Improving the management of asthma and chronic obstructive pulmonary disease

Asthma and chronic obstructive pulmonary disease (COPD) are among the top ten most common chronic diseases in Australia,1 causing significant social and economic burden on the patient, family and healthcare system. More than five million Australians are affected by asthma or COPD, and each year these diseases disrupt daily life and productivity of many individuals and contribute to thousands of deaths.2 Despite the availability of safe and effective respiratory medication, problems such as underdiagnosis, medication adherence issues and poor understanding of asthma and COPD, have led to the conditions being poorly managed in Australia.3,4 The work described in this thesis was directed at learning more about how asthma and COPD are managed in the community and steps that can be take to improve the management of these conditions. Community pharmacists assisted in the implementation of all of the projects described in this thesis. Community pharmacists are ideally placed in the healthcare system to help patients manage chronic diseases in view of their expertise, their regular contact with patients and their accessibility. Community pharmacists also have access to patients' dispensing records, meaning they are uniquely placed to monitor medication adherence issues. The projects described in this thesis utilised an innovative software application ('MedeMine') to data mine pharmacy dispensing records and target patients with asthma or COPD, as evidenced by the supply of specific medications. Part One of this thesis describes two projects targeted at patients with poorly managed asthma. The first project was a follow-up study of a previous intervention conducted in Tasmanian community pharmacies that saw patients with potentially poorly managed asthma referred to their general practitioner (GP) for an asthma management review. The intervention resulted in a three-fold improvement in the management of asthma, as measured by the ratio of dispensed preventer to reliever medications.5 A follow-up of the intervention was conducted to determine whether the improvement in asthma management was sustained, and qualitative interviews were conducted with patients, community pharmacists and GPs, to determine the perceived feasibility of the intervention. The project showed significant, sustained improvements in the ratio of dispensed preventer medications to reliever medications for at least 12 months after the intervention. The qualitative component of this project indicated that a wider roll-out of the asthma intervention, with an improved process for involving GPs, would be feasible and well accepted. Further research should determine the best approach in influencing patients' perceptions of asthma control and whether these perceptions are amenable to a more intensive educational intervention. This could result in more efficient asthma interventions, translating to improved patient outcomes. The second project was designed to test the uptake and effectiveness of two different types of community pharmacy-based asthma intervention across three Australian states. Community pharmacies throughout South Australia, Tasmania and Victoria participated. The project utilised MedeMine to identify patients whose asthma may not be well managed, as evidenced by a high provision of reliever medications. The uptake and effectiveness of mailed and face-to-face pharmacist interventions were studied. Significantly fewer face-to-face interventions were offered to patients compared with mailed interventions, and lack of time was the main reason cited for not offering faceto- face interventions. There were significant improvements in the ratio of dispensed preventer medication to reliever medication after each intervention, but these improvements were limited by pharmacists' uptake of the face-to-face intervention. Time constraints in busy pharmacies may restrict the uptake and effectiveness of faceto- face interventions in the 'real world' setting, making mailed interventions an attractive option. Pharmacists should have both mailed and face-to-face intervention options available to ensure maximum uptake and effectiveness of the interventions. Part Two of this thesis describes a study that aimed to understand the drivers and barriers of persistence with respiratory medication, specifically tiotropium, in patients with COPD. MedeMine was installed in pharmacies throughout Tasmania, Australia, and patients who were likely to be persistent or non-persistent with tiotropium were identified. Patients completed questionnaires and qualitative interviews. Patients' perceptions of the risks and benefits of tiotropium, which appeared to be strongly influenced by personal experience and the prescriber's attitude, were found to be determinants of persistence. Identification of these variables can facilitate the development of interventions that modify or take account of specific patient adherence behaviours and perceptions about the risks and benefits of medication. It is evident that increased awareness of the patients' beliefs about medicines is needed among healthcare providers, and patients should be encouraged to express their views about medicine in order to optimise and personalise their therapy. This body of work presents a number of solutions to issues surrounding the management of asthma and COPD in the community. With the knowledge gained from the results of these projects and using aspects of interventions described in this thesis, community pharmacists can dramatically improve the management of these conditions. Community pharmacists have the necessary skills to communicate with other healthcare providers and patients themselves to improve the management of asthma and COPD, and software tools such as MedeMine can aid in the efficient targeting of high-risk patients. A national roll-out of the asthma intervention, and a specifically designed COPD intervention, would result in better health outcomes for patients, and ultimately less burden on the health system.