Asthma disease management—Australian pharmacists’ interventions improve patients’ asthma knowledge and this is sustained

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Abstract

Objective

To assess any improvements in knowledge of asthma patients after a tailored education program delivered by pharmacists and measure the sustainability of any improvements. To ascertain patients’ perceptions about any changes in their knowledge.

Methods

Ninety-six specially trained pharmacists recruited patients based on their risk of poor asthma control. A tailored intervention was delivered to patients based on individual needs and goals, and was conducted at three or four time points over six months. Asthma knowledge was assessed at the beginning and end of the service, and six and 12 months after it had ended. Patients’ perceptions of the impact of the service on their knowledge were explored qualitatively in interviews.

Results

The 96 pharmacists recruited 570 patients, 398 (70%) finished. Asthma knowledge significantly improved as a result of the service (7.65 ± 2.36, n = 561, to 8.78 ± 2.14, n = 393). This improvement was retained for at least 12 months after the service. Patients reported how the knowledge and skills gained had led to a change in the way they managed their asthma.

Conclusion

Improvements in knowledge are achievable and sustainable if pharmacists used targeted educational interventions.

Practice implications

Pharmacist educational interventions are an efficient way to improve asthma knowledge in the community.

Introduction

Self-management has been a key concept for improving patient care in chronic illness for over a decade. One of the issues with patient self-management in chronic disease is improving patient understanding of how to control and monitor his/her condition. Asthma is a disease in which knowledge of the underlying inflammation, the episodic nature of symptoms, trigger factors for exacerbations, as well as the benefits and risks of medications, can help to improve self-care and adherence to disease-controlling drugs. Taken by itself, knowledge about asthma may not have a direct impact on the practical skills of disease management, but it contributes to patients’ ability to adapt to the disease [1]. It has been shown that in patients with asthma, knowledge of the disease and adherence to treatment are associated with better control, better adherence and improved quality of life [2], [3], [4]. Thus, enhancing patients’ asthma knowledge is an important preliminary step to achieving better outcomes in the longer term. For this reason, education and counseling are components of many structured asthma programs, and asthma management guidelines are designed to improve patient knowledge as a prerequisite step to improved health outcomes [5].

Despite this emphasis in guidelines on enhancing patients’ asthma knowledge, research repeatedly indicates that patients’ asthma knowledge is suboptimal [6], [7], [8]. It has also been established that in higher-risk groups, such as those with poor control, asthma knowledge and awareness are lower than in the general population with asthma [9]. Similarly, in people with non-adherent asthma behaviors, low levels of asthma knowledge are independently associated with poorer quality of life [10]. Therefore, education and care programs must be able to effectively enhance patients’ knowledge of the condition, particularly those in higher-risk groups.

The way in which patient education is conducted is also important. If learning deficits are not identified and appropriately addressed by the health care professional (HCP), learning will not occur. Gaps have been reported between patient information needs and the delivered healthcare [11], [12], [13], [14]. From the patient's perspective, dissatisfaction with the lack of individualization of asthma information provided has been reported [15]. In tailoring asthma education, there is a need to take into account the age, individual needs, health beliefs, socioeconomic-cultural context, preferences and prior experience of the patient [16], [17], [18], [19], [20], [21], [22], [23], [24].

The design and delivery of ‘optimal’ asthma education programs involves more than transmission of knowledge. These programs are multifaceted and should focus on actual individual patient needs. They must address knowledge, skills and attitudes as well as encourage regular medical reviews and written asthma action plans [25]. Structured education programs that include ongoing support and monitoring/feedback have achieved greater improvements in patient self-care and quality of life as well as health outcomes than those that do not [26], [27], [28], [29], [30]. Despite what is known about key elements of asthma education, education opportunities are not fully utilized by HCPs. Further, there is evidence that many HCPs are unaware of their patients’ level of understanding of asthma management and their medication taking behavior. Hence there is a need to improve asthma education and diversify the access to such education. Every HCP involved in asthma management should take the opportunity to reinforce key messages about the disease and its treatment.

In primary care, when it comes to delivering asthma education, pharmacists are in a unique position both in regards to the nature and frequency of intervention delivery. Pharmacists are usually the last HCP to see the person with asthma before the patient decides to use, or not use, the prescribed medication. Pharmacists also see the patient more frequently than other HCPs, as patients collect repeat prescriptions. This provides the pharmacist with further opportunities to monitor the patient. It has been demonstrated that community pharmacies are suitable venues to identify patients in need of asthma education, i.e. those with poorly controlled asthma and those with poor medication adherence identifiable through pharmacy records [31], [32].

It has also been shown that, as a result of pharmacists delivering structured programs focusing on a partnership with the patient, improved health outcomes for people with asthma can be achieved. Pharmacist interventions have been shown to improve asthma control, asthma knowledge and self-care in disease management [26], [33], [34]. Different approaches to asthma education delivery have now been tested in pharmacies, e.g. group education, individualized education and outreach education [34], [35], [36]. In most cases, asthma care programs have been delivered across a period of six months to a year, with very few reporting ongoing patient monitoring beyond the period of program delivery [37], [38]. Moreover, many studies of pharmacy-based asthma care programs do not report on the ‘frequency’ of the education/care sessions [37]. This is possibly an important determinant, as it can affect patient retention of new knowledge [39].

In Australia, a pharmacy asthma care program, based on several research pilot studies, was tested in a randomized control trial with very positive clinical, humanistic and economic outcomes [26], [40]. This program explored the outcomes from either three or four patient consultations over six months and the consultations included tailored patient education. To design sustainable pharmacy-based programs, research should offer direction about the frequency and duration of time over which such services may be offered, and what can be achieved. Sustained positive outcomes and the drive to keep delivering or attending such services may rely on such services comprising both clinical and humanistic perspectives [41], [42].

Thus, the research questions are:

  • (a)

    can pharmacists deliver improvements in asthma knowledge if they tailor the education program to the patient's needs, and if improvements are achieved how sustainable are they? and

  • (b)

    what are patients’ views about any changes in their asthma knowledge?

Section snippets

Methods

This study reports on the asthma knowledge scores from patients enrolled in a six-month intensive asthma service delivered between January and November 2009. Key features of this pharmacy asthma service were founded in the literature and previous research [26]. Patients attended either three or four visits at their pharmacy over a six-month period, and educational needs were assessed by the pharmacists, so that the educational interventions delivered were targeted to individual needs (Fig. 1).

A

Patients

A total of 570 patients were recruited from 96 pharmacies, of which 398 finished the intensive six-month service and 129 were selected for follow-up to the 12 months post-service time point (Fig. 2). Any variation in the number of patients reported at any time point is due to missing data for that variable.

Using the risk-assessment tool, pharmacists identified patients with poor asthma control [26] in need of educational interventions. That is, 77% had poor control and 23% had good/fair

Discussion

This study has demonstrated that pharmacists’ interventions can lead to a sustained increase in asthma knowledge. As knowledge improved, there was a decrease in knowledge-related interventions delivered by pharmacists. Further, patients recognized and appreciated their increased knowledge. This study is the first large-scale research to provide meaningful insight about the role and structure of pharmacy asthma services in making sustained improvements in patient asthma knowledge.

The maximum

Role of funding

The Pharmacy Asthma Management Service was funded by the Australian Government Department of Health and Ageing as part of the Fourth Community Pharmacy Agreement. The funding body had no involvement in the study design, collection, analysis and interpretation of data or writing of the report.

Acknowledgements

We would like to thank Jaya Soma, Phillipa Yabsley, Julie Cooke and Victoria Jarvis, who contributed as Project Officers, and all of the pharmacists who participated in this study.

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