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LONG-TERM CONDITIONS
214 British Journal of Community Nursing June 2018 Vol 23, No 6
The impact of community pharmacy-led medicines management support for people with COPD
Sarah Alton, Lisa Farndon Sarah Alton is Head of Community Pharmacy, Combined Community and Acute Care Group; Lisa Farndon is Clinical Research Podiatrist/Research Lead, Integrated Community Care Directorate; both at Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
It is estimated that three million people have chronic obstructive pulmonary disease (COPD) in the UK (Healthcare Commission, 2006), and it is the fourth lead- ing cause of death worldwide (Global Initiative for Chronic Obstructive Lung Disease (GICOLD), 2018). It has been defined as a non-fully reversible airflow obstruction, charac- terised by breathlessness; it is mainly caused by smoking or
exposure to air pollutants (National Institute for Health and Care Excellence (NICE), 2010). The condition can affect daily activities and reduce quality of life (Weldam et al, 2013).
Clinical diagnosis is based on shortness of breath, a chronic cough or sputum production and a history of exposure to a risk factor, which is followed by spirometry to confirm (GICOLD, 2018).
Treatment The goals of COPD treatment are to slow down disease progression, limit symptoms, increase overall health and prevent and treat flare-ups.
National guidelines set out best clinical practice for the assessment, diagnosis and management of patients with COPD (NICE, 2010). Treatment consists of non-pharma- cological and pharmacological interventions. Non-drug interventions and lifestyle advice, such as smoking cessa- tion, flu vaccination and pulmonary rehabilitation, should be offered to all patients with COPD. Rehabilitation pro- grammes can reduce the risk of hospital readmission and improve the quality of life and the short-term exercise capacity of people with COPD.
Inhaled therapies are the mainstay of treatment. Bronchodilators (short and long acting) have an important and established role in the management of COPD and have been shown to significantly reduce the risk of adverse outcomes such as COPD exacerbations (Department of Health (DH), 2012). The addition of inhaled corticosteroids may benefit patients who remain symptomatic despite regular treatment with a long-acting bronchodilator.
In most cases, bronchodilator therapy is best administered using a handheld inhaler device (including a spacer device if appropriate). If a patient is unable to use a particular device satisfactorily, it is not suitable, and an alternative should be found.
Inhalers should be prescribed only after patients have been trained in how to use them and have demonstrated satisfactory technique. Patients should have their ability to use an inhaler
ABSTRACT Chronic obstructive pulmonary disease (COPD) is a common long-term condition involving restricted airflow, which reduces quality of life. Treatments include lifestyle changes (smoking cessation), pulmonary rehabilitation and medication with inhaled therapies. However, medication adherence is often suboptimal, resulting in poor health outcomes. A pilot project assessed the impact of medicines management support from a community pharmacy team for people with COPD, delivered in their own homes. Individuals were given a medication review and an assessment of their inhaler technique and were followed up at 3 and 6 months. The COPD Assessment Test (CAT) score was administered before and after the intervention. A change in score of 2 or more suggests a significant difference; the average score was 19.2 at the first assessment and 16.7 at the six month follow-up. Seventeen patients had improved CAT scores, 10 patients had a reduced score and three remained unchanged. Most patients evaluated the project positively as it helped them to improve their inhaler technique. Medicines optimisation was also achieved as a person- centred approach was taken; suboptimal practice had not been picked up by health professionals previously. Community pharmacists working in integrated care teams provide invaluable support to patients with COPD. This project will be rolled out across the community team, and training on medicines management and inhaler technique provided to other health professionals involved in the care of these patients.
KEY WORDS w COPD w Pharmacist w Integrated community care w Integrated disease management
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device regularly assessed by a healthcare professional and, if necessary, should be retaught the correct technique.
Oral therapies such as theophylline can be used if symptoms persist or if the patient is unable to use an inhaler. Oral steroids and antibiotics (if there is sign of infection) can be used to manage exacerbations.
Nonadherence to COPD medication is estimated to be 30–70%; as much as 50% of this may be deliberate and 30% or more of these patients may be on suboptimal therapy for the severity of their disease (DH, 2012). Inhaler technique should therefore be assessed regularly to ensure patients get the best from their medication. There should be an emphasis on ensuring medicines are clinically appropriate, cost effective and acceptable by carrying out regular medication reviews to reduce waste, save money and improve outcomes for patients.
Aim The integrated care pharmacy team works with community nursing and therapy staff to provide medicines management support to housebound patients with long-term conditions.
There is increasing evidence to demonstrate that pharmacy- led care for people with long-term conditions can improve outcomes and reduce hospital admissions.
Between October 2015 and May 2016, the community pharmacy and nursing teams undertook a pilot project; the aim was to assess the impact of pharmacy-led medicines man- agement support (in addition to the routine annual nurse-led reviews for long-term conditions) in patients with COPD in one community nursing team in Sheffield.
Outcome measure The outcome measure was the COPD assessment test score before and after intervention as a measure of symptom assessment.
Patient selection This was a service improvement project so ethical approval was not required. An ‘intention to treat approach’ was adopted and all patients with a diagnosis of COPD on the GP register and the community nursing caseload were selected for inclusion.
The patients were referred to pharmacy by the community nursing team, and the pharmacy team contacted them to ask for their consent to visit to review their medication and to participate in the project; verbal consent was obtained for each patient.
Patients were excluded from follow-up if they declined to take part, if they could not be contacted or if they had been taken off the community nursing caseload.
Method All GP practices were contacted by letter to inform them about this initiative.
A member of the pharmacy team carried out an initial visit to assess each patient’s inhaler technique, then undertook a clinical medication review in line with local and national evidence-based guidelines.
At this visit, patients were asked to complete the COPD assessment test (CAT) (GlaxoSmithKline, 2012). This is a vali- dated questionnaire designed to measure the impact of COPD on a person’s life, and how this changes over time. It consists of eight simple questions that most patients should be able to understand and answer easily. CAT scores are in the 0–40 range, with 0 being very low impact/symptom severity and 40 indicating a very high impact/symptom severity. A change in score by 2 points or more suggests a significant alternation in health status. The CAT test was used to measure the impact of COPD on patients in the project group and to help inform discussions and decisions with regard to medicines manage- ment options.
CAT scores were recorded on each patient’s electronic record and in the pharmacy’s secure database for the project.
A follow-up visit was carried out after 3 months to reassess inhaler technique and provide further advice and support as appropriate. A third visit or phone call was made at 6 months to provide further support, reassess inhaler technique if need- ed, repeat the CAT questionnaire and follow up on any rec- ommendations from previous visits (Table 1).
Results Fifty-four patients were initially identified for inclusion. From this sample, nine were excluded for a number of reasons including: moving to a different care home out of the area; discharge from community nursing care; not using inhalers; declined visits; or being in hospital. Forty-five patients were therefore included in the project and were visited by a mem- ber of the pharmacy team.
The average number of visits received per patient was 2.9 within a range of 1–9. Six patients received fewer than two visits for the following reasons: declined follow-up; moved out of the area; or were awaiting hospital treatment; and one patient passed away during the study period. Some patients had more visits if they required additional input from the pharmacy team, for instance if any issues were identified at their medication review that needed follow-up, such as a change in formulation or inhaler that required counselling.
The average length of time spent visiting overall was 89 minutes per patient. More time was spent with each patient
Table 1. Visit schedule Initial visit 3 month follow-up 6 month review
ww Demonstrate and observe ww Initial holistic patient review ww Patient information leaflets provided ww COPD assessment test (CAT) questionnaire undertaken ww Liaise with GP to consider change of inhaler device ww Medication review and follow up as appropriate
ww Reassess inhaler technique ww Further advice and support ww Option for telephone call if needed
ww Repeat CAT questionnaire ww Final inhaler check ww Follow up any outstanding COPD changes/recommendations
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at the initial visit, with subsequent visits taking up less time. Most patients did not know how to use their inhalers cor-
rectly, so visits led to observed improvements in inhaler tech- nique. A number of significant interventions were made dur- ing the course of the project for individual patients: ww Smoking cessation advice was offered and accepted, result- ing in a reduction of 50% in the number of cigarettes smoked per day ww An Oxis Turbohaler replaced a Seretide inhaler as it was causing muscle cramps, which resulted in the patient report- ing that their chest felt much clearer and better ww A patient with a past history of stroke was referred to an occupational therapist/physiotherapist, as their medication was not suitable. They were swapped to a Fostair MDI with spacer and tidal breathing. Carers reported an improvement in symptoms ww A patient with dementia was using an inappropriate device
with a spacer. This was changed to one that was appropriate to use (also with a spacer), which improved symptoms and COPD control ww Medication was changed because a patient’s comoborbid condition had altered but they did not require hospital admission ww A patient was taking a tiotropium inhaler capsule orally, rather than via inhalation, as it had been prescribed in error without the inhaler device into which the capsule is placed; an inhaler was dispensed so the medication could be taken correctly ww Some patients were not able to use their inhaler device properly as they did not have sufficient lung capacity to activate it. These patients were switched to a more appropri- ate device that they were able to use ww Recommendations were made to prescribe spacer devices where these were indicated but had been omitted from the original prescription
Table 2. Change in CAT scores at baseline and 6 months follow up CAT score at baseline CAT score at 6 months Result Differential
19 12 Improved 7 points
18 17 Improved 1 point
4 4 Static n/a
24 24 Static n/a
28 15 Improved 13 points
5 21 Declined 16 points
15 5 Improved 10 points
26 31 Declined 5 points
18 14 Improved 4 points
11 10 Improved 1 point
19 20 Declined 1 point
19 16 Improved 3 points
23 10 Improved 13 points
14 19 Declined 5 points
24 20 Improved 4 points
27 24 Improved 3 points
32 29 Improved 3 points
9 11 Declined 2 points
4 11 Declined 7 points
6 3 Improved 3 points
18 16 Improved 2 points
17 17 Static n/a
33 12 Improved 21 points
23 26 Declined 3 points
20 29 Declined 9 points
12 9 Improved 3 points
33 14 Improved 19 points
27 28 Declined 1 point
24 16 Improved 8 points
19 20 Declined 1 point
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ww Recommendations were made to prescribe alternative therapies for patients with dementia as they were unable to use their inhalers appropriately. CAT scores were recorded in 30 patients. A number of
patients were unable to complete this questionnaire because of a cognitive impairment or because the questions were not relevant to their situation. The average score was 19.2 at the first assessment, and 16.7 at the six month follow-up. A change in score of 2 or more suggests a significant difference or change in health status. Seventeen patients reported an improved CAT score, 10 patients had a reduced score and three patients’ scores remained static (Table 2).
Medicines optimisation was achieved with this pilot project, as a person-centred approach to using medicines in a safe and effective way to ensure people obtained the best outcomes was possible with one-to-one input from the community pharmacy team. Problems may not always have been picked up previously by other health professionals or carers because of time constraints or a lack of training.
Feedback GPs were very positive about the project and acted on the recommendations of the team. Respiratory and practice nurs- es found communication with the pharmacy team very useful to keep them informed about any medication changes. The project raised the profile of the pharmacy team within the integrated care service and, as a result, they received more referrals for inhaler review. Patients valued the input from the pharmacists as it helped them to improve their inhaler tech- nique; many reported that they had never been shown how to use their inhalers correctly.
Discussion The data suggests that more patients showed an improvement than a decline in health status during the intervention period of this project. It is difficult to attribute the improvements directly to the pharmacy interventions, as patients may have been receiving care from other practitioners during this time, but it is likely that the pharmacy project contributed to this.
This study used an integrated disease management approach (Peytremann-Bridevaux et al, 2008) where different compo- nents of care are provided by different health professionals and delivery in a coordinated manner can maximise health out- comes. A large systematic review found this approach to be beneficial for patients with COPD, resulting in improved
quality of life and exercise tolerance up to a year after participat- ing in such a programme; hospital admissions related to exac- erbations in the disease were reduced (Kruis et al, 2013). However, these programmes were delivered in hospitals and GP clinics rather than patients’ own homes as in this current study.
Community pharmacists have been shown to improve symptoms of asthma that were previously poorly controlled in adults by demonstrating correct inhalation techniques and providing education on medicines adherence (Mehuys et al, 2006). They are therefore well placed to provide these types of interventions and can offer advice and support to other community practitioners.
Patients with dementia or significant cognitive impairment were not able to complete the CAT test. They also found it difficult to demonstrate their inhaler technique or use the devices, which are factors that have been highlighted as sig- nificant when investigating adherence with medicines, as part of the list of multifactorial influences for people with COPD (Bourbeau and Bartlett, 2008).
Conclusion This was a short, time-limited project that aimed to assess the role of the pharmacy team in the management of patients with moderate COPD, with a focus on inhaler technique, assess- ment and medication review.
Most patients did not know how to use their inhalers cor- rectly, so improvements in inhaler technique were shown after each visit. However, patients with cognitive impairment or dementia were not able to use their inhalers properly and treatment options for these patients are limited. Further research should be directed at improving inhalation tech- niques and ease of use for this group. Medicines optimisation is therefore not straightforward, which highlights the need for specific treatment guidelines to be developed for housebound patients with comorbidities and cognition problems.
Patients appreciated the time taken by the team and found the face-to-face contact invaluable, resulting in improvements in inhaler technique and medicines optimisation that had not been picked up elsewhere.
Further evaluation is needed to assess the impact of this intervention on exacerbations and hospital admissions.
It is hoped that inhaler technique training will be intro- duced for support workers so they can reinforce techniques at each patient contact. Advice and support for carers on medicines management and inhaler technique could improve overall compliance.
Further work will investigate how community pharmacy and nursing teams can work together on COPD reviews to ensure different skills can be used for patient benefit to work towards a true integrated disease management programme. Highlighting and referring patients to other services that can help with COPD, including pulmonary rehabilitation, Breathingspace community respiratory specialist nurses and community smoking cessation support, will also be incorpo- rated into future training. BJCN
Accepted for publication: April 2018 Declaration of interest: None
KEY POINTS ww Chronic obstructive pulmonary disease (COPD) is a common long-term condition in which airflow is restricted
ww While COPD is often managed using inhaled medication, many patients do not use inhalers correctly
ww Community pharmacists working in integrated care teams provide invaluable support to patients with COPD
ww The COPD assessment (CAT) test is a questionnaire that measures the impact of COPD on a person’s life
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Bourbeau J, Bartlett SJ. Patient adherence in COPD. Thorax. 2008; 63(9):831–838. https://doi.org/10.1136/thx.2007.086041
GlaxoSmithKline. COPD assessment test. 2012. https://tinyurl.com/y8zpppge (accessed 1 May 2018)
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD. 2018 https://tinyurl.com/ yb2dv6jh (accessed 2 May 2018)
Healthcare Commission. Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission; 2006
Kruis AL, Smidt N, Assendelft WJ et al. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2013; (10):CD009437. pub2. https://doi. org/10.1002/14651858.cd009437.pub2
Mehuys E, Van Bortel L, Annemans L et al. Medication use and disease con- trol of asthmatic patients in Flanders: a cross-sectional community pharmacy
CPD REFLECTIVE QUESTIONS ww Would reviewing medicines for a group of your patients result in some better outcomes?
ww Could you introduce the COPD Assessment Test for your patients with Chronic Obstructive Lung Disease to assess this disease on their quality of life and map any changes over time?
ww Are there any examples in your practice where an integrated disease management approach is used?
study. Respir Med. 2006; 100(8):1407–1414. https://doi.org/10.1016/j. rmed.2005.11.013
Department of Health. An outcomes strategy for COPD and asthma: NHS com- panion document. 2012
National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Clinical guideline [CG101]. www.nice.org.uk/cg101 (accessed 2 May 2018)
Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B.. Effectiveness of chronic obstructive pulmonary disease-management pro- grams: systematic review and meta-analysis. Am J Med. 2008; 121(5):433–443. e4. https://doi.org/10.1016/j.amjmed.2008.02.009
Weldam SW, Lammers JW, Decates RL, Schuurmans MJ. Daily activities and health-related quality of life in patients with chronic obstructive pulmonary disease: psychological determinants: a cross-sectional study. Health Qual Life Outcomes. 2013;11:190. https://doi.org/10.1186/1477-7525-11-190
Fundamental Aspects of Community Nursing
Edited by John Fowler
n What does it feel like to be a student on your community experience?
n How do the various nurses who work in the community organise their time and plan their care?
n What does a practice manager do?
n What does it feel like to be a patient in the community?
This is a text book written by a variety of people who are delivering or receiving community nursing. It captures the lived experience of community nursing in a way that seamlessly combines theory and practice underpinned by a core belief in holistic care.
ISBN-13: 978-1-85642-302-1; 234 x 156 mm; paperback; 136 pages; publication 2006; £19.99
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Fundamental Aspects of Community Nursing Edited by John Fowler
Fundamental Aspects of Nursing series
Fundamental Aspects of Community Nursing Edited by John Fow
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About the book What does it feel like to be a student on your community experience? How do the various nurses who work in the community organise their time and plan their care? What does a practice manager do? What does it feel like to be a patient in the community? This is a text book written by a variety of people who are delivering or receiving community nursing. It captures the lived experience of community nursing in a way that seamlessly combines theory and practice underpinned by a core belief in holistic care. As you read each chapter you cannot fail to be inspired by the commitment of the health care professionals and the quality of care that they display to their patients, students and each other.
About the author Dr John Fowler has a joint appointment as Principal Lecturer in Nursing at De Montfort University & Nursing Educational Consultant to Leicester City West PCT. Much of his current work focuses on helping people learn from their clinical experiences either through clinical supervision or independent study.
Other titles in the Fundamental Aspects of Nursing series include: Adult Nursing Procedures Caring for the Acutely Ill Adult Caring for the Person with Dementia Complementary Therapies for Health Care Professionals Gynaecology Nursing Legal, Ethical and Professional Issues in Nursing by Men’s Health Tissue Viability Nursing Palliative Care Nursing Women’s Heath
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