An exploration of clinical interventions provided by pharmacists within a complex asthma service.

BACKGROUND: Pharmacists in Australia are accessible health care professionals, and their provision of clinical pharmacy interventions in a range of areas has been proven to improve patient outcomes. Individual clinical pharmacy interventions in the area of asthma management have been very successful. An understanding of the nature of these interventions will inform future pharmacy services. What we do not know is when pharmacists provide a complex asthma service, what elements of that service (interventions) they choose to deliver. OBJECTIVE: To explore the scope and frequency of asthma-related clinical interventions provided by pharmacists to patients in an evidence-based complex asthma service. METHODS: Pharmacists from 4 states/territories of Australia were trained in asthma management. People with asthma had 3 or 4 visits to the pharmacy. Guided by a structured patient file, the pharmacist assessed the patient's asthma and management and provided interventions where and when considered appropriate, based on their clinical decision making skills. The interventions were recorded in a checklist in the patient file. They were then analysed descriptively and thematically. RESULTS: Pharmacists provided 22,909 clinical pharmacy interventions over the service to 570 patients (398 of whom completed the service). The most frequently delivered interventions were in the themes 'Education on asthma', 'Addressing trigger factors', 'Medications - safe and effective use' and 'Explore patient perspectives'. The patients had a high and ongoing need for interventions. Pharmacists selected interventions based on their assessment of perceived need then revisited and reinforced these interventions. CONCLUSION: Pharmacists identified a number of areas in which patients required interventions to assist with their asthma management. Many of these were perceived to require continuing reinforcement over the duration of the service. Pharmacists were able to use their clinical judgement to assess patients and provide clinical pharmacy interventions across a range of asthma management needs.

Prevalence of airflow obstruction and reduced forced vital capacity in an Aboriginal Australian population: The cross-sectional BOLD study.

BACKGROUND AND OBJECTIVE: Mortality and hospital separation data suggest a higher burden of chronic obstructive pulmonary disease (COPD) in indigenous than non-indigenous subpopulations of high-income countries. This study sought to accurately measure the true prevalence of post-bronchodilator airflow obstruction and forced vital capacity reduction in representative samples of Indigenous and non-Indigenous Australians. METHODS: This study applies cross-sectional population-based survey of Aboriginal and non-Indigenous residents of the Kimberley region of Western Australia aged 40 years or older, following the international Burden Of Lung Disease (BOLD) protocol. Quality-controlled spirometry was conducted before and after bronchodilator. COPD was defined as Global initiative for chronic Obstructive Lung Disease (GOLD) Stage 2 and above (post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1 /FVC) ratio <0.7 and FEV1 < 80% predicted). RESULTS: Complete data were available for 704 participants. The prevalence of COPD, adjusted for age, gender and body weight in Aboriginal participants (7.2%, 95% confidence interval (CI) 3.9 to 10.4) was similar to that seen in non-Indigenous Kimberley participants (8.2%, 95% CI 5.7 to 10.7) and non-Indigenous residents of the remainder of Australia (7.1%, 95% CI 6.1 to 8.0). The prevalence of low FVC (<80% predicted) was substantially higher in Aboriginal compared with non-Indigenous participants (74.0%, 95% CI 69.1 to 78.8, vs 9.7%, 95% CI 7.1 to 12.4). CONCLUSIONS: Low FVC, rather than airflow obstruction, characterizes the impact of chronic lung disease previously attributed to COPD in this population subject to significant social and economic disadvantage. Environmental risk factors other than smoking as well as developmental factors must be considered. These findings require further investigation and have implications for future prevention of chronic lung disease in similar populations.

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

OBJECTIVES: 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 patient's perceptions and experiences with a pharmacy asthma service and to investigate if there was a change over time. METHODS: Interviews and focus groups were conducted with patients participating in the asthma service at three time points. Data were transcribed verbatim and thematically analyzed using a framework approach. KEY FINDINGS: The service led to an enhanced awareness and understanding of asthma, changes in participants' beliefs and attitudes towards asthma management, changes in asthma-related health behaviours and improved self-efficacy. Participants were very positive about the service and the role of the pharmacist in asthma management. There was a shift in participant perceptions and views, from being at an abstract level in those who had completed just one visit of the service to a more experiential level in those who had experienced the entire comprehensive asthma service. CONCLUSIONS: A sustained experience/multiple visits in a service may lead to more concrete changes in patient perceptions of severity, beliefs, health behaviours and enhanced self-efficacy and control. The study highlights a need for such asthma services in the community.

Respiratory symptoms and illness in older Australians: the Burden of Obstructive Lung Disease (BOLD) study.

OBJECTIVE: To measure the prevalence of chronic obstructive pulmonary disease (COPD) among people aged 40 years or older in Australia. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional study of people in the community aged ≥ 40 years, selected at random using electoral rolls, in six sites chosen to reflect the sociodemographic and geographic diversity of Australia, conducted between 2006 and 2010. Standardised questionnaires were administered by interview. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and the FEV1/FVC ratio were measured by spirometry, before and after bronchodilator administration. MAIN OUTCOME MEASURE: Prevalence of COPD, classified according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006 criteria. RESULTS: Complete data were available for 1620 men (participation rate, 26%) and 1737 women (participation rate, 28%). The prevalence of GOLD Stage II or higher COPD (defined as post-bronchodilator FEV1/FVC ratio < 0.70 and FEV1 < 80% predicted) was 7.5% (95% CI, 5.7%-9.4%) among people aged ≥ 40 years, and 29.2% (95% CI, 18.1%-40.2%) among those aged ≥ 75 years. Among people aged ≥ 40 years, the prevalence of wheeze in the past 12 months was 30.0% (95% CI, 27.5%-32.5%), and prevalence of shortness of breath when hurrying on the level or climbing a slight hill was 25.2% (95% CI, 22.7%-27.6%). CONCLUSIONS: Symptoms and spirometric evidence of COPD are common among people aged 40 years or older and increase with age. Further research is needed to better understand the diagnosis and management of COPD in Australia, along with continuing efforts to prevent the disease.

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.

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

BACKGROUND: The 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. METHODS: Feedback 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. RESULTS: Of 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. CONCLUSIONS: The 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.

Sodium cromoglycate and eformoterol attenuate sensitivity and reactivity to inhaled mannitol in subjects with bronchiectasis.

BACKGROUND AND OBJECTIVE: Dry powder mannitol has the potential to be used to enhance clearance of mucus in subjects with bronchiectasis. A reduction in FEV1 has been recorded in some subjects with bronchiectasis after inhaling mannitol. The aim of this study was to investigate if pre-medicating with either sodium cromoglycate (SCG) or eformoterol could inhibit this reduction in FEV1. METHODS: A double-blind, placebo-controlled, randomized cross-over study was conducted. Lung function and airway response to mannitol was assessed on a control day and then re-assessed after pre-medication with placebo, SCG and eformoterol in nine subjects. Sensitivity to mannitol, expressed as the dose required to induce a 15% fall in FEV1 (PD15), and reactivity to mannitol, expressed as the % fall in FEV1 per mg of mannitol (response-dose ratio, RDR), are reported. RESULTS: Subjects had an FEV1 of 68 ± 14% predicted, FVC of 97 ± 15% predicted and FEV1 /FVC of 71 ± 8%. They were mildly hypoxemic and the SpO2 was 95 ± 2%.They had a PD15 to mannitol of 235 mg (95% CI: 150-368 mg) and a RDR of 0.057% fall in FEV1 per mg (95% CI: 0.038-0.085). After pre-medication with SCG, PD15 increased (773 mg, P < 0.05) and RDR was reduced (0.013, P < 0.05). Pre-medication with eformoterol also resulted in an increased PD15 (1141 mg, P < 0.01) and a reduced RDR (0.009, P < 0.01). A small but significant decrease in SpO2 from baseline was noted after mannitol in the presence of SCG (P < 0.05). CONCLUSIONS: Pre-medication with either SCG or eformoterol protects patients with bronchiectasis from developing a significant reduction in FEV1 after inhaling mannitol.

Patient medication knowledge and adherence to asthma pharmacotherapy: a pilot study in rural Australia.

Asthma is a chronic disease with both inflammatory and bronchoconstrictive elements and often requires multiple medications. Most asthma regimens include medications with different therapeutic modes of action and a number of different medication delivery devices. To effectively participate in their asthma management, patients need to recognize each of their medication types, understand their purpose, adhere to their treatment regimen, and be proficient in using the required delivery devices. This study evaluated patient knowledge of asthma pharmacotherapy and adherence. An interview study was undertaken in two rural locations, in Australia, to elicit participants' knowledge, use, and inhalation device technique. Of participants, 75.9% used preventer medication and the remaining 24.1% used reliever medication only. Of those using preventer medication, 82.5% could distinguish their preventer from a range of asthma medicines. Metered dose inhalers (MDIs) were used by 80% of participants; 23% used a Turbuhaler(R); 24% used an Accuhaler(R); and 5% used an MDI with a spacer device. The study established poor medication knowledge, suboptimal device technique, and disturbing levels of adherence with management recommendations. Asthma education strategies need to be modified to engage patients with low asthma knowledge to achieve improved patient outcomes. Further, strategies need to motivate patients to use preventer medication during times when they feel well.

Respiratory function testing: the impact of respiratory scientists on the training and support of primary health care providers.

OBJECTIVE: In rural Australia access to doctors is limited, access to respiratory physicians even more so and these are the traditional sources of lung function testing. The aim of this study was to assess the feasibility of training and supporting existing rural primary healthcare providers in lung function testing as a screening and monitoring mechanism due to the shortage of healthcare professionals capable of providing such a service. METHODOLOGY: As pharmacists are readily accessible healthcare professionals, they were trained in spirometry measurement and supported with ongoing quality assurance by respiratory scientists. Spirometers were provided to the pharmacists. People purchasing respiratory medications or responding to advertising about the service were tested after giving informed consent. Spirometic assessments were assessed for accuracy and reproducibility. Participants' spirometry results were reviewed and those with abnormal test results were referred to their doctor. RESULTS: Pharmacists were able to competently develop the skills necessary for providing spirometry measurement as a screening and monitoring technique. The level of competence exceeded that reported in previously published studies. Pharmacists were able to successfully identify spirometry results within the normal range. CONCLUSIONS: Training and supporting accessible healthcare professionals to provide lung function testing increases access in areas of need and has implications for respiratory morbidity and mortality in such settings.