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Loh ZC, Hussain R, Ong SC, Saini B, Muneswarao J, Ur-Rehman A, Babar ZUD. Over-the-counter use of short-acting beta-2 agonists: a systematic review. J Pharm Policy Pract 2023; 16:119. [PMID: 37814312 PMCID: PMC10561505 DOI: 10.1186/s40545-023-00627-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/28/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND The widespread use of short-acting beta-2 agonists (SABA) as an as-needed treatment for asthma is well-established. However, excessive use of SABA has been linked to undesirable outcomes such as increased risk of asthma attacks, exacerbations, and even death. The availability of SABA as an over-the-counter (OTC) medication has contributed to their overuse, leading to undertreated asthma and reduced access to asthma education. OBJECTIVE This systematic review aimed to summarize the prevalence, characteristic features of, and factors contributing to over-the-counter SABA purchase or overuse. METHODS The databases searched included PubMed, Scopus, Springer Link, Google Scholar, CINAHL, and APA PsycArticles. Original research articles reporting the prevalence, characteristics features, and factors regarding over-the-counter SABA use, available as full text, published in English language between the year 2000 and April 2023 were included in this review. Commentaries, letters to editor, review articles, qualitative studies, clinical trials, and conference proceedings were excluded. Data extraction was followed by a review of the quality of studies included and data were then synthesized for meaningful findings. This systematic review had been registered in the PROSPERO with registration number CRD42023421007. RESULTS A total of 18 articles were included. The prevalence range of OTC SABA users in populations were 1.4% to 39.6% and SABA over-users among OTC users were 14% to 66.4%. Factors mostly associated with this behavior were moderate-severe asthma, and less use of preventers. On top of that, not understanding the risk of SABA overuse was clear in many studies that explored this factor. CONCLUSION Over-the-counter purchase and overuse of SABA medication is a common problem, leading to adverse consequences such as uncontrolled asthma and increased healthcare utilization. Addressing these issues requires improved patient education about their conditions and adequate information regarding the potential long-term effects of SABA use by the healthcare providers. Management and education of asthma patients, including regular monitoring and follow-up, can help reduce overuse of SABA medication and prevent negative consequences.
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Affiliation(s)
- Zhe Chi Loh
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia
| | - Rabia Hussain
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia.
| | - Siew Chin Ong
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Gelugor, Pulau Pinang, Malaysia
| | - Bandana Saini
- Faculty of Medicine and Health, University of Sydney School of Pharmacy, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Jaya Muneswarao
- Pharmacy Department, Hospital Pulau Pinang, 10990, George Town, Pulau Pinang, Malaysia
| | | | - Zaheer-Ud-Din Babar
- Department of Pharmacy, University of Huddersfield, Huddersfield, HD1 3DH, UK
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Schackmann L, Vervloet M, van Dijk L, Heringa M, Koster ES. Communication during encounters about medication switching: Self-reported experiences of pharmacy technicians and patients. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100259. [PMID: 37091628 PMCID: PMC10114223 DOI: 10.1016/j.rcsop.2023.100259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 03/20/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background During conversations about medication switches, pharmacy staff often deliver a message to patients that may lead to negative emotions. In these situations, clear and patient-centered communication is important. Aim To gain insight into pharmacy technician-patient experiences regarding the communication during medication switching encounters, and in specific to map the needs and preferences of patients and whether pharmacy technicians (PTs) meet these. Method PTs were invited to fill in a questionnaire via the Dutch Panel on practical research for Pharmacy Employees. Online questionnaires were distributed to adult chronic mediation users in two patient panels. Questionnaires contained questions on how PTs and patients experience the medication switch conversations at the moment (i.e. type of information patients need/receive, timing of information, channel, communication style), and whether the needs and preferences of patients are met. Results In total, 138 PTs and 4679 patients responded. PTs indicated that they regularly struggle with these conversations due to emotional or negative responses of patients. Most patients expressed the need for information about why the medication switch took place (68%) and about the (same) effect of the medication (61%), while fewer patients currently receive this information (21% and 39%, respectively). Patients also indicated they need verbal information during pick-up/delivery (45%), written information beforehand (29%) and during pick-up/delivery (25%), while patients more often receive verbal information during pick-up (58%), and less frequently receive written information beforehand (6%) and during pick-up/delivery (18%). Conclusion Communication during medication switch conversations generally goes well. However, there is a difference between what PTs claim they do and what patients experience, e.g. space for questions and patients' satisfaction about this aspect. Dealing with patient emotions is also difficult for PTs. Patients emphasize they need more information than they currently receive, preferably before switching. Matching these needs and preferences can improve patient-centered communication.
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Affiliation(s)
- Laura Schackmann
- Nivel, the Netherlands
- University of Groningen, the Netherlands
- Correspondence author at: Nivel, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, the Netherlands.
| | | | - Liset van Dijk
- Nivel, the Netherlands
- University of Groningen, the Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, the Netherlands
| | - Ellen S. Koster
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, the Netherlands
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Paske RT, van Dijk L, Linn AJ, van Boven JFM, Koster ES, Vervloet M. Better use of inhaled medication in asthma and COPD through training, preparation and counselling: the On TRACk study protocol for a cluster randomised controlled trial. BMJ Open 2022; 12:e061266. [PMID: 36691116 PMCID: PMC9454022 DOI: 10.1136/bmjopen-2022-061266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/27/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION About 70% of patients with asthma and/or chronic obstructive pulmonary disease (COPD) use their inhaled medication incorrectly, leading to reduced disease control, higher healthcare use and costs. Adequate guidance from the pharmacy team from first dispense onwards can benefit patients in the long run. We propose an intervention ('On TRACk') to improve medication adherence and inhaler technique of adult patients with asthma and/or COPD. This intervention focuses on training pharmacy technicians (PTs) in patient-centred communication and inhalation instruction skills. In addition, patients are actively involved in refill consultations at the pharmacy. The aim of this study is to improve inhaler technique and better inhaled medication adherence among patients with asthma and/or COPD. This paper describes the study protocol. METHODS AND ANALYSIS A cluster randomised controlled trial (RCT) with an intervention and control group of 15 pharmacies each will be conducted. Per intervention pharmacy, two PTs will be trained online. Each PT will include five patients who will prepare their second and third dispense counselling sessions by selecting three topics they wish to discuss. Pharmacies in the control cluster provide usual care. In total, 300 patients (150 per group) will be included. Up to 12 months after inclusion, patients complete 3-monthly follow-up questionnaires. Both a process evaluation and a cost-effectiveness analysis will be performed alongside the trial. Trial effectiveness on the patient level will be evaluated after the 12-month follow-up period.Patient data will be collected through questionnaires and pharmacy refill data. Patients' inhaler technique will be visually assessed by PTs. Semistructured interviews with PTs and patients will be conducted regarding implementation and fidelity. Direct and indirect health costs will be collected to assess cost-effectiveness.The primary outcome is adherence to inhalation maintenance medication measured with pharmacy refill data. Secondary outcomes are inhaler technique, persistence, patients' attitudes towards medication, self-efficacy in medication use and communication with their PTs. ETHICS AND DISSEMINATION The study was approved by the Vrije Universiteit Amsterdam Ethics Committee (number: 2020.358). Results will be presented at (inter)national conferences and published in peer-reviewed journals. If proven to be (cost-)effective, the intervention should be considered for reimbursement and implementation in Dutch community pharmacies. TRIAL REGISTRATION NUMBER NL9750.
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Affiliation(s)
- R Te Paske
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Department of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Department of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, The Netherlands
| | - Annemiek J Linn
- Amsterdam School of Communication Research/ASCoR, University of Amsterdam, Amsterdam, The Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ellen S Koster
- Utrecht Pharmacy Practice network for Education and Research (UPPER), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
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Comparative educational outcomes of an active versus passive learning continuing professional development activity on self-management support for respiratory educators: A non-randomized controlled mixed-methods study. Nurse Educ Pract 2021; 57:103256. [PMID: 34814074 DOI: 10.1016/j.nepr.2021.103256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 09/16/2021] [Accepted: 11/10/2021] [Indexed: 11/21/2022]
Abstract
AIM We compared educational outcomes associated with an active vs. passive continuing professional development activity on self-management support for respiratory educators. BACKGROUND There is a need to identify learning activities associated with the most successful continuing professional development programs for respiratory educators. DESIGN This was a non-randomized controlled mixed-methods study recruiting respiratory educators attending a continuing professional development activity on self-management support. METHODS In the experimental group, active learning methods (role-play simulations) were employed, whereas passive learning methods (lecture) were used in the comparison group. Educators were allocated to the comparison group (first 15 months of the study), then to the experimental group (last 17 months). Educators filled questionnaires measuring pre-/post-activity knowledge about self-management support (score 0-25) and self-reported competence (score 1-10). Scores were compared using mixed-effect models. Interviews with educators were conducted and content analysis was performed. RESULTS We recruited 94/94 educators (active: n = 51; passive: n = 43). Knowledge scores increased to a greater extent in the active vs. passive learning group (adjusted difference-in-difference [aDID]=2.01; 95% confidence interval [95%CI]: 0.14-3.88), although competence scores increased to a greater extent in the passive learning group (aDID=-0.38; 95%CI: -1.56 to -0.04). Reflecting on their competence, educators of the active learning group identified the need to further improve their self-management support skills, whereas educators of the passive learning group did not. CONCLUSIONS Our results show that an active learning continuing professional development activity on self-management support could help educators to better apply knowledge and appears to engage them in a process of reflection on action.
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Alsubaie S, Grant D, Donyai P. The utility of Conversation Analysis versus Roter's Interaction Analysis System for studying communication in pharmacy settings: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 30:17-27. [PMID: 34741506 DOI: 10.1093/ijpp/riab068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare the usefulness of the Roter Interaction Analysis System with Conversation Analysis (CA) for studying dynamic patient-pharmacist interactions within pharmacy practice. A scoping review was undertaken to identify all studies using Roter's method or CA to investigate patient-pharmacist interactions. The studies were then compared and contrasted for their methodological advantages and disadvantages. KEY FINDINGS In total, 31 studies met the inclusion criteria. Roter's method is effective in briefly describing patient-pharmacist interactions and can be used to measure the effect of training courses without consuming too much time. CA, although a time-consuming undertaking, looks at very specific features and the sequence of conversations including the dynamics of two-way interactions and can therefore be used to identify the source of conflict or misunderstandings. A flowchart showing the usefulness of both methods is suggested to help other researchers select the appropriate method(s) for their own research. SUMMARY Although both methods are effective for investigating patient-pharmacist interactions independently, using them sequentially could enable researchers to firstly identify how to make improvements (via CA), design relevant training and then investigate the impact of such training (via Roter's method) to enrich communications research.
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Affiliation(s)
- Sarah Alsubaie
- School of Pharmacy, University of Reading, Whiteknights Campus, Reading, UK
| | - Daniel Grant
- School of Pharmacy, University of Reading, Whiteknights Campus, Reading, UK
| | - Parastou Donyai
- School of Pharmacy, University of Reading, Whiteknights Campus, Reading, UK
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Hallit S, Zeidan RK, Saade S, Hajj A, Hallit R, Akel M, Yahchouchy C, Kheir N, Iskandar K, Sacre H, Salameh P. Knowledge, Attitude and Practice of Lebanese Community Pharmacists toward Chronic Obstructive Pulmonary Disease. J Epidemiol Glob Health 2021; 10:86-95. [PMID: 32175715 PMCID: PMC7310810 DOI: 10.2991/jegh.k.191215.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 12/11/2019] [Indexed: 12/21/2022] Open
Abstract
Inclusion of a pharmacist showed that pharmacy-led patient education can positively impact treatment outcome, chronic obstructive pulmonary disease (COPD) knowledge, medication adherence, quality of life, significant reduction in hospital admission rates, and emergency department visits. The objectives were to assess the degree of COPD knowledge in Lebanese community pharmacists as well as their attitudes and practice toward disease management. Between January and May 2018, a cross-sectional survey enrolled 709 Lebanese community pharmacists. A committee was created to build up the questionnaire; it was composed of two physicians (one infectious disease specialist and one pulmonologist) and eight pharmacists, with long expertise in community and hospital pharmacy. It comprised 12 questions assessing knowledge, 12 questions for attitude, and 13 questions for practice. Higher attitude (β = 0.56) and higher practice (β = 0.41) were associated with higher knowledge score. Higher knowledge (β = 0.10) and practice (β = 0.16) scores as well as female gender (β = 0.60) were significantly associated with higher attitude scores. Higher knowledge (β = 0.13) and higher attitude (β = 0.19) showed significant association with higher practice scores. Female gender (β = −0.94), however, was significantly associated with decreased practice score. Our study highlights the importance of assessing the capabilities of pharmacists of achieving their support role in COPD patients. In order to improve community pharmacists’ knowledge of COPD, ultimately improving patient outcomes, further education is crucial.
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Affiliation(s)
- Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon.,Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie - Liban (INSPECT-LB), Beirut, Lebanon
| | - Rouba Karen Zeidan
- Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie - Liban (INSPECT-LB), Beirut, Lebanon.,Faculty of Public Health 2, Lebanese University, Fanar, Lebanon
| | - Sylvia Saade
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Aline Hajj
- Laboratoire de Pharmacologie, Pharmacie clinique et Contrôle de Qualité des médicaments, Pôle Technologie-Santé (PTS), Faculty of Pharmacy, Saint-Joseph University, Beirut, Lebanon.,Faculty of Pharmacy, Saint-Joseph University, Beirut, Lebanon
| | - Rabih Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | | | | | - Nelly Kheir
- Faculty of Pedagogy, Holy Family University, 5534 Batroun, Lebanon
| | | | - Hala Sacre
- Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie - Liban (INSPECT-LB), Beirut, Lebanon.,Drug Information Center, Order of Pharmacists of Lebanon, Beirut, Lebanon
| | - Pascale Salameh
- Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie - Liban (INSPECT-LB), Beirut, Lebanon.,Faculty of Pharmacy, Lebanese University, Beirut, Lebanon.,Faculty of Medicine, Lebanese University, Beirut, Lebanon
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Implementation of mouth rinsing after use of inhaled corticosteroids in Australia. Int J Clin Pharm 2020; 43:549-555. [PMID: 33029709 DOI: 10.1007/s11096-020-01161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Clinical guidelines recommend that patients using inhaled corticosteroids should rinse their mouth following inhalation. There is however, a paucity of research regarding patient implementation of this recommendation and the impact it has on the occurrence of adverse effects. OBJECTIVE The aim of this study was to determine how well patients implement mouth rinsing after using inhaled corticosteroids in practice and their understanding of the rationale, information sources and the impact of mouth rinsing on adverse effects. SETTING Australians aged 18 years and over with a diagnosis of asthma and/or chronic obstructive pulmonary disease who were currently using an inhaled corticosteroid. METHOD Participants were recruited via Facebook to complete an online survey. MAIN OUTCOME MEASURE Implementation of a mouth rinse which aligned to current guideline recommendations. RESULTS Of 380 eligible responses, 30.5% of patients reported suboptimal mouth rinsing after using inhaled corticosteroids. Receiving advice on mouth rinsing from a healthcare professional increased the likelihood of correct implementation (P < 0.001) and improved patient understanding of the rationale (P = 0.01). Whilst most (90.0%) patients were aware rinsing may reduce oropharyngeal adverse effects, few (5.5%) were aware of its potential to reduce systemic adverse effects. Patients were more likely to report their rinsing procedure had a positive impact if they had experienced oral candidiasis (P < 0.001) or sore mouth/throat (P = 0.01), compared to cough or hoarse voice. CONCLUSION Almost one-third of patients reported a suboptimal mouth rinsing procedure after using an inhaled corticosteroid. Interventions are required to improve awareness and correct implementation of mouth rinsing.
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Vervloet M, Zwikker HE, Linn AJ, Koster ES, Gipmans SGH, van Aarle MCW, van Dijk L. The Development and Proof of Principle Test of TRIAGE: A Practical Question Set to Identify and Discuss Medication-Related Problems in Community Pharmacy. PHARMACY 2020; 8:pharmacy8040178. [PMID: 32992492 PMCID: PMC7711982 DOI: 10.3390/pharmacy8040178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/19/2020] [Accepted: 09/25/2020] [Indexed: 01/15/2023] Open
Abstract
The pharmacy counter is a good place to identify and discuss medication-related problems. However, there is a lack of practical communication tools to support pharmacy technicians (PTs) in initiating a conversation with patients. This study aimed to develop and test a practical set of questions for PTs, called TRIAGE, to identify problems during encounters. TRIAGE was developed based on insight from the literature, focus groups with PTs and pharmacists, and input from patients and experts. In 10 community pharmacies, 17 PTs used TRIAGE during encounters with patients who collected their cardiovascular medication. For each encounter, PTs registered the identified problems and suggested solutions. A total of 105 TRIAGE conversations were held, 66 for first refill and 39 for follow-up refill prescriptions. In 15 (23%) first refill prescription encounters, a problem was identified. These problems concerned forgetting to take the medication, a complex medication regime or (fear of) side effects. In three (8%) follow-up refill prescription encounters, a problem was identified. Most of the problems were solved on the spot. Pharmacy technicians indicated that they identified medication-related problems with TRIAGE that otherwise would be left unnoticed. They appreciated TRIAGE as a useful instrument for starting the conversation with patients about medication use.
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Affiliation(s)
- Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, 3500 BN Utrecht, The Netherlands;
- Correspondence: ; Tel.: +31-30-2729700
| | - Hanneke E. Zwikker
- Dutch Institute for Rational Use of Medicines, 3502 GB Utrecht, The Netherlands;
| | - Annemiek J. Linn
- Amsterdam School of Communication Research (ASCoR), University of Amsterdam, 1001 NG Amsterdam, The Netherlands;
| | - Ellen S. Koster
- Utrecht Pharmacy Practice Network for Education and Research (UPPER), Utrecht University, 3584 CG Utrecht, The Netherlands;
| | - Suzan G. H. Gipmans
- BENU Netherlands B.V., 3604 BB Maarssen, The Netherlands; (S.G.H.G.); (M.C.W.v.A.)
| | | | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, 3500 BN Utrecht, The Netherlands;
- Department of PharmacoTherapy, -Epidemiology & -Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, 9700 AD Groningen, The Netherlands
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van Eikenhorst L, van Dijk L, Cords J, Vervloet M, de Gier H, Taxis K. Pharmacists' responses to cues and concerns of polypharmacy patients during clinical medication reviews-A video observation study. PATIENT EDUCATION AND COUNSELING 2020; 103:930-936. [PMID: 31859122 DOI: 10.1016/j.pec.2019.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/28/2019] [Accepted: 11/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The research questions of this study are 1) How do pharmacists respond to negative emotions of patients during a clinical medication review (CMR)? 2) How do patients express negative emotions during a CMR? 3) Who (pharmacist or patient) initiates a negative emotion to be discussed during a CMR? METHODS We used video-recordings to observe 132 CMR interviews of 49 pharmacists. Videos were coded with the Verona coding definitions on emotional sequences(-provider responses) (VR-CoDES(-P)). RESULTS In total 2538 negative emotions were identified, mainly expressed as cues (95.0 %). Often cues were expressed as verbal hints to hidden concerns (33.2 %) or were related to cognitive or physical causes (28.3 %).Three-quarters of the negative emotions were elicited by patients. 2670 pharmacists' responses were coded. The most common response was non-explicit providing space (77.6 %) and the least common response was explicit reducing space (5.8 %). CONCLUSION Pharmacists are mainly non-explicitly providing space in their responses. While this hinders their ability to capture patients' problems it also may enable patients to initiate topics. PRACTICE IMPLICATIONS Pharmacists are able to respond to patients' negative emotions. Training should focus on developing pharmacist's skills to be more explicit in their responses to get more in-depth knowledge of patients' problems.
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Affiliation(s)
- Linda van Eikenhorst
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands.
| | - Liset van Dijk
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands; Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Jasper Cords
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Marcia Vervloet
- Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Han de Gier
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Katja Taxis
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
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Kuipers E, Wensing M, De Smet PAGM, Teichert M. Exploring Patient's Perspectives and Experiences After Start with Inhalation Maintenance Therapy: A Qualitative Theory-Based Study. Patient Prefer Adherence 2020; 14:203-212. [PMID: 32099338 PMCID: PMC6996208 DOI: 10.2147/ppa.s234094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/03/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Treatment of obstructive lung disease with inhalation therapy needs changes in patient behavior. Shortly after the start with inhaled corticosteroids (ICS) maintenance therapy, patients might be in need of additional pharmaceutical care, tailored to their individual needs. This study aimed to provide insight into patient behavior, goals and perceptions regarding their medical treatment at start with ICS therapy, by telephone interviews with ICS starters. Besides, this study investigated pharmacists' and patients' experiences with these interviews and opinions on the utility of this type of consultation for daily practice. METHODS Semi-structured telephone interviews were conducted by pharmacists with adult patients 2-3 weeks after starting ICS. The Theoretical Domain Framework (TDF) was used for data analysis and coding. Afterward, the patients and pharmacists were questioned about their experiences with the interview. RESULTS Five pharmacists conducted interviews with 23 ICS starters. Except the domains "environmental context and resources", "optimism", and "reinforcement", the remaining 11 domains in the TDF were addressed in the interviews. The majority of patients defined personal goals, which mainly addressed disease or symptom control (clinical goals). Some patients showed a lack of knowledge regarding the clinical indication or therapy duration. Views on beneficial medication effects differed between patients. Some patients specifically mentioned concerns or anxiety about side effects. The interviewees described different perceptions on the necessity of a personalized routine for regular medication use. Patients and pharmacists both felt positive about an added value of these interviews for daily practice. CONCLUSION Patient interviews shortly after start with ICS therapy revealed various perceptions and beliefs that might influence medication use and achievement of individual treatment goals. The patients appreciated the opportunity to ask questions and share their perspectives and needs with their pharmacist, and the pharmacists experienced that the interviews had added value.
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Affiliation(s)
- Esther Kuipers
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of IQ Healthcare, Nijmegen6500 HB, The Netherlands
- BENU Apotheek Zeist West, Zeist, The Netherlands
- Correspondence: Esther Kuipers Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of IQ Healthcare, PO Box 9101, Nijmegen6500 HB, The NetherlandsTel +31 24 361 0591Fax +31 24 354 0166 Email
| | - Michel Wensing
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of IQ Healthcare, Nijmegen6500 HB, The Netherlands
- University Hospital Heidelberg, Department of General Practice and Health Services Research, Heidelberg, Germany
| | - Peter AGM De Smet
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of IQ Healthcare, Nijmegen6500 HB, The Netherlands
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Clinical Pharmacy, Nijmegen, The Netherlands
| | - Martina Teichert
- Leiden University Medical Centre, Department of Clinical Pharmacy and Toxicology, Leiden, The Netherlands
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COPD-Specific Self-Management Support Provided by Trained Educators in Everyday Practice is Associated with Improved Quality of Life, Health-Directed Behaviors, and Skill and Technique Acquisition: A Convergent Embedded Mixed-Methods Study. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 13:103-119. [PMID: 31502238 DOI: 10.1007/s40271-019-00386-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is a necessity to better document the effect of continuing education activities targeted at respiratory educators providing self-management support for patients with chronic obstructive pulmonary disease (COPD). We therefore sought to describe real-life COPD-specific self-management support delivered by respiratory educators who participated in a lecture-based continuing education activity and assess the outcomes of patients with COPD. METHODS We conducted a convergent embedded mixed-methods study. Respiratory educators attended a 7-h, lecture-based continuing education activity on self-management support held in Québec, Canada. Four months after the continuing education activity, in their professional practice, trained educators provided self-management support to patients with COPD. One month later, to describe the components of self-management support provided, individual telephone interviews were conducted with educators. Interviews were transcribed verbatim and were qualitatively analyzed. Before self-management support and 6 months afterwards, we assessed the following clinical outcomes of patients with COPD: (1) quality of life (St. George's Respiratory Questionnaire for COPD patients, Impact domain; score 0-100; minimal clinically important difference = - 4; telephone administered); (2a) whether patients had one or more unscheduled doctor visit, (2b) one or more emergency room visit, and (2c) one or more hospitalization in the 6 preceding months (Survey on Living with Chronic Diseases in Canada; telephone administered); and (3a) health-directed behaviors and (3b) skill and technique acquisition (Health Education Impact Questionnaire; score 1-4; self-administered at home). We used mixed models to estimate mean differences and prevalence ratios, with associated 95% confidence intervals. RESULTS Trained respiratory educators (nurse: n = 1; respiratory therapist: n = 3; ≥ 15 years of experience of care with patients with chronic disease) invited 75 patients with COPD to participate in the study. Fifty-four individuals with COPD (age, mean ± standard deviation: 68 ± 8 years; men: n = 31) were enrolled and received self-management support. Qualitative analyses revealed that self-management support consisted of one to two visits that included: (1) provision of information on COPD; (2) training in inhalation technique; and (3) smoking cessation advice. No educator reported implementing two or more follow-up visits because of a lack of time and human resources in their work setting. Among patients with COPD, improvements in quality of life were clinically important (adjusted mean difference = - 12.75; 95% confidence interval - 18.79 to - 6.71; p = 0.0001). Health-resource utilization was not different over time (all p values > 0.05). Improvements in health-directed behaviors and skill and technique acquisition were statistically significant (health-directed behaviors: adjusted mean difference = 0.50; 95% confidence interval 0.23-0.77; p = 0.0005; skill and technique acquisition: adjusted mean difference = 0.12; 95% confidence interval 0.01-0.23; p = 0.0293). CONCLUSIONS Following a 7-h, lecture-based continuing education activity on COPD-specific self-management support, respiratory educators with significant experience of care provided self-management support that included provision of information, inhalation technique training, and smoking cessation advice. This resulted in enhanced patient quality of life, health-directed behaviors, and skill and technique acquisition. To decrease health resource utilization, the training could employ active learning methods. More time and resources could also be devoted to implementing regular follow-up visits. CLINICAL TRIALS REGISTRATION NO NCT02870998.
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van Eikenhorst L, Taxis K, Rademakers J, Zullig LL, de Gier H, van Dijk L. How are medication related problems managed in primary care? An exploratory study in patients with diabetes and primary care providers. Res Social Adm Pharm 2019; 16:646-653. [PMID: 31427177 DOI: 10.1016/j.sapharm.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Medication self-management is important for patients who are controlling diabetes. Achieving medication self-management goals, may depend on treatment complexity and patients' capacities such as health literacy, knowledge and attitude. OBJECTIVES The aims of this study were to explore how patients with diabetes self-manage their medications, how patients seek support when experiencing problems and how primary healthcare providers identify patients' medication related problems and provide support. METHODS Semi-structured interviews were conducted among patients with diabetes receiving primary care and with their primary healthcare providers - GPs, nurses, pharmacists and technicians - between January and June 2017. A purposive sampling strategy was used to identify and select participants. An interview guide based on the Cycle of Complexity model was developed. Interviews were audiotaped and transcribed verbatim. Transcripts were coded with a combination of deductive and inductive codes. A thematic analysis was performed to identify categories and themes in the data. Findings were compared with the Cycle of Complexity model. RESULTS Twelve patients and 27 healthcare providers were included in the study. From the transcripts 95 codes, 6 categories and 2 major themes were extracted. Patients used practical solutions and gaining knowledge to manage their medication. Their problems were often related to stress and concerns about using medications. A trusted relationship with the healthcare provider was essential for patients to share problems and ask for support. Informal support was sought from family and peer-patients. Healthcare providers perceive problem identification as challenging. They relied on patients coming forward, computer notifications, clinical parameters and gut-feeling. Healthcare providers were able to offer appropriate support if a medication management problem was known. CONCLUSION Patients are confident of finding their way to manage their medications. However, sharing problems with healthcare providers requires a trusted relationship. This is acknowledged by both patients and healthcare providers.
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Affiliation(s)
- L van Eikenhorst
- University of Groningen, Groningen Research Institute of Pharmacy, PharmacoTherapy, -Epidemiology & -Economics, P.O. Box 196, 9700 AD, Groningen, the Netherlands.
| | - K Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, PharmacoTherapy, -Epidemiology & -Economics, P.O. Box 196, 9700 AD, Groningen, the Netherlands.
| | - J Rademakers
- Nivel, Netherlands Institute for Health Services Research, Otterstraat 118, 3513 CR, Utrecht, the Netherlands; Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, 6200 MD, Maastricht, the Netherlands.
| | - L L Zullig
- Department of Population Health Sciences, Duke University, 215 Morris Street, Durham, NC, 27701, USA; Center to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 West Chapel Hill Street, Suite 600, Durham, NC, 27701, USA.
| | - H de Gier
- University of Groningen, Groningen Research Institute of Pharmacy, PharmacoTherapy, -Epidemiology & -Economics, P.O. Box 196, 9700 AD, Groningen, the Netherlands.
| | - L van Dijk
- University of Groningen, Groningen Research Institute of Pharmacy, PharmacoTherapy, -Epidemiology & -Economics, P.O. Box 196, 9700 AD, Groningen, the Netherlands; Nivel, Netherlands Institute for Health Services Research, Otterstraat 118, 3513 CR, Utrecht, the Netherlands.
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Kuipers E, Wensing M, Wong-Go E, Daemen BJG, De Smet PAGM, Teichert M. Adherence to guideline recommendations for asthma care in community pharmacies: actual and needed performance. NPJ Prim Care Respir Med 2019; 29:26. [PMID: 31296863 PMCID: PMC6624277 DOI: 10.1038/s41533-019-0139-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/17/2019] [Indexed: 12/03/2022] Open
Abstract
Pharmaceutical care guidelines aim to provide recommendations for pharmaceutical care, reduce unwanted pharmacy practice variation and ultimately improve the quality of healthcare. This study evaluated community pharmacists’ adherence to recommendations for the provision of care to asthma patients with first dispensing and follow-up refill encounters in The Netherlands. Data were pharmacists’ self-assessment of adherence to guideline recommendations, independent observations of dispensing encounters and a nationwide questionnaire on pharmacists’ views on the desirable (clinical) necessity of applying guideline recommendations to their patient population. The 21 pharmacists who performed self-assessment judged their adherence concerning inhalation instructions as high. The lowest scores were reported for recommendations to collect additional information on the type of lung disease and for asking patients’ expectations, wishes and concerns. Sixty-eight dispensing encounters were observed. In 83% of the 35 first dispensing observations, inhalation instruction was provided. This percentage was lower (62%) at refill dispensings. During all encounters, pharmacy staff seldom explored patients’ perceptions or responded to patients’ expectations, wishes and concerns. One hundred and four pharmacists completed the feasibility questionnaire. Pharmacists judged that all patients should receive inhalation instruction at first dispensing. They regarded it necessary to check on patients’ expectations, wishes and concerns regarding the treatment for only up to 70% of the patients. More efforts on guideline implementation are needed, especially on follow-up dispensings and on gaining relevant information from patients and other healthcare professionals. Pharmacists still have opportunities to grow in applying a patient-tailored approach and exploring patients’ individual needs, rather than providing practical information.
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Affiliation(s)
- Esther Kuipers
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands. .,BENU Apotheek Zeist West, Zeist, The Netherlands.
| | - Michel Wensing
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Elaine Wong-Go
- Royal Dutch Association for the Advancement of Pharmacy (KNMP), Guideline Development, The Hague, The Netherlands
| | - Bernard J G Daemen
- Royal Dutch Association for the Advancement of Pharmacy (KNMP), Guideline Development, The Hague, The Netherlands
| | - Peter A G M De Smet
- Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Clinical Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
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Heikkilä JM, Parkkamäki S, Salimäki J, Westermarck S, Pohjanoksa-Mäntylä M. Community pharmacists' knowledge of COPD, and practices and perceptions of medication counseling of COPD patients. Int J Chron Obstruct Pulmon Dis 2018; 13:2065-2074. [PMID: 30013334 PMCID: PMC6037276 DOI: 10.2147/copd.s159726] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and purpose COPD is one of the leading causes of morbidity and mortality worldwide. Although medication counseling interventions by pharmacists have been found to support the management of COPD, little is known about pharmacists’ knowledge concerning COPD and regular practices and perceptions concerning medication counseling of COPD patients. The purpose of this study was to research these topics among Finnish community pharmacists. Materials and methods In January 2017, an electronic survey was e-mailed to Finnish community pharmacies (n=741) via the Association of the Finnish Pharmacies. One pharmacist from each pharmacy, preferably a specialist in asthma, was invited to answer the survey. Results Completed responses were received from 263 pharmacists (response rate =35%), of whom 196 pharmacists were specialists in asthma. Response rate among asthma pharmacists was 42%. Pharmacists were positive about their role in medication counseling and in support of the self-management of COPD patients. COPD-related knowledge was self-assessed as being good and was on a good level in respect of basic facts. However, almost half (46%) of the pharmacists did not know that COPD is considered a national public health issue, and ~50% of the pharmacists were not familiar with the current care guideline on COPD. Medication counseling was found to be more medicinal product-driven and less advisory concerning lifestyle changes such as smoking cessation and physical exercise. Conclusion Although the pharmacists’ knowledge of COPD was good on general topics, there were some gaps in their knowledge on the current care guideline and status of the disease. Pharmacists should more systematically individually target medication counseling according to patients’ needs. In addition, lifestyle treatments, including smoking cessation and physical exercise, should be part of the medication counseling.
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Affiliation(s)
- Juha Markus Heikkilä
- Faculty of Pharmacy, Division of Pharmacology and Pharmacotherapy, University of Helsinki, Helsinki, Finland, .,Hartola Pharmacy, Hartola, Finland,
| | | | | | | | - Marika Pohjanoksa-Mäntylä
- Faculty of Pharmacy, Division of Pharmacology and Pharmacotherapy, University of Helsinki, Helsinki, Finland,
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Eton DT, Ridgeway JL, Linzer M, Boehm DH, Rogers EA, Yost KJ, Finney Rutten LJ, Sauver JL, Poplau S, Anderson RT. Healthcare provider relational quality is associated with better self-management and less treatment burden in people with multiple chronic conditions. Patient Prefer Adherence 2017; 11:1635-1646. [PMID: 29033551 PMCID: PMC5630069 DOI: 10.2147/ppa.s145942] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Having multiple chronic conditions (MCCs) can lead to appreciable treatment and self-management burden. Healthcare provider relational quality (HPRQ) - the communicative and interpersonal skill of the provider - may mitigate treatment burden and promote self-management. The objectives of this study were to 1) identify the associations between HPRQ, treatment burden, and psychosocial outcomes in adults with MCCs, and 2) determine if certain indicators of HPRQ are more strongly associated than others with these outcomes. PATIENTS AND METHODS This is a cross-sectional survey study of 332 people with MCCs. Patients completed a 7-item measure of HPRQ and measures of treatment and self-management burden, chronic condition distress, self-efficacy, provider satisfaction, medication adherence, and physical and mental health. Associations between HPRQ, treatment burden, and psychosocial outcomes were determined using correlational analyses and independent samples t-tests, which were repeated in item-level analyses to explore which indicators of HPRQ were most strongly associated with the outcomes. RESULTS Most respondents (69%) were diagnosed with ≥3 chronic conditions. Better HPRQ was found to be associated with less treatment and self-management burden and better psychosocial outcomes (P<0.001), even after controlling for physical and mental health. Those reporting 100% adherence to prescribed medications had higher HPRQ scores than those reporting less than perfect adherence (P<0.001). HPRQ items showing the strongest associations with outcomes were "my healthcare provider spends enough time with me", "my healthcare provider listens carefully to me", and "I have trust in my healthcare provider". CONCLUSION Good communication and interpersonal skills of healthcare providers may lessen feelings of treatment burden and empower patients to feel confident in their self-management. Patient trust in the provider is an important element of HPRQ. Educating healthcare providers about the importance of interpersonal and relational skills could lead to more patient-centered care.
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Affiliation(s)
- David T Eton
- Department of Health Sciences Research
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Correspondence: David T Eton, Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA, Tel +1 507 293 1353, Fax +1 507 284 1731, Email
| | - Jennifer L Ridgeway
- Department of Health Sciences Research
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mark Linzer
- Division of General Internal Medicine, Hennepin County Medical Center
| | | | - Elizabeth A Rogers
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Kathleen J Yost
- Department of Health Sciences Research
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Lila J Finney Rutten
- Department of Health Sciences Research
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Jennifer L Sauver
- Department of Health Sciences Research
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Roger T Anderson
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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Driesenaar JA, De Smet PAGM, van Hulten R, Horne R, Zwikker H, van den Bemt B, van Dulmen S. Beliefs about inhaled corticosteroids: Comparison of community pharmacists, pharmacy technicians and patients with asthma. J Asthma 2016; 53:1051-8. [PMID: 27187172 DOI: 10.1080/02770903.2016.1180696] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare pharmacists' and pharmacy technicians' perceptions of patients' beliefs regarding inhaled corticosteroids (ICS) with those of patients and to compare the ICS beliefs of pharmacists and technicians with those of patients with asthma. METHODS 1269 community pharmacies were approached to fill out an online questionnaire; 1952 patients were sent a questionnaire by post. Beliefs (i.e., necessity and concerns) regarding ICS were measured using (an adapted version of) the Beliefs about Medicines Questionnaire (BMQ-specific). Pharmacists and technicians were instructed to fill out the BMQ for themselves, and to fill it out in the way they thought most of their patients would complete it. RESULTS 136 pharmacists, 90 pharmacy technicians and 161 patients with asthma completed the questionnaire. Pharmacists and technicians thought patients had more concerns about ICS than patients themselves reported (p < 0.0001). They also thought that patients had stronger beliefs in their personal need for ICS than patients reported (p < 0.01). Pharmacists reported lower levels of concerns than patients (p < 0.05) and both providers attributed a higher level of necessity to ICS than patients did (p < 0.0001). CONCLUSION Pharmacists and technicians overestimate the personal need for treatment as well as the concerns patients with asthma have regarding ICS. They also have, to some extent, stronger positive beliefs about ICS than patients. If pharmacists and technicians expect that patients share their positive views about ICS, they might be less likely to elicit and address patients' doubts and concerns about ICS, which might be relevant for effective ICS treatment and subsequent patient outcomes.
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Affiliation(s)
- Jeanine A Driesenaar
- a NIVEL, Netherlands institute for health services research , Utrecht , The Netherlands
| | - Peter A G M De Smet
- b Department of Clinical Pharmacy , Radboud University Medical Center , Nijmegen , The Netherlands.,c IQ Healthcare, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Rolf van Hulten
- d Division of Pharmacoepidemiology & Clinical Pharmacology , Utrecht University , Utrecht , The Netherlands.,e Department of Pharmacotherapy and Pharmaceutical Care , University of Groningen , Groningen , The Netherlands
| | - Rob Horne
- f Centre for Behavioral Medicine, Department of Practice and Policy , UCL School of Pharmacy , London , United Kingdom
| | - Hanneke Zwikker
- a NIVEL, Netherlands institute for health services research , Utrecht , The Netherlands
| | - Bart van den Bemt
- b Department of Clinical Pharmacy , Radboud University Medical Center , Nijmegen , The Netherlands.,g Department of Pharmacy , Sint Maartenskliniek , Nijmegen , The Netherlands
| | - Sandra van Dulmen
- a NIVEL, Netherlands institute for health services research , Utrecht , The Netherlands.,h Department of Primary and Community Care , Radboud University Medical Center , Nijmegen , The Netherlands.,i Faculty of Health Sciences , Buskerud and Vestfold University College , Drammen , Norway
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