Weighing up the benefits

Extensive review including RCTs reveals positive impact of community pharmacy interventions for adults with asthma

A narrative review led by pharmacist researchers and published this month in Research in Social and Administrative Pharmacy has examined the evidence of asthma management in the community pharmacy setting.

The researchers from Liverpool John Moores University in the UK reviewed 20 studies conducted in community pharmacies across different countries between 2001 and 2020.

These included randomised controlled trials (RCTs), controlled trials and observational studies.

Eight of these were Australian studies, with two from Italy and the remainder from the UK, the US, Serbia, Turkey, Spain, Belgium, Germany, France, Lithuania and Finland.

Studies were eligible if they were undertaken in a community pharmacy, provided an intervention to improve asthma control in adult patients with asthma (identified as over 17 years of age). The intervention must have been provided by a community pharmacist.

Among the 20 studies, 19 saw the intervention delivered face to face, with one involving educational material sent to patients by mail.

All of the interventions assessed involved patient education, based around asthma, asthma management and monitoring including self-management skills, for example, monitoring of peak flow readings, symptoms and exacerbations, asthma medication and/or adherence and inhaler technique.

A variety of outcomes were measured to evaluate the interventions.

Thirteen studies measured the effect of the pharmacist’s intervention on asthma control. Four of these reported a significant increase in the number or proportion of patients with controlled or improved asthma after receiving the intervention.

In a Spanish cluster RCT, the number of patients with controlled asthma increased from 28% to 58.1%.

Furthermore, in an Italian RCT, the proportion of patients with controlled asthma was increased by 40.2% and 45% for the two intervention groups that were provided medicine use reviews compared to the control group.

A third study from Lithuania used parallel controlled design and results showed the proportion of patients with controlled asthma increased from 32.56% to 47.6% in the intervention group. The findings of a prospective intervention study from Serbia showed significant increase in asthma control, measured by Asthma Control Test score, in 60% of the patients.

A 2012 Australian study reported significant improvement in asthma control in both study groups who received either a three-visit and a four-visit intervention.

However, there was no significant different in the improvement in asthma control and Asthma Control Questionnaire scores between the two groups (comparing three or four-visit interventions).

Meanwhile another Australian study, a cluster RCT which involved community pharmacies implementing the Pharmacy Asthma Care Program, reported a significant decrease in the proportion of patients with severe asthma in the intervention group from 87.9% to 52.7% and no change in the control group.

Three Australian cluster RCTs reported a decrease in the reliever inhaler use in the patients after receiving the community pharmacy intervention.

Nine studies assessed the medication adherence in asthma patients after receiving intervention by pharmacists using many tools. Seven of these found the intervention had a positive impact on medication adherence in asthma patients.

However two studies found no difference in medication adherence in asthma patients during the study period.

Improvement in asthma patients’ knowledge was reported in four out of six studies looking at this outcome.

Only one study measured the cost-effectiveness of the pharmacist’s intervention. In this study, quality of adjusted life years was used to measure the cost-effectiveness of medicine use reviews in Italy. The findings suggested that reviews, targeted to asthma patients in community pharmacy, were effective and showed a 100% probability of being more cost-effective than the usual care.

Studies included in the review used different study designs, assessed different asthma interventions and measured a variety of outcomes, the authors pointed out.

“Accordingly, there was a variability in the quality of the studies in terms of the study design and intervention provided,” they stated.

More than half (55%) of the included studies showed a good quality rating of the study design and 75% of the studies provided good quality rated asthma interventions.

In this review, asthma intervention provided in community pharmacy had a positive impact mainly on asthma control and inhaler technique.

Most of the included studies had many strengths including the use of validated tools to measure the outcomes, comparison of the intervention with usual care and a study period of six months or more.

On the other hand, the limited sample number in some studies limited the generalisability of the results.

The variability in interventions provided and measured outcomes among the included studies made it impossible to run a quantitative analysis of the findings, said the researchers.

However, overall, the evidence showed there were several successful community pharmacy-based interventions that helped patients improve their asthma management.

“In this review, asthma intervention provided in community pharmacy had a positive impact mainly on asthma control and inhaler technique,” they said.

“Moreover, the studies showed a potential role for community pharmacy to identify and solve medication and self-management problems in asthma patients.

“Such interventions showed improvement in medication use and adherence, patient knowledge and self-efficacy and quality of life. Interestingly, no decrease in A&E visits or hospitalisation were reported in any of the studies.

“The evidence showed that community pharmacy is well-placed to support the management and control of asthma in adult patients.”

Further research could explore the use of technology in the delivery of asthma interventions in the community pharmacy setting, the researchers suggested.

Read the full narrative review in Research in Social and Administrative Pharmacy

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