Sinthia Bosnic-Anticevich

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.

Inhaler competence in asthma: Common errors, barriers to use and recommended solutions

Whilst the inhaled route is the first line administration method in the management of asthma, it is well documented that patients can have problems adopting the correct inhaler technique and thus receiving adequate medication. This applies equally to metered dose inhalers and dry powder inhalers and leads to poor disease control and increased healthcare costs. Reviews have highlighted these problems and the recent European Consensus Statement developed a call to action to seek solutions. This review takes forward the challenge of inhaler competence by highlighting the issues and suggesting potential solutions to these problems. The opportunity for technological innovation and educational interventions to reduce errors is highlighted, as well as the specific challenges faced by children. This review is intended as a policy document, as most issues faced by patients have not changed for half a century, and this situation should not be allowed to continue any longer. Future direction with respect to research, policy needs and practice, together with education requirements in inhaler technique are described.

Complementary and alternative medicine use in asthma: Who is using what?

Abstract:  Consumer interest in complementary and alternative medicine (CAM) has grown dramatically in Western countries in the past decade. However, very few patients volunteer information about CAM use unless directly questioned by their health‐care practitioner. Therefore, by being informed about the prevalence and modality of CAM use for asthma, as well as characteristics of users, health‐care practitioners may be better able to identify patients who use CAM. In turn, this may facilitate proactive discussion and optimization of the patient’s overall asthma management. This review aims to summarize the current knowledge about use of CAM by people with asthma, and to assess the applicability of the available studies to the broader asthmatic population. Computerized literature searches were conducted on Medline, Embase, Cochrane and Allied and Complementary Medicine (AMED) databases from their inception to 13 April 2005. Search terms included: complementary medicine/therapies, alternative medicine/therapies and asthma. The bibliographies of accessible articles were searched for further papers. Seventeen studies have examined the use of CAM by people with asthma. The reported level of use for adults ranged from 4% to 79%, and for children from 33% to 89%. Among the most commonly used CAMs were: breathing techniques, herbal products, homeopathy and acupuncture. There is no strong evidence for effectiveness for any of these modalities. There is little consistency among available prevalence studies making conclusions difficult. Nevertheless, the high rates of CAM use reported in some studies indicate that CAM use should be taken into account when managing patients with asthma.

Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique

OBJECTIVE To evaluate the feasibility, acceptability and effectiveness of a brief intervention about inhaler technique, delivered by community pharmacists to asthma patients. METHODS Thirty-one pharmacists received brief workshop education (Active: n=16, CONTROL: n=15). Active Group pharmacists were trained to assess and teach dry powder inhaler technique, using patient-centered educational tools including novel Inhaler Technique Labels. Interventions were delivered to patients at four visits over 6 months. RESULTS At baseline, patients (Active: 53, CONTROL: 44) demonstrated poor inhaler technique (mean+/-S.D. score out of 9, 5.7+/-1.6). At 6 months, improvement in inhaler technique score was significantly greater in Active cf. CONTROL patients (2.8+/-1.6 cf. 0.9+/-1.4, p<0.001), and asthma severity was significantly improved (p=0.015). Qualitative responses from patients and pharmacists indicated a high level of satisfaction with the intervention and educational tools, both for their effectiveness and for their impact on the patient-pharmacist relationship. CONCLUSION A simple feasible intervention in community pharmacies, incorporating daily reminders via Inhaler Technique Labels on inhalers, can lead to improvement in inhaler technique and asthma outcomes. PRACTICE IMPLICATIONS Brief training modules and simple educational tools, such as Inhaler Technique Labels, can provide a low-cost and sustainable way of changing patient behavior in asthma, using community pharmacists as educators.

Metered-Dose Inhaler Technique: The Effect of Two Educational Interventions Delivered in Community Pharmacy Over Time

Instruction is critical in order to ensure correct technique with pressurized metered-dose inhalers (pMDIs) by patients. The aim of this study was to compare the effects over time of two educational interventions delivered in community pharmacy to pMDI users. In this randomized controlled parallel-group study, pMDI technique was assessed before and after written and verbal instruction, alone or with physical demonstration, at baseline and 4, 8, and 16 weeks. The study recruited 52 subjects with asthma or chronic obstructive pulmonary disease (COPD). Initially only 1/52 (6%) subject had correct pMDI technique (= checklist score 8/8), with mean baseline score 5 (SD 1) for both groups. Written and verbal information improved pMDI technique at 16 weeks (7 ± 1, p < .05). Addition of physical demonstration resulted in significant improvement at weeks 4, 8, and 16 (7 ± 1, 7 ± 1, 7 ± 1 respectively; p < .05 for each). Subjects receiving written and verbal information alone were less likely to return for follow-up than those receiving physical demonstration (8 weeks: 6/25 versus 19/27; p < .001). By the 8-week visit, 80% subjects in the physical demonstration group had correct technique prior to education, compared with 10% of subjects receiving written and verbal information alone (p < .05). There was some decline in inhaler technique by 16 weeks. The results demonstrate that adding a physical demonstration is more effective in improving pMDI technique than written and verbal instructions alone.

Double blind randomised controlled trial of two different breathing techniques in the management of asthma

Background: Previous studies have shown that breathing techniques reduce short acting β2 agonist use and improve quality of life (QoL) in asthma. The primary aim of this double blind study was to compare the effects of breathing exercises focusing on shallow nasal breathing with those of non-specific upper body exercises on asthma symptoms, QoL, other measures of disease control, and inhaled corticosteroid (ICS) dose. This study also assessed the effect of peak flow monitoring on outcomes in patients using breathing techniques. Methods: After a 2 week run in period, 57 subjects were randomised to one of two breathing techniques learned from instructional videos. During the following 30 weeks subjects practised their exercises twice daily and as needed for relief of symptoms. After week 16, two successive ICS downtitration steps were attempted. The primary outcome variables were QoL score and daily symptom score at week 12. Results: Overall there were no clinically important differences between the groups in primary or secondary outcomes at weeks 12 or 28. The QoL score remained unchanged (0.7 at baseline v 0.5 at week 28, p = 0.11 both groups combined), as did lung function and airway responsiveness. However, across both groups, reliever use decreased by 86% (p<0.0001) and ICS dose was reduced by 50% (p<0.0001; p>0.10 between groups). Peak flow monitoring did not have a detrimental effect on asthma outcomes. Conclusion: Breathing techniques may be useful in the management of patients with mild asthma symptoms who use a reliever frequently, but there is no evidence to favour shallow nasal breathing over non-specific upper body exercises.

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.

The Validity and Reliability of Two Asthma Knowledge Questionnaires

Background. This study aimed to develop and validate two asthma knowledge questionnaires, one for consumers (CQ) and one for health care professionals (HQ) to fill an existing gap in the literature. Methods. Following development and pilot testing, the revised CQ and HQ were administered to respiratory physicians, pharmacists and people with asthma and without asthma. Results. Both the CQ and HQ were shown to be reliable with Cronbachs alpha of 0.78 and 0.92 respectively. Both were also found to have good content, face, construct and discriminant validity. Conclusion. The CQ and HQ were shown to be simple, valid and reliable instruments for the assessment of asthma knowledge of consumers and health care professionals and to direct educational resources more appropriately. Future research will evaluate the utility of these instruments in clinical practice.

User error with Diskus and Turbuhaler by asthma patients and pharmacists in Jordan and Australia.

BACKGROUND: Use of inhalers requires accurate completion of multiple steps to ensure effective medication delivery. OBJECTIVE: To evaluate the most problematic steps in the use of Diskus and Turbuhaler for pharmacists and patients in Jordon and Australia. METHODS: With standardized inhaler-technique checklists, we asked community pharmacists to demonstrate the use of Diskus and Turbuhaler. We asked patients with asthma to demonstrate the inhaler (Diskus or Turbuhaler) they were currently using. RESULTS: Forty-two community pharmacists in Jordan, and 31 in Australia, participated. In Jordan, 51 asthma patients demonstrated use of Diskus, and 40 demonstrated use of Turbuhaler. In Australia, 53 asthma patients demonstrated use of Diskus, and 42 demonstrated use of Turbuhaler. RESULTS: The pharmacists in Australia had received inhaler-technique education more recently than those in Jordan (P = .03). With Diskus, few pharmacists in either country demonstrated correct technique for step 3 (exhale to residual volume) or step 4 (exhale away from the device), although there were somewhat fewer errors in Australia than Jordan (16% vs 0% in step 3, P = .007, and 20% vs 0% in step 4, P = .003 via chi-square test). With Turbuhaler there were significant differences between the pharmacists from Australia and Jordan, mainly in step 2 (hold the device upright while loading, 45% vs 2% correct, P < .001). Few of the patients had received inhaler-technique education in the previous year. The patients made errors similar to those of the pharmacists in individual steps with Diskus and Turbuhaler. The essential steps with Diskus were performed correctly more often by the Jordanian patients, and with Turbuhaler by the Australian patients. CONCLUSIONS: Despite differences in Jordans and Australias health systems, pharmacists from both Australia and Jordan had difficulty with the same Diskus and Turbuhaler steps. In both countries, the errors made by the asthma patients were similar to those made by the pharmacists.

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.