We’ve all been there…nervously reading the patient information leaflet of a new inhaler device that we’ve been asked to counsel a patient on in the thirty seconds we have before we hand out the medication, whilst the patient looks on impatiently from the shop floor.
It can be a daunting and overwhelming to consider navigating the ‘inhaler wall’. It is lined with multiple choices of device, colour, inspiratory flow rate, names and molecules.
As pharmacists we are expected to be experts when it comes to medication counselling, as if we have an innate ability to simply pull important information from thin air that we are then able to relay to patients with relative ease. This wonderful superpower in turn ensures the safe and effective use of said medication.
This sounds simple enough, surely it is within our job description? However, this is actually far harder to achieve - especially when you take into account the fairly low access that community pharmacists have to training events and learning resources to maintain an up to date knowledge within each disease area.
I’m sure that amongst my peers will be those that feel hugely confident in undertaking a full Medicines Use Review (MUR) with an asthma patient or counselling a newly diagnosed COPD patient in how to use their inhaler during a New Medicines Service (NMS). Despite this, I believe that due to the exponential growth of the respiratory market over the past decade, this will not be the case for the majority of community pharmacists.
The national picture
According to the British Lung Foundation, there are an estimated 1.2 million people living with diagnosed COPD1 in the UK and that over 8 million people have been diagnosed with asthma2. What is more astounding is the fact that within the UK, 3 people die daily from asthma induced causes3 and that an estimated 30,000 people die from COPD per year1. Despite the unfortunate fact that these diseases cannot be cured, they can still be effectively treated, therefore as pharmacists we have a real opportunity to make a difference.
The changing role of community pharmacist in respiratory care
Despite the difficulties that are presented by the explosion in the inhaled therapy market, it also means that the choice available to a patient is greater than ever before. This allows us to really take the approach that would find ‘the right inhaler for the right patient’ to ensure that the patient receives the best possible care in the format that serves them best.
I believe that in order for us to deliver outstanding patient care, we must first confront the fact that generally speaking, most community pharmacists are not entirely confident in dealing with respiratory patients. Yes – of course we can check that their inhaler has been prescribed at the correct dosage, that the drug selected from the shelf matches the one on the prescription, that the legalities are all as they should be but there is so much more to it than just these points.
Are we capable of assessing if the inhaler prescribed is the correct device for the patient? That the patient is adherent to the prescribed therapy? That the patient feels confident using their device(s)? Can we relay the technique required to inhale optimally from a pMDI or a DPI? Are we comfortable questioning the patients' use of reliever therapies?
Do we ask probing questions to ensure that the patient understands the definition of asthma control or sufficient COPD symptom management? Do we eloquently explain what constitutes an acute exacerbation of symptoms? Do you go through all counselling points associated with using a spacer?
If we do not feel confident in our own knowledge and the answers to the above questions, then are we really likely to provide the best care to our patients?
How can we improve upon the level of respiratory care we provide?
The easy fix of course, is to seek training in any way that we can. Most LPCs will have a newsletter in which they list local training events that are open to community pharmacists and this would be a good place to start. Don’t be afraid to proactively contact any practice-based pharmacists or clinicians that you know from local surgeries to see if they are aware of any meetings that you would be welcome to attend, or any learning resources that you could access. It can be difficult to fit in training time with the increasing workload in community pharmacy, but it is something that I feel should be prioritised due to the impact that our skills have on patient care.
It is worth noting that I do understand that we do not have an abundance of free time to deliver hour long, one on one counselling in medication use reviews or new medicine services with all patients. It is often easy to spot an exacerbating COPD patient due to the recurrent oral steroid prescriptions and breathlessness, or a wheezing asthmatic with their frequent salbutamol collections but it can be hard to know which questions should be asked within an MUR or an NMS. In my experience, the best remedy for this has been the application of the ‘Asthma Control Test (ACT)’4 and the ‘COPD Assessment Test (CAT)’5.
The beauty of these questionnaires is their concise nature which gives you the blueprint of the important factors to consider when treating a respiratory patient. Both the CAT and ACT are sensitive to changes in the patient’s symptoms, can assess the impact of asthma/ COPD on the patient’s life and are simple for all clinicians to use.
The Asthma Control Test (ACT)
The ACT is 5 questions long and allocates up to 5 points per question. The higher your mark, the better your asthma control is thought to be, with a score of over 20 thought to be ‘on target’. The test asks patients to relay their symptoms over the past 4 weeks, with questions regarding reliever use, shortness of breath and how the patient would rate their overall asthma control. This gives us, as pharmacists, an opportunity to really probe the patient on their understanding of what constitutes good asthma control and what reliever use would look like in a well-controlled patient. This test should ideally be carried on a regular basis so that the patient is able to determine if their asthma control has improved over time. It can be worth keeping a record on the electronic patient medical record so that the pharmacist can easily determine if the patient is continually getting the most from their prescribed treatment. It can also be a great tool to use within an NMS so that you can compare the results from the patient prior to initiation of their new therapy in comparison to after a month of use.
The CAT is comprised of 8 questions, with a sliding scale used to allocate points from 1 to 5 depending on the severity of the patient’s symptoms. The lower your score on the test, the less symptomatic you are believed to be. This test is utilised within GOLD guidelines as part of the treatment pathway for individuals with COPD. As with ACT, we can keep a record CAT results on the electronic PMR to establish if the patient’s lung function is being maintained and that the chosen therapy is still effective.
Both tools can be handed to the patient whilst they await their medication dispensing and can subsequently be discussed in greater depth during the medicines use review consultation or new medicine service sign up. The information provided should give us a starting point to develop a clear understanding of the respiratory patient sat in front of us and also the confidence to challenge, support and counsel a patient on their inhaler use.
One of the suggestions made by the ‘Taskforce for Lung Health’ in their recent ‘National Five Year Plan’6 was to remove the 400 MURs per year cap so that patients could always access expert help from pharmacists in regards to their medications and it is my strong feeling that as the value of the MUR is being acknowledged and accepted, it is hugely important for us to truly demonstrate what can be accomplished through the use of these reviews.
Whilst the role of community pharmacist is still developing, the challenge ahead of us is to adapt to the needs of our patients and ensure that they are met with the best care possible each time they come in to our stores.
If we can identify a struggling patient, ask the right questions, counsel effectively and take the time to truly listen – we could have a great impact on quality of life and the long term health outcomes of the patients that we see on a regular basis.
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