Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the Central Development Region, Nepal

Impact of Pharmacist-Led Intervention on Adherence to Inhalers, Inhalation Technique, and Disease Control Among Asthma/COPD Patients in a Resource Limited Center: An Interventional Study

Background

Asthma and Chronic obstructive pulmonary disease (COPD) are chronic respiratory conditions characterized by airflow obstruction and respiratory symptoms. Adherence to prescribed inhaler therapy and correct inhalation technique are essential for effective disease management and optimal disease control. However, non-adherence and incorrect inhalation technique are common challenges faced by patients with asthma and COPD, leading to suboptimal treatment outcomes and increased healthcare burden.

Purpose

To study the impact of a pharmacist-led intervention on inhaler adherence, inhalation technique, and disease control among patients with asthma and COPD.

Patients and Methods

A pre-post interventional design assessed the effects of pharmacist-led intervention on inhaler adherence, inhalation techniques, and disease control in asthma and COPD patients at Dhulikhel Hospital in Nepal. Inclusion criteria: adult patient clinically diagnosed with asthma or COPD patients of all genders. The intervention comprised counseling patients with aids like videos, and informational leaflets. Impact was measured using checklist method for inhalation technique, the Test of Adherence to Inhaler (TAI) questionnaire for adherence to inhaler, and "Asthma Control Test (ACT)" or "COPD Assessment Test (CAT)" for disease control.

Results

The pharmacist-led intervention significantly increased adherence to inhalers, evidenced by a notable rise in the proportion of patients with good adherence (P<0.001). Sporadic, deliberate, and unwitting noncompliance pattern also improved significantly after the intervention (P<0.001, P<0.001 and P=0.001). Inhalation technique exhibited substantial improvement after intervention (P<0.001). The analysis indicated significant moderate negative correlations between "TIA" and "CAT" [ρ=-0.31; P=0.01], and between "inhalation technique score" and "CAT score" [ρ=-0.31; P=0.01] suggesting that as adherence to inhaler usage and inhalation technique improve, CAT scores tend to decrease, indicating reduced disease impact on the patient.

Conclusion

This study shows the potential efficacy of pharmacist-led intervention in enhancing adherence to inhaler, inhalation technique, and disease control in respiratory conditions such as asthma and COPD.

Improvement in Inhaler Techniques After Training and Counseling in Patients With Chronic Obstructive Pulmonary Disease or Asthma

Background Chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma significantly impair quality of life and impose a substantial burden on healthcare systems. Proper inhalation technique is important for effective management of these diseases, yet remains poorly performed by many patients. This study evaluated the impact of structured counseling and training sessions on inhaler use among patients with COPD and asthma, aiming to enhance technique correctness and disease control. Methodology This cross-sectional study analyzed 150 patients with asthma and COPD who fulfilled the inclusion criteria for inhalation techniques. Patients were counseled regarding the proper seven-step inhalation technique for each inhaler type [metered-dose inhaler (MDI), MDI with spacer, and dry powder inhaler (DPI)] through practical demonstration at baseline visits. Correct use of inhalers was assessed by a predefined checklist for each inhaler device at the baseline visit and after three months. The correctness of the inhalation technique was evaluated by scoring each of the seven steps. The disease control assessment was done using the COPD assessment test (CAT) and asthma control test (ACT) at the baseline visit and after three months. Results In this study of 150 patients, there were 97 (64.7%) males and 53 (35.3%) females. In total, 67 (44.7%) were diagnosed with asthma and 83 (55.3%) with COPD. The mean age was 45.33 ± 12.62 years. Post-counseling improvements in inhaler technique were marked, with MDI users enhancing their technique score from an average of 4.4 to 6.1, MDI with spacer from 4.56 to 6.26, and DPI from 4.92 to 6.24 (p < 0.001 for all). Disease control also showed significant gains; CAT scores decreased for MDI users from 23.4 to 20.5, MDI with spacer from 23.92 to 20.96, and DPI from 24.89 to 21.96. Concurrently, ACT scores increased for MDI users from 16.4 to 18.0 (p = 0.002), MDI with spacer from 17.29 to 19.04, and DPI from 16.42 to 18.37 (p < 0.001 for both), reflecting substantive advances in managing COPD and asthma symptoms. Furthermore, patients with primary education exhibited a significant boost in technique mastery post-counseling (p < 0.001), underscoring the potential of well-crafted counseling to transcend educational barriers in promoting effective inhaler use. Conclusions Post-counseling, inhaler technique improved significantly across all types, with MDI with spacer users demonstrating the most progress. Technique scores increased notably (p < 0.001), and disease control scores for COPD and asthma, measured by CAT and ACT, also showed significant improvements (p < 0.001). Remarkably, primary education level participants exhibited substantial technique gains post-intervention, emphasizing the effectiveness of counseling irrespective of initial educational status in enhancing inhaler use and disease management.

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.

Illustrating How to Use the Validated Alsayed_v1 Tools to Improve Medical Care: A Particular Reference to the Global Initiative for Asthma 2022 Recommendations

Purpose

The current research aimed to illustrate a real case using the validated Alsayed_v1 tools as tutorial training to improve the knowledge and skills of healthcare practitioners in the clinical problem-solving process necessary to implement medical and pharmaceutical care.

Patients and Methods

The Alsayed_v1 instruments consist of principal components: data collection, assessment of treatments, the medical problem oriented plan (MPOP), as well as a care plan and patient education.

Results

This study illustrated a real case of asthma patient using the validated Alsayed_v1 tools. These validated and clinically tested tools provide a coding system for the MPOP that permits easy documentation with an open hierarchical structure where higher levels are broad and lower levels are particular, and the possibility to enter free text. The section dedicated to treatment assessments is intended to synthesize patient information to facilitate the identification of the MPOPs. Effective management requires the development of a partnership between the patient with asthma (or the patient's caregivers) and his healthcare professional(s). This partnership aims to allow the patient to control his condition with guidance from the healthcare professional(s), discuss and agree on therapy goals, and develop a personalized, written, self-management asthma care plan.

Conclusion

By implementing Alsayed_v1 tools, the clinical practitioner can actively give the best practice for optimal patient outcomes.

Repetitive instructions at short intervals contribute to the improvement of inhalation technique

BACKGROUND

Inhaled medicines are key drugs for the treatment of asthma or chronic obstructive pulmonary disease. However, the variety of inhaler devices and complicated inhalation procedures have created confusion among patients, affecting their correct understanding of inhalation. Recent studies reported that up to 80% of patients made technical errors in inhalation and emphasized the necessity for patient education.

OBJECTIVE

We aimed to assess the importance of inhalation-related instructions and to find clinical factors associated with improvements in the inhalation technique.

METHODS

We conducted a retrospective, single-center study at a regional core hospital in Japan. Physicians and community pharmacists constructed an interactive instruction system and shared a common inhalation procedure manual. Patients who received instructions for the inhalation technique at least 3 times were recruited.

RESULTS

A total of 125 patients were analyzed in this study. The median age was 73 years (interquartile range, 67-80 years). At the second visit, 67 patients (53.6%) failed to correctly perform the technique despite being guided at the first visit. At the third visit, 48.8% of patients made some errors. After excluding 40 patients who were not subjected to analysis, the remaining 85 were divided into "improvement" and "no-improvement" groups. The total improvement rate was 57.6%. The median time interval between consecutive instructions in the "improvement" groups was 84 days, whereas that in the "no-improvement" group was 128 days (p < 0.05, U test). No significant difference in the age, sex, or primary disease was seen between these groups.

CONCLUSION

Repetitive instructions at shorter intervals may be helpful for patients to develop and maintain an improved inhalation technique.

Individual factors increasing complexity of drug treatment-a narrative review

Purpose

Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment.

Methods

A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients.

Results

Ninety-one influencing factors were identified: fourteen in “dosage forms”, five in “product characteristics”, twelve in “dosage schemes”, nine in “additional instructions”, thirty-one in “patient characteristics” and twenty in “process characteristics”.

Conclusions

Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary.

Electronic supplementary material

The online version of this article (10.1007/s00228-019-02818-7) contains supplementary material, which is available to authorized users.

Checking Inhaler Technique in the Community Pharmacy: Predictors of Critical Errors

Inhaled medications are critical in the pharmaceutical management of respiratory conditions, however, the majority of patients demonstrate at least one critical error when using an inhaler. Since community pharmacists can be instrumental in addressing this care gap, we aimed to determine the rate and type of critical inhaler errors in community pharmacy settings, elucidate the factors contributing to inhaler technique errors, and identify instances when community pharmacists check proper inhaler use. Fourth year pharmacy students on community practice placement (n = 53) identified 200 patients where at least one error was observed in 78% of participants when demonstrating inhaler technique. Prevalent errors of the users were associated with metered dose inhaler (MDI) (55.6%), Ellipta^® (88.3%), and Discus^® (86.7%) devices. Overall, the mean number of errors was 1.09. Possession of more than one inhaler, use of rescue inhaler, and poor control of asthma were found to be significant predictors of having at least one critical error. In all participating pharmacies, inhaler technique is mainly checked on patient request (93.0%) and for all new inhalers (79.0%).

Pharmacist Led Intervention on Inhalation Technique among Asthmatic Patients for Improving Quality of Life in a Private Hospital of Nepal

Purpose

Asthma is a chronic disease which cannot be cured but can be controlled. Although drug therapy is used to relieve and prevent symptoms of asthma and treat exacerbations, still a good asthma control and a better quality of life in many patients is suboptimal due to improper use of inhalation technique. Thus, this interventional study was conducted to evaluate the effect of a pharmacist intervention on asthma control, quality of life and inhaler technique in adult asthmatic patients.

Patients and Methods

A total of 72 patients who met the inclusion criteria and agreed to give written consent were enrolled in the study. These patients were randomly divided into two groups i.e., test group (36) and control group (36) by simple block randomization technique. Test group were the interventional groups. Mini Asthma Quality of Life Questionnaire (AQLQ), Asthma Control Questionnaire (ACQ) and structured questionnaires were used to sort the information like quality of life, asthma control and demographic details. They were counselled by the pharmacist about the asthma management and proper use of inhalers. Out of 72 patients, only forty six patients came for follow up after one month. Data were entered and analyzed using Statistical Package for Social Sciences (SPSS) software version 20.

Results

A significant change was observed in the mean score of quality of life (p = 0.001) in test group as well as control group, however change in the mean score of asthma control in the test group (p = 0.001) was more significant as compared to the control group (p = 0.099). Inhalation technique was found to be improved significantly after intervention among patients using the metered dose inhaler and dry powder inhaler. Majority of the patients were prescribed with Methylxanthines (24.5%) followed by combined Beta 2 agonists and Inhaled Corticosteroids (21.7%).

Conclusion

Pharmacist provided intervention improves the quality of life, asthma control and inhalation technique among asthmatic patients.

Undergraduate pharmacy students' attitudes and perceived barriers toward provision of pharmaceutical care: a multi-institutional study in Nepal

Background: Pharmaceutical care (PC) has a significant impact on optimizing pharmacotherapy and improving patients’ quality of life. We aimed to determine the attitudes and perceived barriers of final year pharmacy undergraduates towards provision of PC services in Nepal.

Methods: A cross-sectional study was conducted among 232 students using a 13-item-standard PC attitude survey (PCAS) questionnaire and 12-itemed PC barrier questionnaires. Mann–Whitney U test and Kruskal–Wallis tests were used to measure the median difference between groups, at alpha=0.05, and Spearman’s rho test was used to measure the strength of the correlation.

Results: Majority of students were self-motivated in undertaking the current pharmacy education (178, 76.7%) and had no previous incomplete grades that could delay their graduation (177, 76.3%). Over 80% of students had a positive attitude toward all items of PCAS (agreed and strongly agreed) except for two items. Whereas, 61 (26.3%) disagreed and strongly disagreed that providing PC takes too much time and effort. The major barriers perceived were inadequate PC training (176, 75.9%), inadequate drug information resources in the pharmacy (170, 73.3%), and lack of access to patient medical records in the pharmacy (165, 71.1%). A significant relationship was noticed between positive attitude towards PC and three factors; source of motivation, current employment in pharmacy job, and incomplete grades delaying graduation. Age factor was significant but negatively correlated with the scores of positive attitudes namely “I would like to perform PC as a pharmacist practitioner”, “Providing PC is professionally rewarding” and “I feel that the PC is the right direction for the provision to be headed”.

Conclusion: Nepalese undergraduate pharmacy students had positive attitudes toward PC. Exercising proper pharmacy practice regulations and educational efforts to overcome the perceived barriers may lead to better delivery of PC.

Opinion of hospital pharmacy practitioners toward the Continuing Pharmacy Education program: a study from a tertiary care hospital in central Nepal

Background

Meeting participants’ needs and matching their preferences are important prerequisites for an effective Continuing Pharmacy Education (CPE) program. The objective of this pilot study was to assess the opinion of hospital pharmacy practitioners with respect to the CPE program.

Methods

The pretested questionnaires were distributed to 20 pharmacy practitioners working in a pharmacy at a tertiary care hospital in Nepal which asked for their opinions and suggestions with respect to the CPE program. Descriptive statistics were performed using IBM SPSS version 20.

Results

Topics related to skills development (75%) and recent innovations in pharmacy practice (65%) were mostly preferred. Live (in-person) presentations (80%) and small group discussion (60%) were the most suitable methods for delivery. Improving knowledge (75%), improving skills (60%) and keeping up-to-date in the latest information (60%) were major motivating factors to participate, while lack of time (75%) was a major barrier. Approximately 55% of the participants believed that face-to-face interview was a suitable method for evaluating the effectiveness. Allocation of separate time for the program, assessing baseline knowledge and skills of the participants along with delivery of quality materials in an understandable way were the top common suggestions for improving the CPE program.

Conclusion

Hospital pharmacy practitioners’ opinions and suggestions were assessed with respect to the CPE program and this was upgraded accordingly to meet their expectations.

Do Face-to-Face Training and Telephonic Reminder Improve Dry Powder Inhaler Technique in Patients with COPD?

Introduction. Current modes of instruction on inhaler technique are inadequate. We aimed to evaluate the value of face-to-face training and telephonic reminder (FFTTR) for improving Rotahaler technique in experienced patients with COPD. Materials and Methods. A single group pre-/postinterventional study was conducted at Chitwan Medical College Teaching Hospital, Nepal. We assessed the Rotahaler technique of thirty consecutive patients using Rotahaler device for more than one year. Patients with incorrect technique (n = 20) were instructed and trained by a pharmacist. Telephonic reminder was used to reinstruct patients on the correct technique on weekly basis for two weeks and technique was reassessed after 4 weeks of their first training. Descriptive statistics including Wilcoxon Signed Rank test were applied. Results. The mean age was 66.06 ± 10.6. Of 30 patients, 10 (33.3%) performed Rotahaler technique correctly at baseline and were excluded from FFTTR intervention. FFTTR corrected the technique in 18 (90%) patients and the median (IQR) score increased from 6 (5-6) to 8 (8-8) (p < 0.001). The most incorrect steps were “breathe out gently but not towards the inhaler mouthpiece” (16, 80%) and “hold breath for about 10 seconds” (18, 90%) at baseline which improved after intervention. Conclusion. FFTTR approach markedly improved Rotahaler technique in patients with COPD.