teaching inhalation techniques. Other studies are needed to complement these results, particularly with representative samples of the general population, or assessing the impact of this intervention in patients with respiratory diseases.

Can Pharmacists' Counseling Improve the Use of Inhalers and Quality of Life? A Prospective "Pre" and "Post" Education Analysis in Mardan, Pakistan

Introduction

Asthma is one of the common major non-communicable respiratory diseases, and is associated with a lower health-related quality of life (QOL). Poor inhalation is a significant contributing factor to poor control of asthma. Community pharmacist has a vital role to play in assisting patients and ultimately improving their asthma conditions through the use of inhalers.

Aim

This study aimed to assess the effectiveness of "pre" and "post" educational intervention by a community pharmacist within a community pharmacy on asthma patients' QOL, inhaler technique, and adherence to therapy during the endemic phase of COVID-19.

Methods

A "pre" and "post" interventional study was performed at a community pharmacy in the city of Mardan, Pakistan, in 2022 during the COVID-19 pandemic. Patients were divided into two groups, ie control and pharmacist-led education groups. After assigning patients to both groups, the baseline data were collected and followed for one month to compare the reduction in errors in the use of inhalers, QOL, and adherence to therapy. A paired sample t-test was performed, keeping a p-value <0.05 as statistical significance.

Results

A total of 60 patients were recruited, majority (58.3%) were females, and 28.3% were from the age group of 46-55 years old. A statistically significant difference was observed in the pre- and post-education QOL score among patients in the pharmacist-led education group, from a mean ± SD at pre-education of 40.23±10.03 to a mean±SD at post-education of 48.10±5.68. Similarly, a statistically significant difference was observed for the correct use of inhalers, ie MDIs and DPIs. Similarly, a statistically significant difference was observed in the adherence status between pre-education and post-education by pharmacists.

Conclusion

The findings of the study revealed a positive impact of community pharmacist-led education on QOL, inhaler technique, and adherence to therapy among patients with asthma.

Assessing the Pharmacist's Role in Counseling Asthmatic Adults Using the Correct Inhaler Technique and Its Effect on Asthma Control, Adherence, and Quality of Life

Purpose

This study was designed to assess inhaler technique skills, asthma control level, adherence, and quality of life scores amongst asthmatic patients living in Amman, Jordan, investigating the role of pharmacist's educational intervention.

Patients and Methods

This single-blinded randomized parallel-group active-controlled study was conducted at the Jordan University Hospital (JUH) clinic in 2019. Patients were assessed at baseline and follow-up (after three months) on their inhaler technique (based on validated published checklists), asthma control based on the asthma control test (ACT) questionnaire, adherence to treatment, and quality of life (QoL). Patients in the active group were counseled on correct inhaler technique and administration skills, orally and using inhaler adhesive labels delivered by the clinical pharmacist.

Results

Asthma patients (n = 157; active, n = 79, and control, n = 78) were recruited into the study and grouped based on the controller inhaler they were using (Turbohaler (TH) and Accuhaler (ACC). There was no statistically significant difference between both groups at baseline for inhaler technique, adherence, ACT, and QoL. At follow-up, 93.7% of the active group patients used their inhalers correctly, while only 16.7% of the control group used them correctly (P-value <0.001). Also, the ACT mean score was significantly higher for the active group (21.21±5.27) versus the control group (15.92±7.31; P-value <0.001). The QoL mean score was significantly improved for the active group compared with the control group (active = 63.85±24.78, Control = 38.746±3.23, P-value <0.001). Improvement in adherence for the active group was noticed compared with the control group but did not reach a significant level (P-value=0.691).

Conclusion

Through a practical educational intervention, pharmacists were found to significantly improve patients' asthma inhaler technique, ACT scores, and QoL scores for patients with asthma.

Variables associated with asthma control among adult patients

Objective: Asthma is one of the most prevalent chronic diseases with a substantial impact on the health status of affected patients. Further research is necessary to identify factors contributing to poor asthma control. The current study aimed to investigate the factors associated with poor asthma control among adult asthmatic patients.Methods: In this case-control study, the Asthma Control Test (ACT) was translated into Arabic and distributed to adults with asthma attending two hospitals in Jordan to evaluate the degree of asthma control. The following variables were collected for each patient: sociodemographic information, comorbidities, appropriate use of inhaler technique, spirometric measurements, and medications use. Binary regression was used to evaluate factors associated with asthma control.Results: A total of 314 participants with a mean age of 51.47 years (±16.37) completed the study. ACT score had a mean of 16.68 (±4.86). The majority of asthmatic patients had insufficiently controlled asthma (64.6%). Binary regression results showed that previous respiratory infection history (p = 0.014, OR = 0.473 (95%CI 0.261-0.857)), higher exposure to irritants (p = 0.010, OR = 0.747 (95%CI 0.598-0.933)) decreased the odds of being in the controlled asthma group. Patients receiving inhaled corticosteroids (ICS) had higher odds of being in the controlled asthma group (p = 0.039, OR = 2.372 (95%CI 1.043-5.392)).Conclusions: The majority of asthma patients had insufficiently managed disease. The main factors that contributed to poor asthma control were respiratory infection history, increased exposure to asthma symptoms triggers, and ICS nonuse.

The Influence of the Pharmacists’ Training on the Quality and Comprehensiveness of Professional Advice Given in the Field of Inhalation Techniques in Community Pharmacies in Poland

Background: Following the example of other countries, it is very important to educate patients on the correct use of inhalers by properly trained healthcare professionals, including pharmacists. Objectives: The aim of the study was to assess the quality and comprehensiveness of professional advice given by pharmacists on the use of inhalers, which was determined by the pharmacists’ level of training. Methods: The study was conducted from June 2019 to March 2020. 150 pharmacists from Poznan and Warsaw (Poland) were involved. Before the study began, the professional education of 240 pharmacists was conducted in Warsaw to implement standard operating procedures. The study used the model of a mystery shopper. Results: The conversation with a trained pharmacist lasted on average 5.5 min, with an untrained one—3.0 min (p < 0.0001). Placebo inhalers were used more often by trained pharmacists during patients’ education (p < 0.0001). Moreover, 10.3% of untrained pharmacists did not provide any education. Additionally, untrained employees’ quality of advice was assessed on an average of 3.5 points, while trained ones—7.6 points (p < 0.0001). Conclusions: This study has shown that there is a need for professional training among pharmacists in Poland, which translates into better patient education in the field of inhalation techniques.

Medical Device-related Counseling Practice and Barriers among Sudanese Pharmacists: A Questionnaire-Based Study

Objective:

The aim of the present study was to assess medical devices-related counseling practice and barriers among pharmacists.

Methods:

This was a cross-sectional study conducted using a convenient sample of Sudanese pharmacists. An online-version survey was used to collect data.

Findings:

One hundred and thirty pharmacists responded to the online survey. Most pharmacists in this sample were master or Ph.D. degree holders (62.3% and 12.3%, respectively), having a clinical training experience (70%) and substantial proportion are board-certified (30%). Medical devices reported to be commonly inquired by patients were blood glucose monitors, nebulizers, blood pressure monitors, dry powder inhalers, and insulin pens. Devices most frequently requiring counselling were blood glucose monitors, blood pressure monitors, syringes, thermometers, nebulizers, dry powder inhalers, insulin, and weighing scales. The most frequently supplied devices reported were syringes, blood glucose monitors, insulin pens, blood pressure monitors, thermometers, nebulizers, and dry powder inhalers. Devices least frequently requiring counselling were implanted devices, respirometers, and stethoscopes. The least frequently supplied devices were respirometers, implanted devices, and heart rate monitors.

Conclusion:

Medical devices reported to be commonly inquired by patients were most frequently requiring counseling, and most frequently supplied. Findings reflect the availability of devices in the market and pharmacists' response to the needs of their patients. Pharmacists should maintain adequate knowledge about the proper use of medical devices because this is a common patient inquiry.

Inhaler Use Technique in Chronic Obstructive Pulmonary Disease Patients: Errors, Practices and Barriers

Background

Inhaled medications are the main therapeutic treatment of chronic obstructive pulmonary disease (COPD) and inhaler technique remained important that can increase medication efficacy, reducing dose and side effects. Poor inhaler technique is multi-factorial and the quality of inhaler technique has not previously assessed in Pakistan. We conducted a study to examine a range of competing factors that impact COPD patient willingness, practices, and preference in using their inhalers.

Methods

A cross-sectional of 765 patients with COPD were interviewed and assessed by qualitative questionnaires. Objective inhalation technique and steps assessment was performed; satisfaction, preferences, perception, and practice of different types of inhaler devices were evaluated at a single cross-sectional visit at the study enrolment.

Results

The study included 765 participants of mean age 58.7 years (SD ±7.8); 32% males and 68% females. Almost all of the females were exposed to biomass fuel smoke exposure (99%) and pipe (Huka) smokers 53%, while most male participants were cigarette smokers (92%). Only 6.3% of participants were able to perform correct steps of inhaler use, and few educated patients completed 7-steps. 66% of patients were using dry powder inhalers (DPI) inhaler devices and mostly performed the steps 1, 2, and 4 (98%) correctly, while 44% who were using metered-dose inhalers (MDI) completed only steps 2 and 4 correctly (88%). The majority of participants reported the particular inhaler devices was prescribed by the visiting consultants (54%). Interestingly, they were using two inhalers together (47%) relieving symptoms of dyspnea (83%) and cough (73%). The inhaler use technique was demonstrated to most of the patients by the pharmacy salesman (38.4%), while 15.8% reported that their doctors taught them the inhaler technique. 54.2% reported reason for poor adherence to inhaler use as they understand it might not work lately and 75.2% were not aware of any side effects associated with the regular use of an inhaler.

Conclusions

Poor inhaler technique is highly prevalent and the associated errors did not appear to be dependent on device type. Most of the participants had not receive proper training about the correct use and were not involved in decision making about the choice of inhaler device.

Asthma Control and Its Predictive Factors in Adult Asthma Patients

BACKGROUND

Asthma is a highly prevalent condition that remains difficult to control, as its associated factors remain poorly understood. Thus, the primary aim of the present investigation was to determine the prevalence of uncontrolled asthma in hospital units in south Jordan and to evaluate the risk factors that may contribute to uncontrolled asthma.

METHODS

This was a cross-sectional study involving 93 patients aged 40.5 ± 13.6 years that met the criteria of the Global Initiative for Asthma (GINA). Relevant patient data were collected via a questionnaire and through a review of medical records. The questionnaire comprised of sections pertaining to sociodemographic and clinical characteristics, as well as pharmacological asthma treatment, asthma severity and asthma control. Asthma severity was determined in line with the GINA guidelines, whereby the patients were classified into four groups (intermittent, mild persistent, moderate persistent or severe persistent). Moreover, based on the findings yielded by the asthma control questionnaire (ACQ), patients were divided into three levels, whereby those diagnosed with partly controlled and uncontrolled asthma were combined into one group, denoted as "poorly controlled asthma", with "uncontrolled asthma" and "controlled asthma" as the remaining two groups. Atopy was defined as one or more positive reactions (A/H ratio > 1) on a skin prick test.

RESULTS

Asthma control was achieved in 45.2% of the sample. Moreover, older age, severe asthma according to the GINA guidelines, longer duration of asthma, atopy, being on treatment for asthma and history of allergic rhinitis were identified as the main risk factors contributing to poorly controlled asthma. Multivariate analyses, however, revealed that only atopy to two or more allergens and having severe asthmatic attacks were statistically significantly associated with poorly controlled asthma, for which the odds ratio Mantel-Haenszel (ORMH) of 17.2 and 2.2 was obtained, respectively.

CONCLUSION

Our findings indicate that severe asthma and atopy to two or more allergens are the main risk factors for uncontrolled asthma. However, further studies with larger sample sizes are needed to confirm these results.