Expanding pharmacists’ role in asthma care
The U.S. National Institutes of Health endorse pharmacist interventions for patients with asthma
The burden of asthma in the United States has continued to increase over recent decades, rising from 20 million people in 2001 (1 in 14) to 26 million in 2011 (1 in 12).1 It also has continued to escalate globally, with an estimated 300 million people around the world affected by asthma.2
Poor medication adherence, especially among patients with chronic diseases, is a global problem. According to a 2003 World Health Organization report, worldwide nonadherence among asthma patients ranged from 28% to 70%, often with clinical consequences and diminished quality of life.3
Problems of nonadherence
In the United States, the nonadherence rate for patients with asthma is 55%.4 The National Asthma Education and Prevention Program 2007 guidelines included an evaluation of controlled trials of pharmacist-delivered asthma education.5 Reduced hospitalizations, better asthma control, reduced symptoms, and improved quality of life were observed.
The panel concluded that “use of interventions provided by pharmacists is feasible, may help improve self-management skills and asthma outcomes, and merits more clinical studies of pharmacists’ providing education interventions.” The guidelines suggested interventions including education about self-management education, medication, and inhaler skills and supported a collaborative approach by clinicians, nurses, respiratory therapists, pharmacists, and asthma educators.
Studies in the European Union have shown positive effects on clinical outcomes and patient quality of life from pharmaceutical care for patients with asthma. This article discusses two studies that demonstrated the successful design and implementation of these programs in Denmark and Germany.
Denmark: Increased role for the pharmacist
The prevalence of self-reported asthma among Danish adults increased from 2.9% in 1987 to 6.4% in 2005, largely due to increasing affluence and urbanization.6 Denmark introduced the Asthma Therapeutics Outcome Monitoring (TOM) program, a community-based collaborative effort that includes patient and professional perspectives on asthma management and increases the pharmacist’s role in asthma care. The program consists of the following seven-step cyclical outcome improvement process in which pharmacists identify and resolve or refer drug therapy issues that could lead to therapeutic failure or adverse effects if left unaddressed:7
- Establish patient–pharmacist–physician relationship.
- Collect patient data via interview.
- Identify and analyze drug therapy problems.
- Outline therapeutic goals.
- Choose intervention and monitoring plan.
- Implement monitoring plan.
- Document and report to physician and patient.
In a study measuring outcomes at 16 TOM and 15 control pharmacies, mean asthma symptom scores for TOM patients improved by 23% from baseline in 12 months, and sick days reported by TOM patients were only 60% of those reported by controls (793 vs. 1,249). In the patient-reported Nottingham Health Profile, TOM patients showed an improvement of 3.8 units in quality of life over 12 months, compared with 1.07 units for controls.7
The Inhaler Techniques Assessment Service (ITAS), an outgrowth of TOM introduced in 2005, consists of a demonstration by the pharmacist of how to use dry inhalers for the treatment of asthma or chronic obstructive pulmonary disease (COPD) provided to first-time patients or repeat patients experiencing problems with inhalation techniques.8 Pharmacists or pharmacy technicians provide the service at the counter or in a private consultation room in a session lasting 5 to 10 minutes. Using a placebo inhaler, the staff demonstrates how to use the device, asks the patient to imitate the technique, corrects errors, and documents the demonstration.
The Association of Danish Pharmacies provides a certification program and manual explaining the service and reimbursement. To implement ITAS, pharmacies gathered placebo devices and trained staff in inhaler pharmacology and techniques as well as documentation and reimbursement forms. ITAS was the first pharmacy service reimbursed by the Danish government. In 2009, almost 44,000 ITAS sessions were provided in 310 pharmacies.9
Germany: Four steps to improved adherence
The prevalence of asthma among German adults is 6.3%, placing a financial burden on the state insurance system in direct costs for medications, hospitalizations, and rehabilitation, and indirect costs due to sick benefits and lost days at work.10
Disease management programs for patients with chronic diseases, including asthma and COPD, were introduced in Germany’s GVK social security system in 2002, covering approximately 90% of the population. As part of these programs, Germany’s Center for Drug Information and Pharmacy Practice implemented a four-stage, pharmacy-based strategy to improve adherence in patients with asthma.
In the first stage, a controlled intervention study of pharmacy-based asthma services centered in Hamburg, all of the city’s 465 community pharmacies were invited to sign up; the intervention and control arms enrolled 22 and 26 pharmacies, respectively.11 Pharmacists were trained in medical, pharmaceutical, and pharmacological knowledge of asthma; communication skills; and study protocol and documentation.
The intervention arm recruited 161 patients with a confirmed diagnosis of asthma and the control arm recruited 81 similar patients. Patients in the intervention arm met with pharmacists in one-on-one sessions at the pharmacy at 6-week intervals, at which time pharmacists assessed inhalation technique and addressed any drug- or health-related problems in cooperation with the patient’s physician. Patients learned how to use an asthma diary and a peak flow meter and were asked to measure peak flow at home and during pharmacy visits. Questionnaires on quality of life, self-efficacy, and asthma knowledge were administered to all study participants at baseline, 6 months, and 12 months.
After 6 months, the intervention group demonstrated increased forced expiratory volume in 1 second by 11.4%, compared with a 4.5% increase for the control group. The increase did not hold at 12 months, however. Inhalation technique also improved significantly in the intervention group, along with disease knowledge and quality of life, both asthma-specific and mental health.
For the second stage, an intervention study in the Trier region invited all of the area’s 148 pharmacies. Pharmacies that accepted agreed to offer community pharmacy–based pharmaceutical care services to patients with asthma for 1 year.12 At each pharmacy, at least one pharmacist working full time received training based on a nationally certified curriculum and manual that comprised medical, pharmaceutical, and pharmacologic knowledge; communication skills; and study protocol and documentation. Monitors visited the practice sites monthly. Pharmacists and patients’ physicians recruited eligible patients 18 years to 65 years old with a confirmed diagnosis of asthma. Of the 57 pharmacies that accepted, 39 recruited a total of 183 patients.
Pharmacists held five meetings with patients over 12 months to discuss asthma pathology, medication, inhaler technique, and self-management skills and to resolve any drug-related problems. Patients used an asthma diary and peak flow meter, using the meter twice daily throughout the study period and during pharmacy consultations. Patients were administered questionnaires at the pharmacy at baseline, 6 months, and 12 months and were monitored by their physicians during the same intervals.
Clinical outcomes showed significant improvement in peak flow rates measured in the pharmacy. Self-reported decreases in asthma symptoms and severity according to the German Asthma Guideline classification were also documented. Improvements were seen in inhalation technique, asthma knowledge, self-efficacy, and adherence from baseline to 6 months to 12 months.
Based on the success of the stage 1 and 2 studies, the service was implemented into daily practice countrywide as part of stage 3. The 17 state chambers of pharmacists now offer certified education programs in accordance with physician associations.
For the final stage, the German Medical Association, National Association of Statutory Health Insurance, and Association of Scientific Medical Societies invited pharmacists to participate in extensive expansion and updating of the country’s National Asthma Care Guideline.13 These new guidelines include a role for pharmacists in the safe and effective use of inhaled medication for asthma.
Centers for Disease Control and Prevention. CDC’s National Asthma Control Program: an investment in America’s health. 2013. Accessed at www.cdc.gov/asthma/pdfs/investment_americas_health.pdf, July 29, 2013.
Global Initiative for Asthma. Global burden of asthma: summary. Accessed at www.ginasthma.org/documents/9, July 29, 2013.
World Health Organization. Adherence to long-term therapies: evidence for action. Accessed at www.who.int/chp/knowledge/publications/adherence_report/en/, July 29, 2013.
Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23(8):1296–310.
National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Guidelines for the diagnosis and management of asthma. Accessed at www.nhlbi.nih.gov/guidelines/asthma/, July 29, 2013.
Ekholm O, Kjøller M, Davidsen M, et al. Public health report, Denmark 2005 and development since 1987. Copenhagen, Denmark: National Institute of Public Health; 2007.
Herborg HH, Soendergaard B, Froekjaer B, et al. Improving drug therapy for patients with asthma: part 1: patient outcomes. J Am Pharm Assoc. 2001;41:539–50.
Kaae S, Christensen ST. Exploring long-term implementation of cognitive services in community pharmacies: a qualitative study. Pharm Pract. 2012;10(3)151–8.
European Observatory on Health Systems and Policies. Health systems and policy monitor: Denmark. Accessed at http://hspm.org/countries/denmark27012013/countrypage.aspx, July 29, 2013.
Stock S, Redaelli M, Luengen G, et al. Asthma: prevalence and cost of illness. Eur Repir J. 2005;25:47–53.
Schulz M, Verheyen F, Muhlig S, et al. Pharmaceutical care services for asthma patients: a controlled intervention study. J Clin Phamacol. 2001;41:668–76.
Mangiapani S, Schultz M, Muhlig S, et al. Community-based pharmacy care for asthma patients. Ann Pharmacother. 2005;39:1817–22.
Fishman L, Khan C, Conrad S, et al. Updating national disease management guidelines: experiences with two approaches. Presented at 9th Annual Guidelines International Network Conference; August 22–25, 2012; Berlin, Germany. Accessed at www.g-i-n.net/document-store/g-i-n-conferences/berlin-2012/orals/o07-fi…, July 29, 2013.
Responsible use of medicines
In October 2012, the IMS Institute for Health Informatics released a landmark report, “The responsible use of medicines: Applying levers for change” (www.responsibleuseofmedicines.org). The report was originally intended for a global summit of 30 health-system leaders, including ministers of health and senior policy makers, from around the world. Many of the case studies in the report, siuch as those about adherence, polypharmacy, and prevention of medication errors, are of interest to pharmacists as well. In a series of articles running from July through October, Pharmacy Today will examine some of the cases in the report from the perspective of the pharmacy professional.