The needs and well-being of severe asthma and COPD carers: A cross-sectional study.

BACKGROUND AND OBJECTIVE: Caring for people with severe asthma and chronic obstructive pulmonary disease (COPD) can impair the quality of life (QoL) of the carer. We aimed to describe the QoL and needs of severe asthma and COPD carers. METHODS: Carers of severe asthma (n = 89) and COPD (n = 48) completed an online cross-sectional survey assessing QoL and carer support needs using the Short Form Health Survey 12v2 (SF-12), the Hospital Anxiety and Depression Scale (HADS) and Carers Support Needs Assessment Tool (CSNAT) questionnaires. RESULTS: Carers of people with severe asthma and COPD were similar in age (mean ± SD 57.78 ± 14.09 vs. 56.93 ± 12.91) and gender (65% female vs. 66%); however, they differed in caring duration (proportion caring for >10 years: 65% vs. 33%, p < 0.002). QoL was impaired in both groups, but there were no significant differences between severe asthma and COPD carers in either of the SF-12 component scores. The HADS scores revealed no difference between groups. Compared to severe asthma carers, COPD carers had significantly greater needs for: 'having time for self' (33% vs. 13%, p = 0.006), 'equipment to help care for relative' (33% vs. 13%, p = 0.006), 'practical help in the home' (35% vs. 18%, p = 0.006) and 'getting a break from caring overnight' (21% vs. 6%, p = 0.023). CONCLUSION: QoL is impaired in carers of people with severe asthma to a similar degree of COPD carers and other debilitating diseases like cancer. These novel data highlight the support needs of severe asthma carers and identifies areas where tailored support is needed to reduce their substantial carer burden.

A consumer designed smartphone app for young people with asthma: pilot of engagement and acceptability.

Objective: This pilot aimed to test the engagement, acceptability, and usefulness of a goal-setting smartphone app, Kiss myAsthma, in young people with asthma.Methods: Young people aged 15-24 years old were invited to trial a smartphone app for asthma management. A mixed-methods approach combined quantitative analysis of self-report questionnaires and app usage log data with qualitative thematic analysis of open-ended questions at baseline and six weeks after downloading the app. App log data (pages visited, frequency of use and content of participants interaction, e.g.goals set, symptoms recorded) were analyzed.Results: Nine of 12 participants completed both baseline and six-week questionnaires. Participants reported high satisfaction with app content and usability (median score 5 out of 6 [range 4-6]) and rated the app highly on "feeling confident in my ability to manage my asthma." At six weeks there was a clinically significant change in asthma quality of life (e.g. Emotional Function domain score baseline: 4.7 [2.7-6.3], follow-up: 5.7 [4.7-6.7]; p = 0.043). Participants logged information about asthma severity, flare-ups and mood and tracked their symptoms with the app's History functionality. Five participants (42%) nominated goals and strategies and 3 participants (25%) entered data in the Inspiration section, a tool to support intrinsic motivation to manage asthma. Qualitative data aligned with quantitative results.Conclusions: This six-week pilot of the Kiss myAsthma app showed its potential to support self-management, quality of life and health behavior change in young people with asthma.

Electronic cigarettes: A position statement from the Thoracic Society of Australia and New Zealand.

The TSANZ develops position statements where insufficient data exist to write formal clinical guidelines. In 2018, the TSANZ addressed the question of potential benefits and health impacts of electronic cigarettes (EC). The working party included groups focused on health impacts, smoking cessation, youth issues and priority populations. The 2018 report on the Public Health Consequences of E-Cigarettes from the United States NASEM was accepted as reflective of evidence to mid-2017. A search for papers subsequently published in peer-reviewed journals was conducted in August 2018. A small number of robust and important papers published until March 2019 were also identified and included. Groups identified studies that extended, modified or contradicted the NASEM report. A total of 3793 papers were identified and reviewed, with summaries and draft position statements developed and presented to TSANZ membership in April 2019. After feedback from members and external reviewers, a collection of position statements was finalized in December 2019. EC have adverse lung effects and harmful effects of long-term use are unknown. EC are unsuitable consumer products for recreational use, part-substitution for smoking or long-term exclusive use by former smokers. Smokers who require support to quit smoking should be directed towards approved medication in conjunction with behavioural support as having the strongest evidence for efficacy and safety. No specific EC product can be recommended as effective and safe for smoking cessation. Smoking cessation claims in relation to EC should be assessed by established regulators.

" I've said I wish I was dead, you'd be better off without me": A systematic review of people's experiences of living with severe asthma.

OBJECTIVE: Our aim was to conduct a systematic review and synthesis of qualitative evidence exploring the lived experience of adults with severe asthma. DATA SOURCES: We searched MEDLINE via OvidSP, PsycINFO via OvidSP, PubMed, CINAHL, EMBASE, Sociological Abstracts, Google Scholar, the journals Qualitative Health Research and Qualitative Research, and a study of experiences of living with asthma by the Health Experiences Research group. STUDY SELECTIONS: Studies were included if they used qualitative methods and explored the subjective experiences of adults (≥18 years) with a clear diagnosis of severe asthma. RESULTS: From 575 identified studies, five met the inclusion criteria. Synthesis revealed an overarching theme of efforts that people living with severe asthma engage in to achieve personal control over their condition. Individuals 'strive for autonomy' through dealing with symptoms and treatment, acquiring knowledge, making decisions and reclaiming identity. CONCLUSION: This systematic review found a paucity of qualitative studies reporting on people's perspectives of living with severe asthma, and a focus on clinical rather than personal issues. Our synthesis reveals that severe asthma was disempowering, and a threat to identity and life roles. What was important to people living with severe asthma was striving to achieve a greater level of personal control over their condition, but these efforts received little support from their healthcare providers. Thus, more attention should be paid to understanding the self-management strategies and personal goals of people living with severe asthma. This may assist in designing interventions to better support patient self-management and improve health outcomes.

Validation of the patient-completed asthma knowledge questionnaire (PAKQ).

BACKGROUND: Asthma is often suboptimally controlled, in part due to patients' disease knowledge. Understanding patients' knowledge, prior to education may help in individualizing content. However, there are no well validated or internationally relevant patient asthma knowledge questionnaires available. OBJECTIVE: To translate and validate the rigorously validated Questionnaire de connaissances sur l'asthme destiné aux patients adultes (QCA-PA) based on key points related to asthma knowledge and self-management accordingly to the Global Initiative for Asthma report. METHODS: Based on Vallerand's methodology, a preliminary version of the "Patient-completed Asthma Knowledge Questionnaire" (PAKQ) was back-translated and evaluated by an expert committee. A sample of 20 individuals with asthma pretested the questionnaire, after which 62 adults were recruited. Sociodemographic data were collected and the PAKQ together with a comparator questionnaire (Consumer Questionnaire (CQ)) were completed. Fourteen days after the first visit, participants returned to recomplete both questionnaires; half were randomly selected to receive a one-on-one asthma education session and again completed both questionnaires immediately after education, and at 10 days follow-up. RESULTS: The PAKQ showed good internal consistency (KR-20 = 0.77). Moderate correlation with CQ (r = 0.596, p = 0.01) attested to its concurrent validity. Confirmatory factor analyses confirmed a single factor structure. A repeated measures ANOVA showed its reproducibility (n = 21:F(1) = 3.578, p = 0.07, ηp2 = 0.152) and responsiveness (n = 21:F(1) = 26.041, P < 0.05, ηp2 = 0.566). CONCLUSION: The PAKQ is a valid asthma knowledge questionnaire which is based on international asthma recommendations and could help healthcare professionals in individualizing educational interventions for people with asthma.

"I have lost in every facet of my life": the hidden burden of severe asthma.

People with severe asthma are thought to face a sizeable daily disease burden. This study aimed to explore the little-known life experiences of people living with severe asthma.Adults with severe asthma were invited for telephone interview. Semistructured interviews were conducted until no new themes emerged. The 25 interviews were recorded, transcribed and analysed thematically.Four themes emerged. 1) "The body as a hindrance": severe asthma placed broad limits on life from daily chores to career, relationships and family life that left interviewees feeling emotionally distressed. 2) "Burden of treatment": participants mostly accepted the need to take treatment, but were particularly concerned about side-effects of oral corticosteroids. 3) "Alone with asthma": interviewees felt misunderstood and alone in their experience of breathlessness and frightening exacerbations; practical and emotional support needs were often lacking and the emotional distress of severe asthma was amplified in those with little support. 4) "Striving to adapt": patients used both positive strategies (acquiring self-management skills) and less positive strategies (avoidance of physical exertion) in the process of adjustment to living with severe asthma.Severe asthma imposes long-term, debilitating burdens and should be considered differently to milder disease. There is an urgent need to improve practical and emotional support services for patients and their carers.

Investigating self-efficacy, disease knowledge and adherence to treatment in adolescents with cystic fibrosis.

AIM: Patient adherence is integral to the effectiveness of prescribed treatment, and is associated with beneficial disease outcomes, yet in adolescents with cystic fibrosis, adherence is often sub-optimal. Multiple factors may contribute to treatment adherence, including disease knowledge and self-efficacy. In adolescents with cystic fibrosis: (i) to compare the disease knowledge of adolescents and their parents before transition to adult care; (ii) to determine the relationship between disease knowledge (adolescent, parent) and adherence; and (iii) to evaluate self-efficacy and its association with disease knowledge and adherence. METHODS: Adolescents with cystic fibrosis and their parents were recruited from a tertiary children's hospital. Disease knowledge and self-efficacy was assessed using the Knowledge of Disease Management-CF and General Self-Efficacy Scales respectively. Using pharmacy records, medication possession ratio was calculated to measure treatment adherence in the preceding year. RESULTS: Thirty-nine adolescent (aged 12-17 (median 14) years) and parent pairs were recruited. Adherence to hypertonic saline, but not other medications, was significantly associated with disease knowledge in adolescents (r 2 = 0.40, P = 0.029). Mean (SD) adolescent self-efficacy was 30.8 (4.0), and not associated with disease knowledge or adherence. Mean (SD) disease knowledge was less in adolescents than parents (55 (16)% and 72 (14)% respectively, P < 0.001). CONCLUSION: Disease knowledge is sub-optimal in adolescents with cystic fibrosis, even in the 2 years immediately before transition to adult care. Given that adherence with some treatments has been associated with disease knowledge our results suggest the need for educational interventions in adolescents with cystic fibrosis to optimise self-management and health outcomes.

Young People's Preferences for an Asthma Self-Management App Highlight Psychological Needs: A Participatory Study.

BACKGROUND: Although the prevalence of mental illness among young people with asthma is known to be twice the rate of the wider population, none of the asthma apps reported have acknowledged or attempted to include psychological support features. This is perhaps because user involvement in the development of asthma apps has been scarce. User involvement, facilitated by participatory design methods, can begin to address these issues while contributing insights to our understanding of the psychological experience associated with asthma and how technology might improve quality of life. OBJECTIVE: The goal of this participatory user research study was to explore the experience, needs, and ideas of young people with asthma while allowing them to define requirements for an asthma app that would be engaging and effective at improving their well-being. METHODS: Young people aged 15-24 years with doctor-diagnosed asthma were invited to participate in a participatory workshop and to complete a workbook designed to elicit their thoughts and ideas about living with asthma, technology use, and the design of an app. Participants generated a number of artifacts (including collages, concept maps, and paper prototypes) designed to reify their ideas, tacit knowledge, and experience. RESULTS: A total of 20 participants (mean age 17.8 years; 60%, 12/20 female) representing a range from inadequately to well-controlled asthma completed a workbook and 13 of these also took part in a workshop (four workshops were held in total), resulting in 102 participant-generated artifacts. Theoretical thematic analysis resulted in a set of personal needs, feature ideas, and app characteristics considered relevant by young people for an asthma support app. The data revealed that psychological factors such as anxiety, and impediments to autonomy, competence, and relatedness (as consistent with self-determination theory [SDT]), were considered major influences on quality of life by young people with asthma. Furthermore, the incorporation of features pertaining to psychological experience was particularly valued by participants. CONCLUSIONS: In addition to practical features for asthma management, an app for young people with asthma should include support for the mental health factors associated with lived experience (ie, anxiety, lack of autonomy, and social disconnectedness). We show how support for these factors can be translated into design features of an app for asthma. In addition to informing the development of asthma-support technologies for young people, these findings could have implications for technologies designed to support people with chronic illness more generally.

General practitioner-delivered adherence counseling in asthma: feasibility and usefulness of skills, training and support tools.

OBJECTIVE: Poor medication adherence contributes to uncontrolled asthma in primary care. Good doctor-patient communication around adherence increases patients' medication taking but general practitioners (GPs) often feel poorly equipped to provide effective adherence counseling. This study aimed to assess the feasibility and usefulness of adherence counseling training, skills and support tools for GPs. METHODS: Twenty-five GPs enrolled in a 6-month cluster randomized-controlled trial of adherence interventions for asthma were randomized to an intervention delivering personalized adherence discussions. They received 2 hours training in delivering brief, motivational-interviewing-based adherence counseling and were provided with asthma-specific counseling support tools. At baseline, post-training and study end, GPs rated the training, reported confidence/frequency of using counseling skills and satisfaction with their consultations, and commented on support tools. Patients reported their barriers to adherence and rated their GPs empathy at baseline and at 6-months. RESULTS: 96% of GPs rated adherence counseling training as very/extremely useful. At the end of the study (17 ± 4 months) GPs' confidence in using counseling skills increased, as did the frequency they applied the skills and their satisfaction with consultations. GPs were positive about counseling support tools, stating that they were easy to use and facilitated covering more ground within single consultations. Half the GPs expressed some difficulty implementing counseling due to time constraints. Patients reported good GP empathy and no significant change in adherence barriers. CONCLUSIONS: GPs valued counseling training and support tools. Although implementation was sometimes challenging, GPs reported increased frequency of use and confidence in applying adherence counseling skills, which persisted for 17 months.

Barriers and facilitators to patient recruitment to a cluster randomized controlled trial in primary care: lessons for future trials.

BACKGROUND: Primary-care based randomized controlled trials (RCTs) build an important evidence base for general practice but little evidence exists about barriers to recruitment which often hamper such trials. We investigated the issues that impeded and facilitated recruitment to a clinical trial in general practice. METHODS: GPs participating in a cluster RCT that tested interventions for improving medication adherence and asthma control completed a survey comprising quantitative and free text questions about their recruitment experiences. We used backward regression to analyze quantitative data and coded free text responses into themes. RESULTS: 40/55 of enrolled GPs recruited patients, but only one-third reached the planned recruitment target (5 patients/GP). In univariate analyses, poor patient recruitment by GPs was significantly associated with longer time to first patient enrolment, GP-perceived poor access to eligible patients and GP working in a practice training medical students. In regression analysis, only the first was significant (p = 0.001); the explained variance of the model was 48%. Themes from free text responses described recruitment barriers at the level of GP (e.g. GPs excluding patients for whom research appeared too challenging), practice (e.g. practice cultures disempowered GPs), patient (e.g. reluctance to change treatment for research) and study (e.g. protocol requirements complicating recruitment). Facilitators included GPs perceiving good support from the research team. CONCLUSION: Targeted recruitment support early in the recruitment phase may enhance recruitment rates. Over time, interventions to enhance a general practice research culture are also likely to enhance skills to recruit patients, even for complex interventions. We recommend systematic evaluation of recruitment approaches and outcomes in future RCTs to optimize feasibility and success of these important trials. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610000854033 (date registered 14/10/2010).

Inhaler reminders improve adherence with controller treatment in primary care patients with asthma.

BACKGROUND: Poor adherence contributes to uncontrolled asthma. Pragmatic adherence interventions for primary care settings are lacking. OBJECTIVE: To test the effectiveness of 2 brief general practitioner (GP)-delivered interventions for improving adherence and asthma control. METHODS: In a 6-month cluster randomized 2 × 2 factorial controlled trial, with GP as unit of cluster, we compared inhaler reminders and feedback (IRF) and/or personalized adherence discussions (PADs) with active usual care alone; all GPs received action plan and inhaler technique training. GPs enrolled patients prescribed combination controller inhalers, with suboptimal Asthma Control Test (ACT) scores (ACT score ≤19). Inhaler monitors recorded fluticasone propionate/salmeterol adherence (covertly for non-IRF groups) and, in IRF groups, provided twice-daily reminders for missed doses, and adherence feedback. PAD GPs received communication training regarding adherence. Outcomes collected every 2 months included ACT scores (primary outcome) and severe exacerbations. Intention-to-treat mixed-model analysis incorporated cluster effect and repeated measures. RESULTS: A total of 43 GPs enrolled 143 patients with moderate-severe asthma (mean age, 40.3 ± 15.2 years; ACT score, 14.6 ± 3.8; fluticasone propionate dose, 718 ± 470 µg). Over 6 months, adherence was significantly higher in the IRF group than in non-IRF groups (73% ± 26% vs 46% ± 28% of prescribed daily doses; P < .0001), but not between PAD and non-PAD groups. Asthma control improved overall (mean change in ACT score, 4.5 ± 4.9; P < .0001), with no significant difference among groups (P = .14). Severe exacerbations were experienced by 11% of the patients in IRF groups and 28% of the patients in non-IRF groups (P = .013; after adjustment for exacerbation history; P = .06). CONCLUSIONS: Inhaler reminders offer an effective strategy for improving adherence in primary care compared with a behavioral intervention or usual care, although this may not be reflected in differences in day-to-day asthma control.

The reliability and patient acceptability of the SmartTrack device: a new electronic monitor and reminder device for metered dose inhalers.

OBJECTIVE: The SmartTrack (ST) is a new adherence monitoring device for pressurized metered-dose inhalers (pMDI), with remote upload and ringtone reminder capabilities. Our aim was to assess its reliability and patient acceptability. METHODS: Baseline Quality Control (QC): Actuation log accuracy and device functionality tests were undertaken. Simulated Patient Use: Salmeterol/fluticasone inhalers with STs were actuated two times twice daily for 48 h. Accuracy of reminders, data logging, and uploads was tested. Patient Field Testing: Devices were quality tested before dispensing. Asthma patients each field-tested one ST for 7 days and recorded actuations in a diary. Uploaded data were compared to pMDI dose counter and patient diaries. Patient-reported ease of use for the ST was recorded. RESULTS: Baseline QC: 9/10 devices had 100% accuracy; one had an electrical circuit failure. Simulated Patient Use: Accuracy was 99% (2/342 actuations duplicated). Patient Field Testing: One device failed pre-dispensing testing (electrical circuit failure). Eight devices were field-tested by asthma patients (mean age 45, 5 females). Mean actuation log accuracy was 97%. Reminders were 100% accurate. All devices successfully uploaded data. Average patient-rated difficulty of use was 6/100 (1 = extremely easy, 100 = extremely difficult). CONCLUSIONS: The ST has acceptable reliability and utility comparable to other electronic monitoring devices. Its remote data upload capability, reminder functions for missed doses, and graphical display of medication use for patient- and physician-feedback are useful additional features.

Novel Methods of Measuring Adherence Patterns Reveal Adherence Phenotypes with Distinct Asthma Outcomes.

Rationale: Poor adherence with asthma controller medication contributes to worse symptom control and increased exacerbation risk. Adherence is often expressed as the mean proportion of prescribed doses taken over a period of 6-12 months. New metrics may capture individual day-to-day variability patterns linked with distinct clinical outcomes. Objectives: To test the hypotheses that novel time- and dose-based adherence variability metrics offer independent value to mean adherence in identifying distinct adherence patterns that are associated with symptom control (Asthma Control Test [ACT] score) and exacerbation risk, using electronically recorded medication data from a 6-month cluster randomized trial examining the effect of inhaler reminders on adherence. Methods: Adherence metrics were calculated from the first 2 months (Months 0-2) of the study period. In addition to mean adherence (percentage prescribed puffs/day taken), we examined novel metrics, including time adherence area under the curve (T-AUC), reflecting cumulative gaps in adherence over time; entropy, reflecting disorder in the ways in which a patient changed their medication dose adherence from day to day; and standard deviation of the percentage prescribed puffs/day taken. Dominant metrics identified from factor analysis were included in hierarchical clustering analysis. We compared the resultant clusters in terms of outcomes over Months 2-6 and exacerbation risk over the entire study period. Results: Two factors explained >65% of the total variance in adherence, primarily driven by T-AUC and entropy. Two main patient clusters based on their adherence metrics were identified: cluster 1 (high time adherence, n = 75) had better T-AUC (i.e., fewer gaps between medication-taking days) than cluster 2 (low time adherence, n = 23). Though both clusters had similar symptom control at 2 months, cluster 1 showed less subsequent decline in ACT over Months 2-6 (median [interquartile range] change in ACT score: 1 [-1 to 4] vs. -2 [-3.75 to 0.75]; P = 0.012), and had better symptom control at 6 months (ACT score: 20 [17-23] vs. 17 [15-20]; P = 0.034). There were no significant differences between the clusters in terms of proportion of exacerbators or time to exacerbation. Conclusions: Novel metrics showed that low time adherence was associated with greater risk of decline in asthma symptom control. Adherence patterns may exhibit "memory" relevant to future clinical status, warranting validation in a larger dataset.

Digital Coaching Using Smart Inhaler Technology to Improve Asthma Management in Patients With Asthma in Italy: Community-Based Study.

BACKGROUND: Reliance on short-acting ß-2 agonists and nonadherence to maintenance medication are associated with poor clinical outcomes in asthma. Digital health solutions could support optimal medication use and therefore disease control in patients with asthma; however, their use in community settings has not been determined. OBJECTIVE: The primary objective of this study is to investigate community implementation of the Turbu+ program designed to support asthma self-management, including adherence to budesonide and formoterol (Symbicort) Turbuhaler, a combination inhaler for both maintenance therapy or maintenance and reliever therapy. The secondary objective is to provide health care professionals with insights into how patients were using their medication in real life. METHODS: Patients with physician-diagnosed asthma were prescribed budesonide and formoterol as maintenance therapy, at a dose of either 1 inhalation twice daily (1-BID) or 2 inhalations twice daily (2-BID), or as maintenance and reliever therapy (1-BID and reliever or 2-BID and reliever in a single inhaler), and they received training on Turbu+ in secondary care centers across Italy. An electronic device attached to the patients' inhaler for ≥90 days (data cutoff) securely uploaded medication use data to a smartphone app and provided reminders, visualized medication use, and motivational nudge messages. Average medication adherence was defined as the proportion of daily maintenance inhalations taken as prescribed (number of recorded maintenance actuations per day or maintenance inhalations prescribed per day) averaged over the monitoring period. The proportion of adherent days was defined as the proportion of days when all prescribed maintenance inhalations were taken on a given day. The Wilcoxon test was used to compare the proportion of adherent days between patients in the maintenance regimen and patients in the maintenance and reliever regimen of a given dose. RESULTS: In 661 patients, the mean (SD) number of days monitored was 217.2 (SD 109.0) days. The average medication adherence (maintenance doses taken/doses prescribed) was 70.2% (108,040/153,820) overall and was similar across the groups (1-BID: 6332/9520, 66.5%; 1­BID and reliever: 43,578/61,360, 71.0%; 2-BID: 10,088/14,960, 67.4%; 2-BID and reliever: 48,042/67,980, 70.7%). The proportion of adherent days (prescribed maintenance doses/doses taken in a given day) was 56.6% (31,812/56,175) overall and was higher with maintenance and reliever therapy (1-BID and reliever vs 1-BID: 18,413/30,680, 60.0% vs 2510/4760, 52.7%; P<.001; 2-BID and reliever vs 2-BID: 8995/16,995, 52.9% vs 1894/3740, 50.6%; P=.02). Rates of discontinuation from the Turbu+ program were significantly lower with maintenance and reliever therapy compared with maintenance therapy alone (P=.01). CONCLUSIONS: Overall, the high medication adherence observed during the study might be attributed to the electronic monitoring and feedback mechanism provided by the Turbu+ program.

Correction: Digital Coaching Using Smart Inhaler Technology to Improve Asthma Management in Patients With Asthma in Italy: Community-Based Study.

[This corrects the article DOI: 10.2196/25879.].

"It's like being on a roller coaster": the burden of caring for people with severe asthma.

INTRODUCTION: Family carers and significant others play a fundamental role in the well-being of people with severe asthma. This study aimed to investigate the challenges faced by family carers/significant others of people with severe asthma, to understand if there is an unmet need and to explore coping strategies. METHODS: Carers of people with severe asthma were invited to participate in a face-to-face or telephone interview. Semi-structured interviews were conducted until reaching data saturation of themes. The 20 interviews were recorded and transcribed, and analysis of data followed an inductive thematic approach. RESULTS: We report three overarching emergent themes: 1) "Caring role impacts", which centred around the negative and positive impacts of caring on carers' well-being; 2) "Unmet needs", which encapsulated the support needs participants desired and were categorised into unmet information, biopsychosocial needs and carers' involvement in decision-making; and 3) "Coping strategies", which were central to the range of tools and positive approaches in dealing with caring demands. DISCUSSION: Caring for someone with severe asthma can be burdensome and may negatively affect the physical and psychosocial health of the carer. Various coping strategies are used to manage the demands of these caring roles. Carers of people with severe asthma expressed a need for informational, biopsychosocial and involvement in care decision-making support. Tailored support services that are sensitive to their needs may improve their quality of life and encourage healthcare providers to value and acknowledge the important contribution that carers make.

Dynamics of inhaled corticosteroid use are associated with asthma attacks.

Inhaled corticosteroids (ICS) suppress eosinophilic airway inflammation in asthma, but patients may not adhere to prescribed use. Mean adherence-averaging total doses taken over prescribed-fails to capture many aspects of adherence. Patients with difficult-to-treat asthma underwent electronic monitoring of ICS, with data collected over 50 days. These were used to calculate entropy (H) a measure of irregular inhaler use over this period, defined in terms of transitional probabilities between different levels of adherence, further partitioned into increasing (Hinc) or decreasing (Hdec) adherence. Mean adherence, time between actuations (Gapmax), and cumulative time- and dose-based variability (area-under-the-curve) were measured. Associations between adherence metrics and 6-month asthma status and attacks were assessed. Only H and Hdec were associated with poor baseline status and 6-month outcomes: H and Hdec correlated negatively with baseline quality of life (H:Spearman rS = - 0·330, p = 0·019, Hdec:rS = - 0·385, p = 0·006) and symptom control (H:rS = - 0·288, p = 0·041, Hdec: rS = - 0·351, p = 0·012). H was associated with subsequent asthma attacks requiring hospitalisation (Wilcoxon Z-statistic = - 2.34, p = 0·019), and Hdec with subsequent asthma attacks of other severities. Significant associations were maintained in multivariable analyses, except when adjusted for blood eosinophils. Entropy analysis may provide insight into adherence behavior, and guide assessment and improvement of adherence in uncontrolled asthma.

A mixed methods analysis of community pharmacists' perspectives on delivering COPD screening service to guide future implementation.

BACKGROUND: Studies have shown that COPD screening by community pharmacists is effective, but it is unknown if it can be successfully implemented in Australian pharmacies. OBJECTIVE: We aimed to investigate the pharmacist-perceived barriers and facilitators to the implementation of a community pharmacy-based COPD screening service guided by implementation science methodology. METHODS: Trained pharmacists participated in a 6 month longitudinal study designed and based on implementation science frameworks. Pharmacists completed feedback questionnaires pre-and post-study and participated in semi-structured telephone interviews about their experience of implementing the service, the training provided, their views on patient recruitment, their interactions with health professionals and patients, and their future recommendations for such a service. Interviews were recorded and transcribed verbatim, analysed thematically, and questionnaire and interview data were triangulated. RESULTS: Of 20 pharmacists providing questionnaire data, 15 pharmacists (male 53%; age 39.8 ±â€¯8.6yrs, rural 47%) participated in an interview. Questionnaire data revealed that pharmacists engaged positively with the service and reported that it was very useful for patients and for the profession. In-depth qualitative analysis revealed 6 main implementation themes: 1. Patient recruitment (pharmacists lacked patient recruitment skills), 2. Adaptation and entrepreneurship (protocol adaptation increased patient engagement), 3. Training and resource needs (face-to-face training was preferred for skill-based learning), 4. Lack of GP involvement (sub-optimal GP-pharmacist collaboration), 5. Factors related to the operation or full implementation phase (high professional satisfaction, need for remuneration) and 6. Suggestions for refining the screening service (raise public awareness about the service, provide service remuneration, use electronic methods to improve GP referral uptake). A number of effective adaptations to the service were reported by pharmacists, such as advertising, recruitment practices, patient inclusion criteria and inter-professional communication with GPs which would be beneficial to implementation. CONCLUSION: This mixed methods study identified a number of key facilitators to service implementation and challenges such as difficulty with patient recruitment, low public awareness of pharmacy-based clinical services, remuneration, and sub-optimal GP-pharmacist collaboration. Working with stakeholders to identify and resolve challenges and to optimise the fit of the service for individual settings may lead to increasingly successful implementation of pharmacy-based service models.

Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study.

Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.