Lorraine Smith

Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community

Background: Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design. Methods: Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status. Results: 186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from “severe” to “not severe” than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference −149.11 μg, 95% CI −283.87 to −14.36; p = 0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting β agonist (OR 3.80, 95% CI 1.40 to 10.32; p = 0.01) and improved scores on risk of non-adherence (difference −0.44, 95% CI −0.69 to −0.18; p = 0.04), quality of life (difference −0.23, 95% CI −0.46 to 0.00; p = 0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference −1.39, 95% CI −2.44 to −0.35; p<0.01). No significant change in spirometric measures occurred in either group. Conclusions: A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.

Stroke: an exploration of the experience of informal caregiving:

Objective: To explore the experience of caregiving in informal carers of stroke patients. Design: The research approach was qualitative. Data were collected one year after the stroke occurred using a semi-structured interview. The audio-taped interviews were transcribed and following this process were analysed thematically using constant comparative procedures. Setting: West of Scotland. Subjects: Twenty-two informal carers of stroke patients. Results: The results are presented under the headings: Preparation for discharge/feelings about discharge; The early weeks/months at home; A year of caring; and The future. The main themes identified within these broad areas were as follows: physical preparation; emotional support; the supply of information and advice; and the provision of appropriate services (both social and health service provision). Conclusions: The data gathered in this small-scale study suggest that the physical and emotional toll associated with caregiving was great. Unfortunately, the help and support provided by the health and social services was often inadequate, inappropriate and poorly tailored to their individual needs. There was little evidence of a seamless flow of care between the secondary and primary care settings.

Assessment of changes in general health status using the short-form 36 questionnaire 1 year following coronary artery bypass grafting

OBJECTIVE The problem addressed in the study was to gain a greater understanding of the health benefits of coronary artery bypass grafting (CABG). The purpose of the study was to assess general health status, using the short-form (SF)-36 questionnaire, approximately 12 months following CABG, and to document any associations between pre-operative health status, level of social support, coronary artery disease (CAD) risk factors, CAD symptom severity and post-operative health status. METHODS The study was prospective and observational in design and included assessments at two time points, namely pre-operatively in a hospital outpatient department (1995-1996) and post-operatively at home (1996-1997). Two hundred and fourteen patients awaiting elective CABG were recruited a month before the expected date of operation. Pre-operative assessment included: (1), severity of symptoms; (2), CAD risk factors; (3), SF-36 questionnaire; and (4), social activities questionnaire. Post-operative assessment measured health status using the SF-36 instrument (mean, 16.4 months). Correlation and multiple linear regression analyses were used to identify factors associated with improved health status following CABG. RESULTS Two hundred and fourteen patients were assessed pre-operatively and underwent CABG. There was a 4.8% 30-day mortality rate, and 183 patients were followed for a mean of 16.4 months after CABG. SF-36 scores following CABG were improved across all of the eight domains (P<0.001). A higher social network score and higher pre-operative health status were associated with improved health status. Patients with lower health levels (SF-36 scores) prior to CABG were less likely to gain improvement in health (SF-36 scores) following CABG. Lower SF-36 scores following operation were influenced by the presence of diabetes mellitus, cigarette smoking, younger age, a high socio-economic deprivation category and higher alcohol intake. Many patients had uncorrected CAD risk factors at pre-operative assessment. CONCLUSIONS The SF-36 instrument was shown to be a useful and sensitive tool to assess differences and changes in the general health status of patients before and following CABG. High levels of social support were associated with improved health status post-operatively. Lower pre-operative general health status, the presence of diabetes mellitus and cigarette smoking were associated with poorer post-operative general health status.

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.

Personal benefit, or benefiting others? Deciding whether to take part in clinical trials.

Background Participation in clinical trials is critical for the success of evidence-based healthcare. Much previous research suggests that people take part in clinical trials mostly for altruistic reasons, and that deriving personal benefit is a secondary consideration. Purpose To investigate patients’ reasons for deciding whether to take part in clinical trials and the extent to which personal benefit may be a motivating factor. Methods A qualitative study utilizing in-depth semi-structured interviews. Participants were 42 men and women who had been asked to participate in clinical trials testing a range of interventions in different conditions, including some who did not participate or withdrew. Trials were based in either primary or secondary care. Interviews were conducted at home. Results Reasons for taking part were complex and a wide variety of personal considerations were evident. Gaining some personal benefit emerged as an important primary motivation in this group of respondents, whereas altruistic considerations appeared to be largely subsidiary. People who decided not to take part were also mainly concerned about the balance of personal risk and benefit. Limitations Public dissemination of the results may have influenced participants’ responses. Conclusions Achieving target sample sizes for clinical trials may be enhanced by an understanding of what is likely to motivate patients to take part. In this study, respondents identified a range of attractive benefits, such as care in a specialist team with expert staff, active engagement in their health monitoring or care, more frequent or intensive monitoring, and information about the latest research into their condition.

Postoperative pain assessment and management in adolescents

A 3-year study investigated the experience and management of postoperative pain following elective surgery in an adolescent sample, using a variety of valid, reliable instruments and semi-structured interviews. In addition to the adolescent subjects, the views of one parent of each adolescent were sought and a sample of health professionals comprising surgeons, anaesthetists and nurses were interviewed about acute pain in adolescent patients. This paper presents some of the main findings pertaining to pain assessment and management. Pain, experienced by most adolescents on the 1st and 3rd postoperative days, was influenced by the presence of anxiety and depression, in addition to the maturational stage; differences between in-patients and day cases are highlighted. Recommendations for practice include the need for more effective pain management and raising awareness of the importance of both psychological state and adjustment to adolescence in this age-group.

Impact and influences on caregiver outcomes at one year post-stroke

Background and Purpose: Four outcome measures of carer stress and coping at one year post-stroke were identified: carer general health, anxiety, depression and perception of stress. Methods: Each outcome was assessed using valid and reliable instruments. In addition, we collected demographic data from both carers and patients which could reasonably be expected to influence carer stress and coping (e.g. age, deprivation levels) as well as information specific to the caring role. Results: Carers were found to be more anxious than previously reported. Neither satisfaction with caring nor the adoption of helpful coping strategies were associated with positive carer outcomes but, nevertheless, carers were not reluctant to care. The SF-36 is a useful predictor of carer stress, in particular the vitality score. Conclusions: Patient data are not sufficient to predict carer general health at one year. At one year, both patients and carers are more anxious than depressed. And there may be a group of patients and carers who can be characterised as borderline anxious and/or depressed and who warrant specific attention to prevent carer burnout.

Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma.

Background:  Asthma guidelines advise addressing adherence at every visit, but no simple tools exist to assist clinicians in identifying key adherence‐related beliefs or behaviours for individual patients.

Experience of cardiac rehabilitation after coronary artery surgery: effects on health and risk factors

OBJECTIVE Cardiac rehabilitation (CR) programs are provided to support the recovery process following acute myocardial infarction and coronary artery bypass grafting (CABG). Attendance varies. We related attendance following CABG to severity of cardiac symptoms, general health status (Short Form-36) and prevalence of modifiable coronary artery disease (CAD) risk factors. METHODS 209 patients due to undergo CABG were recruited and assessed preoperatively as well as at a mean of 16.4 months postoperatively. General health status was measured using the Short Form-36 questionnaire. Severity of cardiac symptoms was assessed on a visual analogue scale. Modifiable coronary artery disease risk factors (smoking, body mass index, hypertension and elevated cholesterol) and social deprivation index were noted. RESULTS There were ten early and three late deaths. Thirteen patients withdrew consent for investigation, therefore 183 were fully studied. Of these 65.0% completed a CR programme and 24.6% did not attend any programme; 10.4% partially completed (less than 50% of time) and were excluded from analysis. Nonattenders were more likely to be smokers (P=0.002), diabetic (P=0.028) and were more from socially deprived geographical areas (P=0.013), but the proportion of patients with BMI>25, BP>140/90 or cholesterol >5.0 mmol l(-1) were the same. There were no differences in age, preoperative NYHA score, number of grafts, angina recurrence (46 vs. 38%, P=0.35) or breathlessness (62 vs. 69%, P=0.40) between attenders and nonattenders. The severity scores of angina (2.7 vs. 3.2, P=0.286) and breathlessness (3.5 vs. 3.6; P=0.79) were no different. However, four of the eight health domains measured showed significantly better values for attenders than nonattenders; namely: general health (60 vs. 46%, P=0.001), physical function (64 vs. 51% P=0.01), role limitation physical (48 vs. 29%; P=0.02) and social function 74 vs. 62%, P=0.04). CONCLUSIONS This is the first report using SF 36 to evaluate benefits from attending CR. Higher general health scores (SF-36) were associated with attendance at CR although CAD risk factors and cardiac symptoms were not improved but this may be due to the long interval between assessments.

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.