Educating the patient, controlling the disease: a point prevalence evaluation of structured pharmaceutical asthma care in real world settings.

Prevalence and characteristics of medication sharing behavior in a pediatric Medicaid population with asthma

Community pharmacists can play an important role in controlling chronic diseases. This study aimed to evaluate the effects of pharmacists' educational interventions in the community pharmacy settings on asthma control and severity, quality of life (QOL) and medication adherence. Databases PubMed, Scopus and Web of Science were searched for evidence regarding asthma severity and control, QOL, and medication adherence after pharmacists' interventions in community pharmacy settings. Twenty-one studies were eligible for qualitative and quantitative analysis. Indices and questionnaires were used in the studies, such as Asthma-related quality of life (IAQLQ), Asthma Control Test (ACT), Perceived Control of Asthma Questionnaire (PCAQ), inhaler technique (IT), Asthma Control Questionnaire (ACQ), 36-Item Short Form survey (SF-36) and peak expiratory flow rate (PEFR). The outcomes were extracted, pooled and analysed as percentages, means, standard deviations and errors, and 95% confidence intervals (CIs). Community pharmacists in all studies educated and followed up the asthmatic patients, addressing the outcome measures. Pharmacists underwent training courses of at least a day. Standardized mean differences for the indices were pooled as follows: IAQLQ -0.241 (95% CI, -0.362 to -0.121), ACT 0.14 (95% CI, 0.02 to 0.27), PCAQ -0.15 (95% CI, -0.28 to 0.01), IT 0.79 (95% CI, 0.05 to 1.54), ACQ -0.50 (95% CI, -0.69 to -0.30), SF-36 0.39 (95% CI, 0.16 to 0.62), PEFR 0.13 (95% CI, 0.01 to 0.26) and asthma symptoms score -0.34 (95% CI, -0.49 to -0.18). Pharmacists' educational interventions in community pharmacy settings could significantly improve asthma severity and control, QOL and medication adherence.

Background: Incorrect inhaler usage is very common issue that leads to poorly managed asthma. Clinical pharmacist enhanced patient education is critical in reducing such errors. Education on inhaler technique is one area where pharmacists may significantly impact on asthma therapy and improvement in clinical features. Aim: This study aim to evaluate the efficacy of a pharmacist-delivered education program for improving patients' inhaler technique and clinical outcomes. Patients and Methods: This prospective cohort trial included 51 individuals with asthma, divided up between an intervention group of 26 participants who were subjected to pharmacist intervention as well as a control group of 25 participants. MDI and turbuhaler users were gathered to participate in the study from five community pharmacies in different areas of the Thi-Qar province (Nasirriya, Suq Al-Shoyookh, and Al Eslaah cities). Basic asthma control and spirometry parameters were evaluated using standardized questionnaire of asthma control test and spirometer respectively. Patients in intervention group were taught how to properly use their inhalers using a combination including demonstrations and re-demonstrations counselling with aid of advices leaflet. After one month for both groups, clinical outcomes (asthma control and spirometry) were reassessed and comparisons were made. Results: A total of 51 patients were involved, with 35 using a turbuhaler and 16 using an MDI. At first session of assessment for all participants, a low asthma control and low median value of FEV1/FVC ratio were recording. After intervention, the median values for asthma control test and all pulmonary parameters was increased significantly (for ACT of 18.5 to 21, p=0.000, for PEF of 2.2 to 2.8, p=0.001, for FEV1 of 1.6 to 1.9, p=0.001, for FEV1/FVC ratio of 63 to 71.5, p=0.002). Conclusion: Community pharmacist based education program applied to patients with asthma to increase awareness of patients about proper inhaler technique have positive impact in improvement of asthma control level and pulmonary functions parameters. This short education program highly applicable and should be consider as one of daily community pharmacist duties. Keywords: Community pharmacist, asthma control test, asthmatic patients, spirometer, inhaler technique, Thi-Qar.

Background: Question 4 (Q4) of the Asthma Control Test (ACT) asks patients to report their SABA use over the prior 4 weeks, a criterion for evaluating the impairment domain of asthma control. Biases in recall may lead to a misclassification of asthma control and has implications for asthma control determination and management strategies.Objective: To correlate objective electronic-recorded short-acting beta-agonist (SABA) use with self-reported use via Q4 of the ACT.Methods: Patients ≥18 years of age with a self-reported diagnosis of asthma were enrolled in a digital health electronic medication monitoring (EMM) platform, which recorded the date and time of SABA actuations and prompted the completion of the ACT. The correlations between ACT Q4 responses and EMM-recorded SABA use were evaluated using Spearman’s rank correlation coefficients.Results: 1,062 patients (mean age: 35.4 years, mean ACT: 16.3) were included in analyses. Higher Q4 scores, indicating lower SABA use, were moderately and negatively correlated with EMM-recorded SABA use (ρ = -0.59 [95% CI: -0.63, -0.54]). Thirty-five percent of patients underreported SABA use when comparing Q4 to EMM-recorded SABA use.Conclusions: While ACT Q4 and EMM-recorded use were moderately correlated, underreported SABA use on the ACT highlights the need for objective measures of SABA use in asthma control assessments. The use of EMM-recorded SABA data has the potential for clinicians to more accurately determine asthma control, guide changes to controller therapy, and estimate imminent exacerbation risk.

Asthma and Chronic obstructive pulmonary disease (COPD) are chronic respiratory conditions characterized by airflow obstruction and respiratory symptoms. Adherence to prescribed inhaler therapy and correct inhalation technique are essential for effective disease management and optimal disease control. However, non-adherence and incorrect inhalation technique are common challenges faced by patients with asthma and COPD, leading to suboptimal treatment outcomes and increased healthcare burden. To study the impact of a pharmacist-led intervention on inhaler adherence, inhalation technique, and disease control among patients with asthma and COPD. A pre-post interventional design assessed the effects of pharmacist-led intervention on inhaler adherence, inhalation techniques, and disease control in asthma and COPD patients at Dhulikhel Hospital in Nepal. Inclusion criteria: adult patient clinically diagnosed with asthma or COPD patients of all genders. The intervention comprised counseling patients with aids like videos, and informational leaflets. Impact was measured using checklist method for inhalation technique, the Test of Adherence to Inhaler (TAI) questionnaire for adherence to inhaler, and "Asthma Control Test (ACT)" or "COPD Assessment Test (CAT)" for disease control. The pharmacist-led intervention significantly increased adherence to inhalers, evidenced by a notable rise in the proportion of patients with good adherence (P<0.001). Sporadic, deliberate, and unwitting noncompliance pattern also improved significantly after the intervention (P<0.001, P<0.001 and P=0.001). Inhalation technique exhibited substantial improvement after intervention (P<0.001). The analysis indicated significant moderate negative correlations between "TIA" and "CAT" [ρ=-0.31; P=0.01], and between "inhalation technique score" and "CAT score" [ρ=-0.31; P=0.01] suggesting that as adherence to inhaler usage and inhalation technique improve, CAT scores tend to decrease, indicating reduced disease impact on the patient. This study shows the potential efficacy of pharmacist-led intervention in enhancing adherence to inhaler, inhalation technique, and disease control in respiratory conditions such as asthma and COPD.

Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists

Objective Medicines Use Reviews (MUR) may benefit asthma and chronic obstructive pulmonary disease (COPD) control. The present study evaluates the effect of respiratory-targeted MUR-plus (MUR+) services delivered by community pharmacists on disease control. Methods A retrospective analysis of MUR+ data in the PharmOutcomes database was conducted. All patients receiving respiratory-targeted MUR+ in Milton Keynes were included. Changes in asthma control test (ACT) and COPD assessment test (CAT) scores were analysed. Key findings A total of 191 asthma and 81 COPD patients received MUR+. Asthma and COPD control improved as shown by the increase in mean ACT [+1.2 (95% CI, 0.6–1.8)] and decrease in mean CAT [−0.2 (95% CI, −1.4 to 1.0)]. Baseline ACT, smoking cessation, absence of change in drug therapy, patient education, healthcare professional referral, device training and baseline ACT score ≤19 were associated with change in ACT, but only smoking cessation was related to CAT change. A multivariable regression model comprising the aforementioned variables explained 19% of the variance in ACT change (P &amp;lt; 0.001). Only baseline ACT was associated with ACT change (beta = −0.34, P &amp;lt; 0.01). Baseline CAT, absence of change in drug therapy, smoking cessation and baseline CAT score &amp;gt;20 accounted for 12% of the variance in changes in CAT (P = 0.046). No variable was significantly associated with CAT change. Conclusions Respiratory-targeted MUR+ service by community pharmacists was associated with improvements in asthma control among patients with poorer baseline ACT, but not in patients with COPD. Several potentially modifiable factors such as education were associated with changes in control.

BackgroundAsthma has been shown to have a significant association with the diagnoses of mental health disorders, including depression; however, information from India is scarce.ObjectivesThe study aims to estimate the prevalence of depression in asthma patients and identify associated risk factors.MethodsA total of 248 participants aged 18 and above who presented to the pulmonary medicine outpatient clinic of the Christian Medical College, Vellore, Tamil Nadu, India, were recruited. Socio-demographic and clinical details, including treatment compliance were collected, and inhaler technique was assessed. Asthma control was measured by the Asthma Control Test (ACT) and the quality of life by Asthma Quality of Life Questionnaire (AQLQ). The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depression. Logistic regression was used to determine the risk factors for depression.ResultsOut of the 248 participants, 24.6% screened positive for depression. Asthma control was worse (ACT 19.07 ± 4.87 vs 21.93 ± 3.66; p < 0.001) and quality of life was poorer (AQLQ 5.53 ± 0.72 vs 6.06 ± 0.63; p < 0.001) in those with depression. There was a low negative correlation (ρ = −0.332, P < 0.001) between ACT score and PHQ-9 score and a moderate negative correlation (ρ = −0.451, P < 0.001) between AQLQ score and PHQ-9 score. Univariate logistic regression analysis showed six independent factors associated with depression: female gender (OR 1.87), presence of one or more comorbidities (OR 2.10), incorrect inhaler technique (OR 3.59), poor compliance with inhaled corticosteroids (ICS) (OR 2.30), poorly controlled asthma (ACT) (OR 2.92) and lower AQLQ score (OR = 0.32). Multivariate logistic regression analysis revealed that the AQLQ was the only independent risk factor for depression (OR 0.27, P = 0.001).ConclusionAdult asthma patients in this Indian cohort showed a high prevalence of depression. The study highlights key risk factors for depression in asthma and reiterates the need to screen asthma patients for depression.

Asthma has been shown to have a significant association with the diagnoses of mental health disorders, including depression; however, information from India is scarce. The study aims to estimate the prevalence of depression in asthma patients and identify associated risk factors. A total of 248 participants aged 18 and above who presented to the pulmonary medicine outpatient clinic of the Christian Medical College, Vellore, Tamil Nadu, India, were recruited. Socio-demographic and clinical details, including treatment compliance were collected, and inhaler technique was assessed. Asthma control was measured by the Asthma Control Test (ACT) and the quality of life by Asthma Quality of Life Questionnaire (AQLQ). The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depression. Logistic regression was used to determine the risk factors for depression. Out of the 248 participants, 24.6% screened positive for depression. Asthma control was worse (ACT 19.07 ± 4.87 vs 21.93 ± 3.66; p < 0.001) and quality of life was poorer (AQLQ 5.53 ± 0.72 vs 6.06 ± 0.63; p < 0.001) in those with depression. There was a low negative correlation (ρ = -0.332, P < 0.001) between ACT score and PHQ-9 score and a moderate negative correlation (ρ = -0.451, P < 0.001) between AQLQ score and PHQ-9 score. Univariate logistic regression analysis showed six independent factors associated with depression: female gender (OR 1.87), presence of one or more comorbidities (OR 2.10), incorrect inhaler technique (OR 3.59), poor compliance with inhaled corticosteroids (ICS) (OR 2.30), poorly controlled asthma (ACT) (OR 2.92) and lower AQLQ score (OR = 0.32). Multivariate logistic regression analysis revealed that the AQLQ was the only independent risk factor for depression (OR 0.27, P = 0.001). Adult asthma patients in this Indian cohort showed a high prevalence of depression. The study highlights key risk factors for depression in asthma and reiterates the need to screen asthma patients for depression.

A multicenter trial was designed to validate the "Assessment Tools for Asthma (ATA)" questionnaire, a newly developed questionnaire, which evaluates both asthma control and risk factors associated with asthma control with a single instrument. This cross-sectional study involved 810 cases from 14 clinics in 9 Turkish cities. The ATA questionnaire and Asthma Control Test (ACT) were administered. The Visual Analog Scale (VAS) was used to evaluate the control status of 100 randomized cases. ATA is an eight-item physician-administered questionnaire. It comprises the following two sections-ATA1, assesses symptomatic control criteria, and the remaining section, queries the flare-up of asthma, control of comorbidities, treatment adherence, and inhaler technique. The mean scores for ATA1, ATA total, VAS, and ACT were 24.7±14.8, 53.8±19, 7.1±3, and 18.8±5.5, respectively. According to the ATA questionnaire, among all patients, 34.3% had controlled, 18.8% had partly controlled, and 46.9% had uncontrolled asthma. Furthermore, 16.6% patients had flare-ups between visits, 96.4% patients had uncontrolled comorbidity, 17% patients had irregular asthma treatment, and only 8.4% patients used the incorrect inhaler technique. The ATA questionnaire showed internal consistency (Cronbach's alpha coefficient=0.683). ACT, ATA1, and two specialists' evaluations using VAS correlated strongly with the ATA total scores (Spearman correlation coefficient (r) values: 0.776, 0.783, and 0.909, respectively; p-values: p<0.001, p<0.001, and p<0.001, respectively). According to Receiver Operating Characteristic analysis, the cut-off value of ATA was 50 (sensitivity=84.4%, specificity=82.40%). The validated ATA questionnaire may be a practical tool for physicians in asthma management.

Limited data exist on allergic rhinitis and asthma control in rural primary care. Therefore, the aim of our study was to assess asthma and comorbid allergic rhinitis control in patients attending primary care in both urban and rural settings in Greece. Additionally, we aimed to identify potential factors associated with the control of asthma and comorbid allergic rhinitis. In this cross-sectional study, patients with asthma and comorbid allergic rhinitis completed questionnaires assessing demographic, co-morbidities and treatment status. Symptom control was evaluated by the Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ) and Control of Allergic Rhinitis/Asthma Test (CARAT). Multivariate logistic regression analysis was applied to identify associated factors of asthma and comorbid allergic rhinitis control after adjusting for age, gender, smoking status and comorbidities. Out of 121 subjects with asthma and comorbid allergic rhinitis 75 (62%) resided in rural areas. A significant percentage of participants reported suboptimal asthma control using the ACT (54%) and ACQ (67%). Moreover, 88% of participants had not-well-controlled asthma and comorbid allergic rhinitis based on CARAT. Females (odds ratio (OR)=4.1, 95% confidence interval (CI) 0.8-19.9, p=0.043) and patients living in rural areas (OR=3.8, 95%CI 1.34-10.5, p=0.010) were more likely to report well-controlled asthma and allergic rhinitis based on CARAT score (>24). Patients reporting intranasal steroid use (OR=3.6, 95%CI 1.1-121, p=0.035) were more likely to have well-controlled asthma based on ACT score. Analysis also indicated a trend towards significance for the association between short-acting beta-agonist use and not-well-controlled asthma based on the ACT (score&le;19) (OR=5, 95%CI 0.9-10, p=0.066) and partially and not-well-controlled asthma based on the ACQ (score>0.75) (OR=5, 95%CI 0.9-10, p=0.066). Our results suggest that asthma and allergic rhinitis control remain suboptimal in a large proportion of patients in primary care. Area of residence, female gender and medications emerged as significant associated factors that must be taken into account in order to effectively improve asthma and comorbid allergic rhinitis outcomes.

Long-term adherence to inhaled corticosteroids in clinical phenotypes of adult-onset asthma

Objective Treatment adherence, asthma control, inhaler satisfaction, and quality of life of patients with asthma were investigated to examine whether there were any differences between conventional fixed combined therapy and maintenance and reliever therapy after inhaler education. Methods Cross-sectional observational follow-up of 120 patients with asthma receiving third- and fourth-step treatment was completed at zero, three, and six months. Fifty-eight patients received long-acting beta-agonists or inhaler corticosteroids (ICS) as maintenance therapy and short-acting beta-agonists (SABA) as reliever therapy (CONV) with Diskus and Ellipta devices. Sixty-two patients received ICS/formoterol as maintenance and reliever therapy (MART) with metered-dose inhaler and Turbuhaler devices. The asthma control test (ACT), feeling of satisfaction with the inhaler (FSI-10) questionnaire, Morisky Green Levine (MGL) scale, and quality of life questionnaire (AQLQ) were evaluated at each visit. Results Significant improvement was observed in the ACT, AQLQ, FSI-10, MGL scales, and inhaler technique in both groups over time (p < 0.05). There was no difference in the MGL scale between the groups at all visits. Nonadherence was highest in the Diskus device group (55%) and lowest in the Ellipta device group at the first visit (25%). While 36% of the patients had low adherence at the first visit, this decreased to 12% by the last visit. A significant correlation was found between ACT and MGL at all visits (p < 0.001). Conclusion Asthma control, adherence, inhaler satisfaction, and quality of life improved equally with regular follow-up and standard inhaler education in the CONV and MART groups.

The 2014 Asia Pacific - Asthma Insight and Management (AP-AIM) study showed that none of the Indian asthmatics had controlled asthma when evaluated objectively. Our study aims to detect through objective measurements, uncontrolled asthma in OPD patients, the adequacy of their inhaler technique, and their awareness regarding the importance of inhaler technique. The asthma Control Test (ACT) score was used to screen for uncontrolled asthma. A validated objective questionnaire and scoring were used to objectively assess the correctness and awareness of the inhalation technique. The study was carried out over 2 month period and 80 patients meeting the inclusion criteria were enrolled. Out of 80 patients; 47 (58.75%) had well-controlled asthma and 33 (41.25%) had uncontrolled asthma. 64 (80%) patients had good, and 16 (20%) had poor inhalation techniques. Among the 64 patients with good inhalation technique 43 (67.18%) had well-controlled asthma and 21 (32.82%) had uncontrolled asthma. Among the 16 patients with poor inhalation technique 4 (25%) had well-controlled asthma and 12 (75%) had uncontrolled asthma. There was a statistically significant association between asthma control and inhaler technique (P value 0.002). In the study population 56 (70%) patients were aware of the inhalation technique and 24 (30%) were unaware of the inhalation technique. Out of the 56 patients who were aware of the inhalation technique 53 (94.64%) had good inhaler technique and 3 (5.36%) had poor inhalation technique. Among the 24 patients who were unaware of the inhaler technique 11 (45.83%) had good inhaler technique and 13 (54.17%) had poor inhaler technique. There was a statistically significant association between awareness of inhaler technique and good inhaler technique (P value 0.001). There is a statistically significant association between asthma control and inhaler technique and between inhaler technique and inhaler awareness. Improving the awareness regarding inhaler technique among bronchial asthma patients is the way forward to improve asthma control in our country.

Pressurized metered-dose inhalers (pMDIs) are among the most commonly used aerosol delivery devices. Poor lung deposition from a pMDI is often a result of incorrect inhalation technique. The aim of this study was to compare the impact of combining a newly released training device with a smartphone application (advanced counseling) in asthma control to the impact of traditional verbal training. A total of 371 subjects with asthma were divided into 2 groups: advanced counseling (n = 187) and verbal counseling (n = 184). Both groups had 3 visits, each meeting being a month apart. At each visit, lung function (ie, FEV1, ratio of FEV1 to forced vital capacity [FEV1/FVC], and peak expiratory flow) were measured, an asthma control test was given, and subjects were trained in the correct inhalation technique. Inhalation flow through the pMDI was also recorded at each visit because the correct pMDI technique requires an inspiratory flow of < 60 L/min. In the advanced counseling group, lung function significantly improved after both the first and the second visit (P < .001), whereas in the verbal group, lung function improved significantly only after the second visit (P < .001). Although the inspiratory flow through the pMDI improved significantly in both groups, it was closest to the target range in the advanced counseling group. In addition, more subjects in the advanced counseling group had monthly increases of ≥ 3 points in their asthma control test scores compared to the verbal counseling group. The use of a training device with a smartphone application in conjunction with traditional verbal counseling in pMDI technique resulted in significant improvements in asthma control compared to traditional verbal counseling in pMDI technique alone.