Evaluation of a Community Pharmacy Inhaler Check Service
A Report for NHS Doncaster Clinical Commissioning Group (CCG)
May 2014
Evaluation of a Community Pharmacy Inhaler Check Service
A Report for NHS Doncaster Clinical Commissioning Group (CCG)
May 2014
Abstract
Aim and Objectives: To evaluate a Community Pharmacy Inhaler Check Service. To identify the number of patients using the service, inhaler use issues identified and interventions provided by community pharmacists, exploring patient satisfaction with the service and ideas for service development/improvement.
Setting: Twenty-nine community pharmacies across Doncaster.
Methods: A mixture of research methods were used for data collection: audit of 616 consultations and analysis of 577 patient satisfaction questionnaires. Audit and questionnaire results were analysed using descriptive statistics, qualitative comments using a thematic approach.
Key Findings: A total of 400 patients had an initial inspiration rate (IR) out of the optimum range for their inhaler device. The majority of patients were prescribed a metered dose inhaler (MDI), 79% of these patients did not achieve the optimum IR on initial assessment. Sixty percent of patients were using one type of inhaler only, the number of different inhaler devices ranged from 1-3. A statistically significant relationship (p>0.001) was found between patients prescribed MDIs not achieving the optimum IR rate on initial assessment and reporting that they had not had any previous instruction. Following consultation with the pharmacist over 98% of patients achieved the optimum IR for their inhaler device. Patients expressed a high level of satisfaction with the service.
Conclusion: The evaluation demonstrates the need for regular inhaler technique checks. Many patients had not achieved optimum IR for their inhaler device on initial assessment, however the community pharmacists were able to support almost all these patients to achieve the optimum IR by the end of their consultation. Community pharmacists have a key role in improving inhaler technique and inhaled medicines use, complying with recommendations made in current guidelines for asthma and COPD.
The service is beneficial to patients and the wider NHS; improving inhaler use can improve condition control improving quality of life, reducing hospital admissions and even deaths, funding should continue.
Acknowledgements
The author of this report would like to acknowledge and thank all those who participated in and assisted with this service evaluation. Firstly I would like to thank the patients who took the time to complete feedback questionnaires during the course of the evaluation. I would especially like to thank Mark Garrison for giving up his time to help promote the service.
I would like to acknowledge all the community pharmacists and their support staff who engaged with and delivered this service, and submitted data for evaluation. I would like to acknowledge the work done previously by the pilot Pharmacy Local Professional Network for NHS South Yorkshire & Bassetlaw, in particular; Matt Auckland, Nicola Gray, Richard Harris and Nick Hunter, on which this service has been based.
I would like to acknowledge the contributions made by NHS Doncaster Clinical Commissioning Group in implementation and evaluation of the service, especially; Jonathan Briggs, Ian Carpenter, Martha Coulman, Dr Andrew Oakford and Emma Smith.
Finally I would like to thank fellow members of Doncaster Local Pharmaceutical Committee and colleagues at H. I. Weldrick Ltd for their help and support in implementing and evaluating the service; Paul Chatterton, Michelle Foley, Richard Harris, Nick Hunter, Darren Powell, Richard Wells and especially Alison Ellis for her hours spent data inputting.
This service evaluation was commissioned by NHS Doncaster Clinical Commissioning Group.
Contents
Page
Introduction 5
Methodology and Methods 10
Results 14
Discussion 29
Conclusions 35
References 36
Appendices 38
For further information regarding this evaluation please contact:
This report was written by Claire Thomas MPharm, MSc, MRPharmS, GPhC, Doncaster LPC Member on behalf of NHS Doncaster Clinical Commissioning Group.
1. Introduction
Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common respiratory conditions in the United Kingdom (UK). Asthma is a multifactorial and often chronic respiratory condition that can result in episodic or persistent symptoms and in episodes of suddenly worsening wheezing (asthma attacks/exacerbations) that can prove fatal. Symptoms include; intermittent presence of wheeze, breathlessness, chest tightness and cough. Airway obstruction results from airway hyper-responsiveness and inflammation resulting in swelling of airway walls and accumulation of secretions. Triggers can include viral infections, exercise and allergens. Up to 5.4 million people in the UK are currently prescribed treatment for asthma. During 2011-12 there were more than 65,000 hospital admissions for asthma in the UK. Asthma is still killing people and the number of reported deaths in the UK is the highest in Europe.1
COPD is characterised by airflow obstruction that is not fully reversible. The obstruction does not change markedly over several months and is usually progressive. COPD is predominantly caused by smoking however occupational exposures may also contribute to the development of COPD. Exacerbations occur where there is a rapid and sustained worsening of symptoms. The airflow obstruction occurs because of a combination of airway and parenchymal damage caused by chronic inflammation that differs to that seen in asthma. COPD is estimated to affect 3 million people in the UK. It produces symptoms, disability and impaired quality of life.2 One person with COPD dies every twenty minutes in England, which is approximately 23,000 deaths a year. Death rates are almost double the average for Europe. 15% of those admitted to hospital with COPD die within 3 months and around 25% die within a year of admission.3
The mainstay of treatment for both asthma and COPD is inhaled therapy. Short-acting bronchodilators (‘reliever’ inhalers) are used when required to relieve breathlessness/wheezing. Maintenance treatment is with ‘preventer’ inhalers such as those containing corticosteroids and/or long-acting beta2 agonists (LABAs) or long-acting muscarinic agonists (LAMAs) in the case of COPD.2,4 There is a wide range of different inhaler devices on the market with different mechanisms of drug delivery in to the lungs. Examples include metered dose inhalers (MDIs) and dry powder inhalers (DPIs) e.g. TurbohalerTM and AccuhalerTM. Different devices require patients to use different inhalation techniques and inspiration rates (IR). Many patients are prescribed more than one different type of inhaler device.
It is widely recognised in primary care that inhaler technique among patients is often poor.5 Whilst prescribing might be optimal, if a patient is not using their inhaler properly this can lead to poor condition control and medicines waste either lost in to the atmosphere or in to the body if the medicine is swallowed. Poor condition control can lead to more intensive management such as unnecessary hospital admissions, increased practice visits, and higher preventer inhaler doses.6 Any drug that gets into the body but not into the lungs is undesirable and can result in side effects. Beta2 agonists can cause tremor and tachycardia. Inhaled corticosteroids can cause oropharyngeal candidiasis (oral thrush) and systemic effects such as hypertension and reduced bone mineral density.
Performing a check of inhaler technique and practical instruction of inhaler use by an expert should be the first line of action if a patient’s symptoms are not controlled. There is a concern that many health professionals do not know themselves how to teach inhaler technique.7 Pharmacists are all taught as part of their undergraduate course about different inhaler devices.6 Community pharmacists with their knowledge of inhaler use and frequent contact with inhaler users should be commissioned to provide services to support patients to optimise the use of their inhaled medicines.
The pilot Pharmacy Local Professional Network for NHS South Yorkshire & Bassetlaw developed a respiratory support service that could be deployed within existing Medicines Use Review (MUR) or New Medicines Service (NMS) consultations. Supported by Barnsley, Bassetlaw, Doncaster, Rotherham and Sheffield Local Pharmaceutical Committees (LPCs), the project ran from September 2012 until the March 2013. Evaluation of the service concluded: most people were not in the optimum inspiration rate (IR) range for their inhaler device, however the pharmacists helped over 1,000 people achieve the range during one consultation.
There was little need to contact prescribers. Most patients agreed that their knowledge and confidence had increased. By encouraging people to maintain good inhaler technique it could lead to a potential reduction in hospital admissions, GP consultations, prescribing and other NHS costs.6
There are examples of similar community pharmacy respiratory projects across the country, some of which have demonstrated reduction in prescribing costs and hospital admissions such as one in the Isle of Wight . The project, involving enhanced consultations for COPD/asthma patients, reported that reliever therapy (measured by ePACT) showed that within the first year costs of selective beta-agonists fell by 22.7% - a saving greater than seven times the initial investment by the PCT. Additionally, within 12 months, the Isle of Wight PCT was able to demonstrate that emergency admissions due to asthma had reduced by 50%, and deaths by 75%.8
NHS Yorkshire and the Humber evaluated a project where pharmacists and technicians received advanced inhaler technique training and targeted patients for respiratory MUR or NMS consultations. The pharmacists and technicians successfully retrained 97.7% of patients who had been found to be using their inhaler device incorrectly.9 In Wessex, the Inhaler Technique Improvement Project was able to show improvement in the health of people with COPD and asthma using the Asthma Control Test (ACT) and COPD assessment scores. Benefits included secondary care reduction in emergency admission, reduction in medicines waste and reduced prescribing due to improved symptom control.10 In Greater Manchester a Community Pharmacy Inhaler Technique service evaluation found that patients seen by a pharmacist showed improvements in inhaler technique, target inspiration flow rate, asthma/COPD control indicators and quality of life measures.11
Doncaster has a population of around 302,402.12 Figures from records at GP practices in Doncaster in 2010/11 show the number of patients registered with a diagnosis of COPD was 7,711 and with a diagnosis of asthma was 21,023.13. Between April 2013 and February 2014 there were 313 emergency admissions for asthma at Doncaster Royal Infirmary with inpatient costs totalling £306,127. During the same period there were 869 emergency admissions due to COPD with an inpatient cost of £1,871,651.14 Improved inhaler technique and adherence with prescribed inhaled medication may help reduce the number of emergency admissions due to COPD and asthma in Doncaster.
A confidential enquiry published recently; the National Review of Asthma Deaths (NRAD) calls for an end to complacency around asthma care so that more is done to save lives. This enquiry from the Royal College of Physicians is the first national investigation of asthma deaths in the UK and the largest study worldwide to date.1 This enquiry found there was widespread under-use of preventer inhalers and excessive over-reliance on reliever inhalers. There was evidence of inappropriate prescribing of LABAs with 3% of patients prescribed a LABA without an inhaled corticosteroid. 10% of patients who died did so within one month of discharge from hospital following treatment for asthma; at least 21% had attended an emergency department at least once in the previous year. Nineteen percent of those who died were smokers and others were exposed to second hand smoke in the home.1
NRAD recommends; better monitoring of asthma control; where loss of control is identified, immediate action is required. All asthma patients who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should have an urgent review of their asthma control. An assessment of inhaler technique should be routinely under taken annually and when a new device is dispensed. Non-adherence to preventer inhaled corticosteroids is associated with increased risk of poor asthma control and should be continually monitored. Where LABAs are prescribed for people with asthma they should be prescribed with an inhaled corticosteroid in a single combination inhaler device. There needs to be better education for patients to make them aware of the risks. They need to be able to recognise the warning signs of poor control and what to do during an attack.1 Current guidelines for the management of patients with COPD recommends that patients should have their ability to use an inhaler device regularly assessed by a competent healthcare professional and if necessary, should be re-taught the correct technique.2
As previous studies have shown community pharmacists have the skills and knowledge to help improve use of inhaled medication and through opportunistic targeting of patients when they present at the pharmacy they may be able to provide interventions to patients who may not routinely access services and support from their GP practices. Doncaster Local Pharmaceutical Committee (LPC) secured Winter Pressures funding from NHS Doncaster to re-commission the respiratory support service developed by the pilot Pharmacy Local Professional Network for NHS South Yorkshire & Bassetlaw in Doncaster from January to March 2014 to improve management of respiratory conditions in Doncaster. This report is an evaluation of this service.
1.1 Description of Service
The service aims to improve the management of patients with respiratory conditions by trained pharmacists undertaking targeted inhaler technique training to ensure that patients use inhalers correctly. Patients aged 18 and over, including those who reside in a nursing/residential home or are housebound are eligible for the service. Pharmacies target patients who have been prescribed an inhaler and offer them a face-to-face review with the pharmacist and training in use of their inhaler, using the In-check DIALTM device. This could be part of a Medicines Use Review (MUR) or a New Medicines Service (NMS) with patients who use inhalers. The service includes a discussion about the diagnosis of respiratory disease (specifically asthma or COPD), pattern of use of different medicines (including inhaled and oral forms), and symptom control as well as assessment of inhaler technique. Pharmacies also accept referrals from other members of the health care team who consider that a patient would benefit from this service.
Interventions made as part of an inhaler technique check may, but not exclusively include: advice on inhaler usage aiming to develop improved adherence, effective use of ‘preventer’ inhalers, effective use of ‘reliever’ inhalers, ensuring appropriate use of different inhaler type, identification of the need for a change of inhaler type to facilitate effective use and appropriate referral to GP or nurse prescriber when necessary. The service specification can be found in Appendix 1.