Chronic obstructive pulmonary disease is a leading cause of death in Australia and yet half of all people with the condition don’t even know they have it
This presents a huge opportunity for pharmacy to offer screening as well as assist with medication management.
Over the last few years a growing number of pharmacies have extended their role in chronic obstructive pulmonary disease (COPD) to include screening, inhaler technique advice, assisting with self-management plans and medicine adherence.
In fact, last year 21 community pharmacies in New South Wales took part in a study undertaken by The University of Sydney, with support from the Lung Foundation Australia and The Pharmacy Guild, to assess the role of the pharmacy in identifying the risk of COPD.
Professor Carol Armour from The University of Sydney explains that the six-month study saw the participating pharmacies receive COPD training from the Lung Foundation Australia and assistance on how to use the PiKo-6 spirometry device.
She explains, “Recruitment was based on what the pharmacy knew about the person. For example, if they had someone older than 35 years of age requesting smoking cessation products, who perhaps also had a recurrent cough, requested cough suppressants or who had a history of antibiotic course for respiratory tract infections, they would invite them to fill in a risk assessment questionnaire and have a lung function test using the PiKo-6.
“Based on these results, the person was either referred to their GP for further assessment or simply given some take-home information on COPD.”
Professor Armour says 167 patients were screened in total. Of which, 68 people were considered to be at medium or high risk of COPD and referred to their GP.
“Of the original cohort 10 per cent were diagnosed with COPD. This demonstrates that there’s a lot of scope for pharmacies to screen for COPD. The primary aim of our research was to show that COPD screening in pharmacy works. It’s brief, feasible and you can identify people who need follow up,” says Professor Armour.
Alison O’Driscoll from Oberon Pharmacy in Oberon, NSW, was one of the pharmacists who participated in the study. She tells The AJP that the service was well received by customers and something they will endeavor to continue to offer in the future.
“In our waiting area we set up a table with the checklist on, which people could fill in themselves while waiting for their script. If one of our pharmacists were roaming free they would approach the customer and ask if they suffer from sputum or coughing and work through the checklist with them.
“We also had signs up around the store promoting the service, which was free, and we put flyers in with the asthma puffers and cough syrups to help identify people for screening.
“The feedback we received from customers was really positive. Also, a local GP who’s worked in the area of lung health saw that we were doing the screening and contacted us to compliment us and tell us how happy she was that we were offering this service.
“We happen to have a high open fire, sawdust and smoking rate in Oberon, so we’re a prime area for COPD screening. The fact we had a few people diagnosed made it really worthwhile.
“While the trial itself went well, the main limitation of the study was the difficulty we had using the PiKo-6. Even though we had a fair amount of practice, we still had trouble using it.
“In the end, we found that the easiest way for us to do it was to actually hold the machine for customers while they did the puffing.
“It can be time consuming too, particularly if you have an elderly patient as they can have difficulty getting that strong blast of breath out that is needed to get the results.
“However, on the whole it’s a great idea. We’re continuing to have people come in for the service and we intend to do another driver to advertise the screening in the future,” O’Driscoll says.
Increasing the role of the pharmacist
Lung Foundation Australia CEO Heather Allan says a concerted effort is required by pharmacists to build knowledge, confidence and skills in working with customers at higher risk of COPD.
“Lung Foundation Australia has a COPD case finding activity, which is not screening in the true sense of the word; a screening intervention involves all people in a population including those who are asymptomatic.
“The COPD case finding activity that we offer targets those people more likely to have COPD, as they have risk factors and/or symptoms. Building the capacity of pharmacists involves them participating in online training combined with hands-on practice in delivering the activity, for example delivering the steps in COPD case finding activity including the use of a COPD screening device such as the PiKo-6, COPD-6 or Air Smart Spirometer.
“Other factors in increasing the role of the pharmacist include involving the whole pharmacy team and having a process to identify and engage with customers or patients for this activity. The environment for undertaking the test will also need to be considered as it is important to have a private space available to conduct the test, record and discuss the results,” she says.
Identifying who’s at risk
Essentially there are three criteria that a customer should meet before they are eligible for a test with a COPD screening device. They should be:
- Aged 35 years or older
- Have no current diagnosis of COPD
- Have a risk factor and/or symptom
Symptoms of COPD include:
- Shortness of breath
- Chronic cough
“There are many clues that pharmacists can pick up in their pharmacy to help identify people who may be at risk of COPD. People purchasing smoking cessation products, cough mixture, and short-acting beta-agonists on a regular basis may be candidates to participate in the activity. Even the customer that walks in wearing their fluro work attire might have a job that exposes them to dust, gas or fumes. All of these people could participate in the test if they are 35 years or older and don’t currently have a diagnosis of COPD,” says Allan.
When it comes to offering spirometry Allan says there’s the opportunity for any health professional to be trained in spirometry, yet the challenge is being able to deliver a good quality, reliable service on a regular basis.
“Spirometry is not a simple and quick activity as it requires pre and post testing with the administration of a short-acting beta-agonist to assess for reversibility. It is essential that spirometry operators participate in accredited training and perform this activity on a regular basis in order to maintain their skills.
“Pharmacists are not in a position to diagnose COPD and would therefore need to have a relationship with the GPs in the area. A very good business model would need to be developed to make the delivery of a spirometry service in a pharmacy setting viable and accepted by other health professionals. The delivery of a COPD case finding activity in the pharmacy setting is a much better option and has greater acceptance,” she says.
An important role that pharmacists can easily involve themselves in is promoting general lung health and raising awareness of COPD.
Allan says, “Pharmacists can promote better lung health in a variety of ways. Firstly, they can use Lung Foundation Australia’s Lung Health Checklist to identify those that have risk factors and symptoms that may require further investigation.
“Pharmacists can also participate in Lung Foundation Australia’s awareness raising campaigns such as ‘Have the Chat’ and ‘World COPD Day’. Pharmacists can share our key messages through social media as well as online and print newsletters. They can also have promotional materials in store to help start the conversation with customers, such as posters, shelf wobblers and printed resources like the Lung Health Checklist.
“Finally, pharmacists can promote lung health with patients already diagnosed via inhaler device checks, smoking cessation advice and referral to local programs such as pulmonary rehabilitation, local support groups and Lung Foundation Australia for self-management resources.”
Promoting better medication management
“Evidence suggests that patients are often intentionally non-adherent to their COPD medicines because they don’t perceive any benefits to their condition with treatment, or they experience side effects or are worried about potential side effects,” says Dr Andrew Boyden, NPS MedicineWise medical adviser.
“Pharmacists can address these concerns explaining both the expected benefits and potential side effects to patients, and providing guidance on when it might be appropriate to check-in with a GP.”
Key points that the pharmacist can discuss with COPD patients regarding their medicine include:
- What the medicine is for
- How the medicine works and the benefits for taking it as prescribed
- How long before the medicine takes effect
- How and when to administer the medicine (e.g. morning or night)
- How long the effects of the medicine last and how often they must take the medicine
- For how long they must take the medicine (e.g. short course or lifelong treatment)
- What the possible side effects of the medicine are and how to limit or avoid side effects, for example, long-term use of oral steroids increases the risk of osteoporosis
- If the medicine will interact with other medicines.
Allan says, “To increase treatment adherence it is important to develop relationships with patients and talk with them directly about what they are doing to look after their health, including how they are managing their medicines.
“Time is often cited as a barrier to working with patients. A discussion with the pharmacy team can help to develop a system which allows the pharmacists to directly engage with patients and every pharmacy will have its own way of delivering a service.
“Financing is another barrier, but there are many examples of pharmacists that have successfully set up appointment systems to work with patients on medicine adherence and COPD case finding. Some of these services are reimbursable via the MBS, for example MedsChecks and others are user pays.
“Another enabler is having a space to talk with patients privately and this can assist in building relationships to support better self-management,” she says.
A notable area where pharmacists can make a big impact is inhaler technique. Pharmacists can reinforce correct technique by asking patients to demonstrate how they use their device each time they dispense a device.
Dr Boyden says, “We know that up to 90% of patients don’t use their inhalers correctly. Pharmacists should check inhaler technique regularly. NPS MedicineWise, in collaboration with the National Asthma Council, developed an inhaler checklist (available online) that includes the steps required to operate 12 different devices,” he says.
O’Driscoll agrees, “Inhaler technique is certainly a problem, as is dexterity. We have a lady who has terrible arthritis and can’t use a single-dose dry powder inhaler because a capsule must be loaded before each use. Finding an alternative for her is confusing. Continuous product training is paramount for pharmacists to ensure they stay up-to-date with the latest medicines and devices.”
“The number of inhalers listed on the PBS has doubled since 2014. This means health professionals can choose from a wider variety of device types to match individual patient needs. Spacers are usually recommended for use with pressurised metered dose inhalers, because they need less hand-breath coordination and they improve lung deposition,” says Dr Boyden.
“Pharmacists can refer patients who are having difficulties using their devices to their GPs, and recommend alternative device types that may be more suitable.”
O’Driscoll says, “Determining the difference between the inhalers and how you use each of them will be an important role for pharmacy in the future. Pharmacists can certainly play a big part in helping to cut through the confusion while addressing dexterity problems too.”
November 15, 2017 is World COPD Day. Lung Foundation Australia has fact sheets and resources, including patient guides, available to download. Visit: lungfoundation.com.au.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has information, news and resources available to help keep health practitioners up-to-date with the latest advances in COPD. Visit: www.goldcopd.org.