Kate LeMay

Feasibility and Effectiveness of an Evidence-Based Asthma Service in Australian Community Pharmacies: A Pragmatic Cluster Randomized Trial

Objective. To test the feasibility, effectiveness, and sustainability of a pharmacy asthma service in primary care. Methods. A pragmatic cluster randomized trial in community pharmacies in four Australian states/territories in 2009. Specially trained pharmacists were randomized to deliver an asthma service in two groups, providing three versus four consultations over 6 months. People with poorly controlled asthma or no recent asthma review were included. Follow-up for 12 months after service completion occurred in 30% of randomly selected completing patients. Outcomes included change in asthma control (poor and fair/good) and Asthma Control Questionnaire (ACQ) score, inhaler technique, quality of life, perceived control, adherence, asthma knowledge, and asthma action plan ownership. Results. Ninety-six pharmacists enrolled 570 patients, with 398 (70%) completing. Asthma control significantly improved with both the three- and four-visit service, with no significant difference between groups (good/fair control 29% and 21% at baseline, 61% and 59% at end, p = .791). Significant improvements were also evident in the ACQ (mean change 0.56), inhaler technique (17–33% correct baseline, 57–72% end), asthma action plan ownership (19% baseline, 56% end), quality of life, adherence, perceived control, and asthma knowledge, with no significant difference between groups for any variable. Outcomes were sustained at 12 months post-service. Conclusions. The pharmacy asthma service delivered clinically important improvements in both a three-visit and four-visit service. Pharmacists were able to recruit and deliver the service with minimal intervention, suggesting it is practical to implement in practice. The three-visit service would be feasible and effective to implement, with a review at 12 months.

Using the community pharmacy to identify patients at risk of poor asthma control and factors which contribute to this poor control

Background. Although asthma can be well controlled by appropriate medication delivered in an appropriate way at an appropriate time, there is evidence that management is often suboptimal. This results in poor asthma control, poor quality of life, and significant morbidity. Methods. The objective of this study was to describe a population recruited in community pharmacy identified by trained community pharmacists as being at risk for poor asthma outcomes and to identify factors associated with poor asthma control. It used a cross-sectional design in 96 pharmacies in metropolitan and regional New South Wales, Victoria, Queensland, and Australian Capital Territory in Australia. Community pharmacists with specialized asthma training enrolled 570 patients aged ≥18 years with doctor-diagnosed asthma who were considered at risk of poor asthma outcomes and then conducted a comprehensive asthma assessment. In this assessment, asthma control was classified using a symptom and activity tool based on self-reported frequency of symptoms during the previous month and categorized as poor, fair, or good. Asthma history was discussed, and lung function and inhaler technique were also assessed by the pharmacist. Medication use/adherence was recorded from both pharmacy records and the Brief Medication Questionnaire (BMQ). Results. The symptom and activity tool identified that 437 (77%) recruited patients had poor asthma control. Of the 570 patients, 117 (21%) smoked, 108 (19%) had an action plan, 372 (69%) used combination of inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) medications, and only 17–28% (depending on device) used their inhaler device correctly. In terms of adherence, 90% had their ICS or ICS/LABA dispensed <6 times in the previous 6 months, which is inconsistent with regular use; this low adherence was confirmed from the BMQ scores. A logistic regression model showed that patients who smoked had incorrect inhaler technique or low adherence (assessed by either dispensing history or BMQ) and were more likely to have poor control. Conclusion. Community pharmacists were able to identify patients with asthma at risk of suboptimal control, and factors that contributed to this were elicited. This poorly controlled group that was identified may not be visible or accessible to other health-care professionals. There is an opportunity within pharmacies to target poorly controlled asthma and provide timely and tailored interventions.

Experiences of community pharmacists involved in the delivery of a specialist asthma service in Australia

BackgroundThe role of community pharmacists in disease state management has been mooted for some years. Despite a number of trials of disease state management services, there is scant literature into the engagement of, and with, pharmacists in such trials. This paper reports pharmacists’ feedback as providers of a Pharmacy Asthma Management Service (PAMS), a trial coordinated across four academic research centres in Australia in 2009. We also propose recommendations for optimal involvement of pharmacists in academic research.MethodsFeedback about the pharmacists’ experiences was sought via their participation in either a focus group or telephone interview (for those unable to attend their scheduled focus group) at one of three time points. A semi-structured interview guide focused discussion on the pharmacists’ training to provide the asthma service, their interactions with health professionals and patients as per the service protocol, and the future for this type of service. Focus groups were facilitated by two researchers, and the individual interviews were shared between three researchers, with data transcribed verbatim and analysed manually.ResultsOf 93 pharmacists who provided the PAMS, 25 were involved in a focus group and seven via telephone interview. All pharmacists approached agreed to provide feedback. In general, the pharmacists engaged with both the service and research components, and embraced their roles as innovators in the trial of a new service. Some experienced challenges in the recruitment of patients into the service and the amount of research-related documentation, and collaborative patient-centred relationships with GPs require further attention. Specific service components, such as the spirometry, were well received by the pharmacists and their patients. Professional rewards included satisfaction from their enhanced practice, and pharmacists largely envisaged a future for the service.ConclusionsThe PAMS provided pharmacists an opportunity to become involved in an innovative service delivery model, supported by the researchers, yet trained and empowered to implement the clinical service throughout the trial period and beyond. The balance between support and independence appeared crucial in the pharmacists’ engagement with the trial. Their feedback was overwhelmingly positive, while useful suggestions were identified for future academic trials.

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.

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

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 patients perceptions and experiences with a pharmacy asthma service and to investigate if there was a change over time.

Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis

Background: Guidelines recommend basing asthma management on assessment of asthma control. Validated control tools, while suitable for clinical research, may not be feasible for routine use in primary care. Aims: To describe the performance of the Pharmacy Asthma Control Screening tool (PACS) compared with the Asthma Control Questionnaire (ACQ-6). Methods: Data were obtained from a multicentre study of a community pharmacy asthma management programme in Australia, with three or four visits over six months. Eligible participants had suboptimal asthma control or no recent visit to their doctor for asthma. Asthma control was assessed at baseline and at six months with the PACS tool and ACQ-6. Results: A total of 570 patients were enrolled and 398 (70%) completed the programme. The average ACQ-6 score was 1.58±1.05 at baseline and 0.96±0.88 (n=392) after six months. Sensitivity and specificity of PACS ‘poor control’ for not well-controlled asthma (ACQ-6 ≥1.0) were 0.92 and 0.66, respectively, at baseline and 0.76 and 0.83 at six months. Agreement between the two tools at six months was moderate (κ=0.54). Both tools showed highly significant change during the study (p<0.0001 for each), but agreement between the change in the two tools was only fair (κ=0.31). Conclusions: This study shows that a simple asthma control screening tool is feasible for use in community pharmacies and has good sensitivity for identifying patients with not well-controlled asthma. Screening tools are useful in primary care to identify patients who require more detailed assessment of their asthma status, whereas for monitoring asthma control over time, a continuous control measure is more appropriate.

Implementation and evaluation of a pharmacist-led hypertension management service in primary care: outcomes and methodological challenges.

Background: Suboptimal utilisation of pharmacotherapy, non-adherence to prescribed treatment, and a lack of monitoring all contribute to poor blood (BP) pressure control in patients with hypertension. Objective: The objective of this study was to evaluate the implementation of a pharmacist-led hypertension management service in terms of processes, outcomes, and methodological challenges. Method: A prospective, controlled study was undertaken within the Australian primary care setting. Community pharmacists were recruited to one of three study groups: Group A (Control – usual care), Group B (Intervention), or Group C (Short Intervention). Pharmacists in Groups B and C delivered a service comprising screening and monitoring of BP, as well as addressing poor BP control through therapeutic adjustment and adherence strategies. Pharmacists in Group C delivered the shortened version of the service. Results: Significant changes to key outcome measures were observed in Group C: reduction in systolic and diastolic BPs at the 3-month visit (P<0.01 and P<0.01, respectively), improvement in medication adherence scores (P=0.01), and a slight improvement in quality of life (EQ-5D-3L Index) scores (P=0.91). There were no significant changes in Group B (the full intervention), and no differences in comparison to Group A (usual care). Pharmacists fed-back that patient recruitment was a key barrier to service implementation, highlighting the methodological implications of screening. Conclusion: A collaborative, pharmacist-led hypertension management service can help monitor BP, improve medication adherence, and optimise therapy in a step-wise approach. However, blood pressure screening can effect behaviour change in patients, presenting methodological challenges in the evaluation of services in this context.

Preparing pharmacists to deliver a targeted service in hypertension management: evaluation of an interprofessional training program

BackgroundNon-adherence to medicines by patients and suboptimal prescribing by clinicians underpin poor blood pressure (BP) control in hypertension. In this study, a training program was designed to enable community pharmacists to deliver a service in hypertension management targeting therapeutic adjustments and medication adherence. A comprehensive evaluation of the training program was undertaken.MethodsTailored training comprising a self-directed pre-work manual, practical workshop (using real patients), and practice scenarios, was developed and delivered by an inter-professional team (pharmacists, GPs). Supported by practical and written assessment, the training focused on the principles of BP management, BP measurement skills, and adherence strategies. Pharmacists’ experience of the training (expectations, content, format, relevance) was evaluated quantitatively and qualitatively. Immediate feedback was obtained via a questionnaire comprising Likert scales (1 = “very well” to 7 = “poor”) and open-ended questions. Further in-depth qualitative evaluation was undertaken via semi-structured interviews several months post-training (and post service implementation).ResultsSeventeen pharmacists were recruited, trained and assessed as competent. All were highly satisfied with the training; other than the ‘amount of information provided’ (median score = 5, “just right”), all aspects of training attained the most positive score of ‘1’. Pharmacists most valued the integrated team-based approach, GP involvement, and inclusion of real patients, as well as the pre-reading manual, BP measurement workshop, and case studies (simulation). Post-implementation the interviews highlighted that comprehensive training increased pharmacists’ confidence in providing the service, however, training of other pharmacy staff and patient recruitment strategies were highlighted as a need in future.ConclusionsStructured, multi-modal training involving simulated and inter-professional learning is effective in preparing selected community pharmacists for the implementation of new services in the context of hypertension management. This training could be further enhanced to prepare pharmacists for the challenges encountered in implementing and evaluating services in practice.

Does personality influence how people with asthma manage their condition

Abstract Objective: Personality traits have been found to be associated with the management of chronic disease, however, there is limited research on these relationships with respect to asthma. Asthma management and asthma control are often suboptimal, representing a barrier to patients achieving good health outcomes. This explorative study aimed to investigate the relationship between correlates of asthma management and personality traits. Methods: Participants completed a postal survey comprising validated self-report questionnaires measuring personality traits (neuroticism, extraversion, openness to experiences, agreeableness, conscientiousness), asthma medication adherence, asthma control and perceived control of asthma. Relationships between asthma management factors and personality traits were examined using correlations and regression procedures. Results: A total of 77 surveys were returned from 94 enrolled participants. Significant relationships were found between personality traits and (i) adherence to asthma medications, and (ii) perceived control of asthma. Participants who scored high on the conscientiousness dimension of personality demonstrated higher adherence to their asthma medications. Women who scored low on the agreeableness dimension of personality and high on the neuroticism dimension had significantly lower perceived confidence and ability to manage their asthma. No statistically significant associations were found between asthma control and personality traits. Conclusions: Three of the five personality traits were found to be related to asthma management. Future research into the role of personality traits and asthma management will assist in the appropriate tailoring of interventional strategies to optimize the health of patients with asthma.

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

Abstract 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.