Asthma
Asthma is a chronic respiratory disorder that is characterized by airway inflammation resulting in reversible airflow obstruction.1The onset of asthma is early in life for most patients. Up to 35% of the children worldwide suffer from asthma, whereas the prevalence of childhood asthma in Europe lies around 10%. Economic burden of asthma is expected to be the highest among chronic diseases. Currently, 300 million people suffer from asthma and its prevalence rises by 50% every decade.2,3
Medication use
Pharmacotherapy has a major role in the management of asthma. It includes the use of controller medication such as inhaled corticosteroids (ICS) and mast cell stabilizers for controlling airway inflammation and reliever medication such as β2-agonists and anticholinergics to manage symptoms.4,5 However, despite the high quality of available medicines and its regimen that is being simplified on a regular basis, asthma is still not sufficiently controlled in many patients.6 The major issue in the pharmacotherapy of asthma is the inappropriate use of asthma medication, including incorrect inhaler technique, overuse of short-acting medication, and low compliance to the long-term controller medication.7-9
Pharmaceutical care in asthma
Over the last decades, the role of pharmacist has expanded moving from solely compounding and dispensing medication to include provision of patient-centered, outcomes-oriented pharmaceutical care.10 It requires pharmacists to cooperate with patients and other health care providers to assess, monitor, and modify medication use to assure that pharmacotherapy is effective and safe. Community pharmacists have a potential role to manage medication use-related problems in chronic diseases with their expertise and frequent contact with patients during prescription refills.10 However, it has been recognized that the expertise and skills of community pharmacists are frequently under-utilized.11,12
Therefore, it is important to identify recent strategies of community pharmacy-based asthma care. For the future uptake and long-term sustainability of the service, it is also important to gain an understanding about patient preferences on this service. With this insight, pharmaceutical care programs can be designed to match these preferences, rather than around health outcomes viewpoints alone. Several systematic reviews have studied pharmaceutical asthma services.
A literature search was conducted by a student of Utrecht University to identify studies that assessed the effectiveness of community pharmacists asthma care and studies that assessed patient preferences on these programs. The primary search was conducted in three databases (Pubmed, Embase and International Pharmaceutical Abstracts) which included studies published between 2006 and 2015. In total, 25 studies were included in this review, of them, 18 studies assessed the effectiveness of community pharmacist asthma care and seven studies assessed patient preferences on such program.
Patient education and counseling
Seven included assessed the effectiveness of community pharmacists care using standard strategies, in which usual patient education and counseling were performed.13-19 In general, the studies showed that these services improved various clinical outcomes, such as asthma severity, the forced expiratory volume (FEV1), inhaler technique, adherence to medication, use of β2 agonists,and humanistic outcomes, such as quality of life, asthma knowledge, perceived asthma control, and nighttime awakening. The strategies are summarized in table 1.
Community pharmacy asthma service using innovative pharmaceutical care
Eleven studies assessed effectiveness of community pharmacists care using innovative strategies.20-30 These strategies are relatively new, or specific for certain population, or useful to address the challenge in integrating pharmacist care into normal community pharmacy workflow. The innovative strategies included the provision of rural asthma management service, daily SMS reminder, telephone consultation, mailed intervention, labeling of inhaler procedure in inhalation device, providing interactive visual inhalation measurement feedback during inhalation counseling, giving devices-like tool that can give audio warning to correct patient’s inhaler technique, screening of dispensing database to optimize the impact of the service and small group discussion approach.
In general, these strategies are beneficial to improve patient outcomes. In clinical perspective, these strategies were shown to have impact on asthma severity score, inhaler technique, improvement in preventer:reliever (P:R) ratio, the use of oral high dose corticosteroid, and drug-related problems. These services could also beneficially influenced humanistic outcomes such as perceived control of asthma, asthma knowledge, and quality of life. Cost saving and incremental cost effectiveness ratio were also improved with the implementation of these strategies. The strategies are summarized in table 2.
Patient preferences
Studies show that patients in general appreciate asthma pharmacy service. However, some groups of patients are still unaware of additional pharmaceutical care that community pharmacists can provide.31 In providing pharmacists asthma care, studies underlined the importance of (1) protecting patients’ privacy by conducting the intervention in separate area other than the pharmacy counter, (2) maintaining positive attitude towards patients, e.g. caring, friendly, and empathy, (3) providing services needed by patients, including assessment of medication use, action plan, and lung testing.31-37
References
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2. Ismaila AS, Sayani AP, Marin M, Su Z. Clinical, economic, and humanistic burden of asthma in Canada: a systematic review. BMC Pulm Med. 2013;13:70. doi:10.1186/1471-2466-13-70.
3. Moin M. Asthma Control Challenges : Global and National Perspectives. 2013;4(3):127-128. doi:10.17795/compreped-.
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5. Choby GW, Lee S. Pharmacotherapy for the treatment of asthma: current treatmet options and future directions. Int Foumr Allergy Rhinol. 2015;5(1):35-340.
6. Barnes P, Virchow JC, Sanchis J, Welte T, Pedersen S. Asthma management: important issues. Eur Respir Rev. 2005;14(97):147-151. doi:10.1183/09059180.05.00009704.
7. Aljahdali H, Ahmed A, Alharbi A, Khan M, Baharoon S, Salih S. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy Asthma Clin Imunol. 2013;9(8):1-7.
8. Cockcroft DW. Clinical concerns with inhaled β2-Agonist: Adult Asthma Clin RevAllergy Immunol. 2006;31:197-207.
9. Gaude G. Poor compliance to inhaler therapy in bronchial asthma patients:A prospective study in general population. Sci J Clin Med. 2014;3(1):4. doi:10.11648/j.sjcm.20140301.12.
10. Hepler CD. Clinical pharmacy, pharmaceutical care, and the quality of drug therapy. Pharmacotherapy. 2004;24(11):1492-1498.
11. Armour CL, Hons BP. Using the community pharmacy to identify patients at risk of poor asthma control and factors which contribute to this poor control using the community pharmacy to identify patients at risk of poor asthma control and factors which contribute to this. J Asthma. 2016;48(9):914-922. doi:10.3109/02770903.2011.615431.
12. Swieczkowski D, Poniatowski P, Merks P, Jaguszewski M. The pharmaceutical care in asthma: Polish and global perspective. Pneumonol Alergol Pol. 2016;84(4):225-231. doi:10.5603/PiAP.2016.0028.
13. Garcı V, Kenny P, Martı F, Benrimoj SI. Effect of a pharmacist intervention on asthma control . A cluster randomised trial. Respir Med. 2013;107:1346-1355. doi:10.1016/j.rmed.2013.05.014.
14. S MS, K AJAJ, Sundaran S. Study on The Impact of Patient Counseling on the Quality of Life and Pulmonary Function of Ashmatic Patients. Int J Pharm Pharm Sci. 2012;4(5):300-304.
15. Hammerlein A. Pharmacist-led intervention study to improve inhalation technique in asthma and COPD patients. J Eval Clin Pract. 2011;17:61-70. doi:10.1111/j.1365-2753.2010.01369.x.
16. Janson SL, Mcgrath W, Covington JK, Cheng S, Boushey HA, Francisco S. Individualized asthma self-management improves medication adherence and markers of asthma control. J Allergy Clin Immunol. 2009;123(4):840-846. doi:10.1016/j.jaci.2009.01.053.
17. Mehuys E, Bortel L. Effectiveness of pharmacist intervention for asthma control improvement. Eur Respir J. 2008;31(4):790-799. doi:10.1183/09031936.00112007.
18. Bosnic-anticevich S, Mitchell B, Saini B, Krass I, Armour C. Treating asthma with a self-management model of illness behaviour in an Australian community pharmacy setting. Soc Sci Med. 2007;64:1501-1511. doi:10.1016/j.socscimed.2006.11.006.
19. Armour C, Bosnic-anticevich S, Brillant M. Pharmacy asthma care programs improves outcomes for patients in the community. Thorax BMJ. 2007;62:496-503. doi:10.1136/thx.2006.064709.
20. Ottenbros S, Teichert M, Groot R De, Griens F. Pharmacist-led intervention study to improve drug therapy in asthma and COPD patients. Int J CLin Pharm. 2014;36:336-344. doi:10.1007/s11096-013-9887-4.
21. Toumas-shehata M, Price D, Basheti IA, Bosnic-anticevich S. Exploring the role of quantitative feedback in inhaler technique education : a cluster-randomised, two-arm, parallel-group, repeated-measures study. Prim Care Respir Med. 2014;(July):2-7. doi:10.1038/npjpcrm.2014.71.
22. Ammari WG. Optimizing the inhalation flow and technique through metered dose inhalers of asthmatic adults and children attending a community pharmacy (technique through metered dose optimizing the inhalation flow and inhalers of asthmatic adults and children attending a community pharmacy. J Asthma. 2013;50(5):505-513. doi:10.3109/02770903.2013.783064.
23. Yanhua L. Zhao H, Lian Z, Dong H, Liu L, Zhang D, Cai S. A Mobile Phone Short Message Service Improves Perceived Control of Asthma: A Randomized Controlled Trial. Telemed e-health. 2011:420-426. doi:10.1089/tmj.2011.0218.
24. Young HN, Havan , Griesbach S, Torpe JM. Patient And phaRmacist Telephonic Encounters (PARTE) in an underserved rural patient population with asthma: results of a pilot study. Telemed e-health. 2012;18(6):427-433. doi:10.1089/tmj.2011.0194.
25. Bereznicki BJ, Peterson G, Jackson S, Walters EH. Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management. J Clin Pharm Ther.2013:212-218. doi:10.1111/jcpt.12017.
26. Nelson P, Young HN, Knobloch MJ, Griesbach SA. Telephonic Monitoring and Optimization of Inhaler Technique. Telemed e-health. 2011;(1):734-740. doi:10.1089/tmj.2011.0047.
27. Saini B, Filipovska J, Bosnic-anticevich S, Taylor S, Krass I, Armour C. An evaluation of a community pharmacy-based rural asthma management service. Aust J Rural Heal. 2008;16:100-108. doi:10.1111/j.1440-1584.2008.00975.x.
28. Basheti IA, Armour CL, Bosnic-anticevich S, Reddel HK. Evaluation of a novel educational strategy , including inhaler-based reminder labels , to improve asthma inhaler technique. Patient Educ Couns. 2008;72:26-33. doi:10.1016/j.pec.2008.01.014.
29. Elliott RA, Barber N, Clifford S, Horne R, Hartley E. The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newly prescribed medicines. Pharm World Sci. 2008;30:17-23. doi:10.1007/s11096-007-9134-y.
30. Kritikos V, Armour CL, Bosnic-anticevich S. Interactive small-group asthma education in the community pharmacy setting: a pilot study J Asthma. 2007. 44(1):57-64. doi:10.1080/02770900601125755.
31. Kaae S, Ka S. Patients’ reasons for accepting a free community pharmacy asthma service. Int J CLin Pharm. 2015;37(5):917-924. doi:10.1007/s11096-015-0142-z.
32. Naik-panvelkar P, Saini B, Lemay KS, Emmerton LM, Stewart K. A pharmacy asthma service achieves a change in patient responses from increased awareness to taking responsibility. Int J Pharm Pract. 2015:182-191. doi:10.1111/ijpp.12134.
33. Kong ML, Armour C, Lemay K.. Information needs of people with asthma. Int J Pharm Pract. 2014:22(3)178-185. doi:10.1111/ijpp.12057.
34. Naik-panvelkar P, Armour C, Rose J, Saini B. Patient preferences for community pharmacy asthma services a discrete choice experiment. Pharmacoecnomics. 2012;30(10):961-976.
35. Bereznicki B. Perceived feasibility of a community pharmacy-based asthma intervention: a qualitative follow-up study. J Clin Pharm Ther. 2011;36:348-355. doi:10.1111/j.1365-2710.2010.01187.x.
36. Naik-panvelkar P, Armour C, Saini B. Community pharmacy-based asthma services-what do patients prefer? J Asthma. 2010:47(10):1085-1093.
37. Portlock J, Holden M, Patel S. A community pharmacy asthma MUR project in Hampshire and the Isle of Wight. Pharmaceutical J. 2009;282(January):109-112.
Table 1. Summary of the result of community pharmacists asthma care using standard strategies
|
No.
|
General characteristics (Author/ Year of publication/ Location/
Study Design/ Duration/ Sample Size)
|
Strategies
|
Outcomes Measured
|
|
1.
|
Cardenaz/ 2013/ Spain/ randomized controlled trial (RCT)/ 6 months/ 373 patients (208 were in the intervention group (IG) and 165 were in the control group (CG)).13
|
3 counseling visits were scheduled during 6 months of intervention. At each visit, personal counseling regarding knowledge about asthma, review of patient adherence, goal setting, and inhaler technique was provided. In inhaler technique education, patients were given verbal instruction, physical demonstration, and written information about turbuhaler use.
|
Proportion of patients with correct inhaler technique was significantly higher in IG vs CG (P<.001)
In the IG, final reduction of asthma perceived control score was statistically significant compared to CG (P<.001)
|
|
2.
|
Saji/ 2012/ India/ RCT / 3 months/ 53 patients (28 were in IG and 25 were in CG).14
|
Single counseling visit was conducted during 3 months of intervention. The counseling topic covered inhaler technique, self-management of asthma, time the drugs should be administered, and about the dose and dosage form. Supportive materials used, including; patient information leaflet, dummy inhalers, and visual presentations of inhalation technique
|
FEV1 was significantly improved between baseline and last visit result in IG (P<.05) No significant difference found between those of CG.
Quality of life was significantly improved in IG (P<.05). No significant difference found in CG.
|
|
3.
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Hammerlein/ 2010/ Germany/ prospective multicenter intervention study/ / 4-6 weeks/ 597 patients (all in IG).15
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2 counseling visits were scheduled during 4-6 weeks of intervention. Counseling focus on the education and assessment of inhaler technique. Interactive counseling was performed, giving the chance for patients to demonstrate their inhalation technique to pharmacists. Written inhalation procedures were provided.
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The percentage of patients with incorrect inhalation technique was significantly decreased by 50.6% (<.001).
|
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4.
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Janson/ 2009/ USA/ RCT/ 6 months/ 84 patients (45 were in IG and 39 were in CG).16
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3 counseling visits were scheduled during 6 months of intervention. The counseling consisted of education of asthma and inhalation technique, spirometric testing and allergic skin testing.
|
Adherence to medication was significantly higher in IG vs CG. (P=.02).
Inhaled β2 agonist used significantly decreased in IG vs CG (P=.01).
Perceived asthma control and nighttime awakenings was significantly improved in IG vs CG (P=.006) and (P=.01).
|
|
5.
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Mehuys/ 2008/ Belgium/ RCT/ 6 months/ 201 patients (107 were in IG vc 94 were in CG) 17
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3-5 visits were scheduled during 3 months follow up. The topic of counseling included the correct use of inhaler device, the management of asthma (symptoms, triggers, early warning), asthma medication and the purpose of the compliance to medication.
At 1-month and 3-month, pharmacists evaluated the asthma control based on Asthma Control Test (ACT) scores. If ACT score <15: immediate referral to general practitioner (GP) was performed. If ACT score 15-19: inhalation technique and adherence were checked. If ACT score ≥20: no advice needed.
|
Inhalation technique was significantly higher in IG vs CG. (P=.004).
Adherence to controller medication was significantly higher in IG vs CG (P=.01)
No significant difference found in the quality of life of patients in IG vs CG.
Mean perceived asthma control scores did not change from baseline in both groups.
|
|
6.
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Smith/ 2007/ Australia/ controlled parallel group study/ 9 months/ 91 patients (35 were in IG and 56 were in CG).18
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6 counseling visits were undertaken by patients in IG during 9 months of intervention. In counseling sessions, patients were helped to identify areas of asthma control that are problematic and set the goals to resolve the issues. The most common goals were related to the adherence to medication, avoiding asthma triggers, lifestyle, and exercise tolerance. The process was supported by the provision of a workbook containing information about medical use, goals, strategies, and progress.
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There was significant improvement over time in perceived asthma control in both groups, but significant time x group interaction effect was not observed.
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7.
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Armour/ 2007/ Australia/ multi-site randomised intervention versus
control repeated measures design/ 6 months/ 351 patients (165 were in IG and 186 were in CG) 19
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50 pharmacies were randomized into two groups: intervention pharmacies implemented Pharmacy Asthma Care Program (PACP) and control pharmacies.
Interventions were performed 2-3 times during 6 months. PACP included assessment of medication use (inhaler technique, adherence, detection of drug-related problem), education on lifestyle issues, goal setting, and referral to GP if necessary.
|
The proportion of patients in IG which had severe asthma decreased significantly (P<.001), while in CG remain unchanged (P=.11).
Quality of life, asthma knowledge, and perceived asthma control were significantly improved in IG vs CG (P=.05 ; P<.01 ; P<.01, respectively)
|
Table 2. Summary of the result of community pharmacists asthma care using innovative strategies
|
No.
|
General characteristics (Author/ Year of publication/ Location/
Study Design/ Duration/ Sample Size)
|
Strategies
|
Outcomes Measured
|
|
1.
|
Ottenbros/2014/ The Netherlands/ prospective cohort study/ 9 months/ 14.314 patients (3757 were in IG and 105.507 were in CG). 20
|
Screening of dispensing data was performed by pharmacists to identify asthma patients with suboptimal pharmacotherapy.
19 medication use-related problems were used as filters in the screening process, which were classified in 5 main categories, i.e. overuse of a short acting beta agonist, suboptimal controller therapy, suboptimal co-medication, inappropriate inhaler technique, and poor adherence.
Patients with suboptimal drug use patterns, then were selected to participate in pharmacy asthma service, which included evaluation and education about inhaler technique, patient adherence, and suitability of devices.
|
The asthma medication problems were decreased in the IG vs CG, in the following issues: the use of obsolete medication (acetylcyteine, cromoglicic acid or nedocromil), by 35%, contra-indicated medication by 61% and inappropriate use of powder inhalers in elderly by 29% patients.
|
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2.
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Toumas-Shehata/ 2014/ Australia/ cluster-RCT
repeated-measures design / 1 month/ 101 patients (50 were in group 1 and 51 were in group 2).
CG only received verbal and physical demonstration regarding inhalation technique, IG received additional interactive visual inhalation measurement feedback.21
|
In addition with verbal and physical demonstration on inhaler technique, pharmacists provided interactive visual inhalation measurement feedback using inhalation manager tool.
With this tool, patients could visualize what errors they made and how to correct their breathing to achieve proper inhalation technique. Feedback was repeated until patients were able to demonstrate correct inhalation technique.
|
The magnitude of improvement in inhalation technique was significantly higher in IG vs CG (P=.02).
|
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3.
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Ammari/ 2013/ UK/ RCT/ 6 weeks/ 34 patients (15 were in training aid group, 14 were in verbal counseling group, and 5 were in CG).22
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Pharmacists provided inhaler technique education with a training aid, i.e. device-like tool that could give audio warning depending on inhalation technique of patients.
Trial investigators compared this intervention with verbal counseling group and control group (without counseling).
|
Inhalation flow rates were improved in training aid group and verbal conseling group compared to CG (P<.001).
Mean diferences in quality of life score was significant in counseling group, while the improvement in training aid group was higher than in CG.
|
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4.
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Yanhua/ 2012/ China/ RCT/ 12 weeks/ 71 patients (14 patients were in CG, 27 were in standard counseling group, 30 were in SMS group).23
|
In addition to standard counseling, pharmacists sent SMS daily reminder to patients’ mobile phone regarding medication use and asthma management twice a day at 10.00 am and 8.00 pm, for 12 weeks. If patients had any questions related to medication problem, they could send the SMS to trial investigators.
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- Ø Humanistic outcomes: Patients perceived control of asthma and patients quality of life were significantly increased in SMS group and standard counseling group compared to CG (P<.001).
The improvement in quality of life was higher in SMS group vs standard counseling group (P=.018).
|
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5.
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Young/ 2012/ USA/ RCT/ 3 months/ 98 patients (49 were in IG and 49 were in CG).24
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Pharmacist-patients telephone consultations were performed 3 times during 3 months of intervention. Trained pharmacists identified and resolved patient’s barrier in managing their asthma medication use. Patients also received education about self-management in asthma. If necessary, patients were referred to GP.
|
Patient adherence was significantly improved in IG vs CG (P<.01).
- Ø Humanistic outcome: Perceived asthma control score was significantly improved in IG vs CG (P<.05).
|
|
6.
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Bereznicki/ 2011 / Australia/ RCT/ 12 months / 1483 patients (510 mailed intervention, 480 face-to -face intervention, 493 CG). 25
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Combination of patients screening using dispensing data and mailed intervention.
Sccreening of dispensing data was performed to identify patients who received 6 or more canisters of short acting β2-agonists in the last 12 months (reflected poor astma control). The screening was conducted in several pharmacies.
Subsequently, each pharmacy performed only 1 intervention. In mailed intervention, pharmacists sent following items: asthma educational brochure regarding asthma medication, management, and first aid for acute exacerbation; a personalized letter to patients, encouraging them to visit their GP (due to poor asthma control) and an information letter to hand in to GP for asthma medication review.
In face-to-face intervention, included participants who visit pharmacy during study period received direct counseling from pharmacists regarding medication use.
|
Significant improvements in the P:R ratio were observed in mailed intervention and face-to-face intervetion, compared to CG.
|
|
7.
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Nelson/2011/ USA/ prospective study/ 30 patients (all in IG).26
|
Trial investigators assessed the method for assessing and correcting patient inhaler technique via telephone consultation.
Pharmacists gave education about inhaler technique via telephone consultation and assessed patient’s inhaler technique by evaluating the procedures mentioned by patients. Patients responses were video-recorded and assessed by other pharmacists to check the inhaler technique, visually.
Patients were assessed before and after education based on telephone and video assessment.
|
A higher percentage of patients demonstrated correct inhaler technique after the education, compared to initial assessment (P<.05).
|
|
8.
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Saini/ 2008/ Australia/ Parallel group controlled- repeated measures study/ 6 months/ 90 patients (51 were in IG vs 39 were in CG) 27
|
The Rural Asthma Management Service (RAMS Model) included: the provision of pharmacists training which focus on asthma local issues; initiating involvement and support with local GP, and promoting patient awareness of pharmacy-based care through community health education.
The pharmacists care included: needs analysis based on asthma severity and medication use; goal setting using chart goals; assessment and monitoring, e.g. by conducting spirometry; and proceedings documentation.
|
Asthma severity score was significantly improved in IG vs CG (P<.001).
Confidence of managing asthma attack and patients perceived control of asthma were significantly improved in IG vs CG. (P<.05). Asthma-related quality of life was not significantly different between IG and CG.
|
|
9.
|
Basheti/ 2008/ Australia/ RCT/ 6 months/ 97 patients (53 were in IG and 44 were in CG).28
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Personalized novel inhaler technique labels interventions were perfomed in the IG. In addition to the counseling and assessment of inhaler technique, a label of personalized procedures of inhalation technique was attached to the inhalation device (not in the box) as a daily reminder for patients to follow the procedures correctly.
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- Ø Clinical outcome: Improvement in inhaler technique was significantly higher in IG vs CG (P<.001).
|
|
10.
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Elliott/ 2008/ UK/ RCT/ 2 months/ 205 patients (118 were in IG and 87 were in CG).29
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The telephone call consultations were conducted based on patient-centered approach. The self-regulatory model (SRM) framework was used to guide the consultation since patients adherence might be influenced by patients’ belief about their illness. Pharmacists followed the flow of patient’s conversation, identified the problems in medication use, and gave advices in response to patients’ expressed needs. Patients received one telephone call consultation in a month.
|
Non-adherence was significantly lower in the IG vs CG (P<.05).
The mean incremental cost effectiveness ratio was -£2168 per extra adherent patient.
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11.
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Kritikos/ 2007/ Australia/ parallel group repeated measures design/ 12 weeks/ 125 patients (31 were in IG 1, 38 were in IG 2, 56 were in CG).30
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The education was delivered in small group discussion, approximately 5-8 patients. (IG 1). As comparison, single standard education (IG 2) was also included, beside CG. Both education covered asthma management, asthma medication and inhaler technique. Interventions were performed 3-4 times during 12 weeks of intervention.
|
Proportion of patients with severe asthma was significantly decreased in IG 1 and IG 2 compared to CG (P<.05).
The proportion of patients with optimal inhaler technique was significa
ntly higher in IG 1 and IG 2 compared to CG (P<.001)
Asthma knowledge scores was significantly improved in IG 1 and IG 2 compared to CG over time
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