Osteoporosis management in Australian general practice: an analysis of current osteoporosis treatment patterns and gaps in practice.

BACKGROUND: Among Australians aged 50 and over, an estimated 1 in 4 men and 2 in 5 women will experience a minimal trauma fracture during their remaining lifetime. Effective fracture prevention is hindered by substantial undertreatment, even of patients who clearly warrant pharmacological therapy. Poor adherence to osteoporosis treatment is also a leading cause of repeat fractures and hospitalisation. The aim of this study was to identify current osteoporosis treatment patterns and gaps in practice in Australia, using general practice data, and to explore general practitioners' (GPs') attitudes to osteoporosis treatment and their views on patient factors affecting osteoporosis management. METHODS: The study was conducted in two phases. Phase 1 was a longitudinal retrospective cohort study which utilised data from MedicineInsight - a national general practice data program that extracts longitudinal, de-identified patient data from clinical information systems (CISs) of participating general practices. Phase 2 included semi-structured, in-depth telephone interviews with a sample of MedicineInsight practice GPs. Data were analysed using an inductive thematic analysis method informed by the theory of planned behaviour. RESULTS: A diagnosis of osteoporosis was recorded in 12.4% of patients over the age of 50 years seen in general practice. Of those diagnosed with osteoporosis, almost a quarter were not prescribed osteoporosis medicines. From 2012 to 17, there was a progressive increase in the number of denosumab prescriptions, while prescriptions for bisphosphonates and other osteoporosis medicines decreased. More than 80% of patients who ceased denosumab treatment had no subsequent bisphosphonate prescription recorded. Interviews with GPs revealed beliefs and attitudes that may have influenced their intentions towards prescribing and osteoporosis management. CONCLUSIONS: This study suggests that within the Australian general practice setting, osteoporosis is underdiagnosed and undertreated. In addition, it appears that most patients who ceased denosumab treatment had no record of subsequent antiresorptive therapy, which would place them at risk of further fractures. The study supports the need for the development of clinical education programs addressing GP knowledge gaps and attitudes, and the implementation of specific interventions such as good reminder/recall systems to avoid delays in reviewing and treating patients with osteoporosis.

A pharmacy asthma service achieves a change in patient responses from increased awareness to taking responsibility for their asthma.

OBJECTIVES: If novel health services are to be implemented and sustained in practice, the perceptions and views of patients form a critical part of their evaluation. The aims of this study were to explore patient's perceptions and experiences with a pharmacy asthma service and to investigate if there was a change over time. METHODS: Interviews and focus groups were conducted with patients participating in the asthma service at three time points. Data were transcribed verbatim and thematically analyzed using a framework approach. KEY FINDINGS: The service led to an enhanced awareness and understanding of asthma, changes in participants' beliefs and attitudes towards asthma management, changes in asthma-related health behaviours and improved self-efficacy. Participants were very positive about the service and the role of the pharmacist in asthma management. There was a shift in participant perceptions and views, from being at an abstract level in those who had completed just one visit of the service to a more experiential level in those who had experienced the entire comprehensive asthma service. CONCLUSIONS: A sustained experience/multiple visits in a service may lead to more concrete changes in patient perceptions of severity, beliefs, health behaviours and enhanced self-efficacy and control. The study highlights a need for such asthma services in the community.

Effectiveness of computerized clinical decision support systems for asthma and chronic obstructive pulmonary disease in primary care: a systematic review.

BACKGROUND: The use of computerized clinical decision support systems may improve the diagnosis and ongoing management of chronic diseases, which requires recurrent visits to multiple health professionals, disease and medication monitoring and modification of patient behavior. The aim of this review was to systematically review randomized controlled trials evaluating the effectiveness of computerized clinical decision systems (CCDSS) in the care of people with asthma and COPD. METHODS: Randomized controlled trials published between 2003 and 2013 were searched using multiple electronic databases Medline, EMBASE, CINAHL, IPA, Informit, PsychINFO, Compendex, and Cochrane Clinical Controlled Trials Register databases. To be included, RCTs had to evaluate the role of the CCDSSs for asthma and/or COPD in primary care. RESULTS: Nineteen studies representing 16 RCTs met our inclusion criteria. The majority of the trials were conducted in patients with asthma. Study quality was generally high. Meta-analysis was not conducted because of methodological and clinical heterogeneity. The use of CCDSS improved asthma and COPD care in 14 of the 19 studies reviewed (74%). Nine of the nineteen studies showed statistically significant (p < 0.05) improvement in the primary outcomes measured. The majority of the studies evaluated health care process measures as their primary outcomes (10/19). CONCLUSION: Evidence supports the effectiveness of CCDSS in the care of people with asthma. However there is very little information of its use in COPD care. Although there is considerable improvement in the health care process measures and clinical outcomes through the use of CCDSSs, its effects on user workload and efficiency, safety, costs of care, provider and patient satisfaction remain understudied.

Asthma interventions in primary schools--a review.

OBJECTIVE: To explore, in depth, the literature for evidence supporting asthma interventions delivered within primary schools and to identify any "gaps" in this research area. METHODS: A literature search using electronic search engines (i.e. Medline, PubMed, Education Resources Information Center (ERIC), International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and Informit) and the search terms "asthma", "asthma intervention" and "school-based asthma education program" (and derivatives of these keywords) was conducted. RESULTS: Twenty-three articles met the inclusion criteria; of these eight were Randomised Controlled Trials. There was much variety in the type, content, delivery and outcome measures in these 23 studies. The most common intervention type was asthma education delivery. Most studies demonstrated improvement in clinical and humanistic markers, for example, asthma symptoms medication use (decrease in reliever medication use or decrease in the need for rescue oral steroid), inhaler use technique and spacer use competency, lung function and quality of life. Relatively few studies explored the effect of the intervention on academic outcomes. Most studies did not report on the sustainability or cost effectiveness of the intervention tested. Another drawback in the literature was the lack of details about the intervention and inconsistency in instruments selected for measuring outcomes. CONCLUSION: School-based asthma interventions regardless of their heterogeneity have positive clinical, humanistic, health economical and academic outcomes.

The role of community pharmacists in screening and subsequent management of chronic respiratory diseases: a systematic review.

OBJECTIVE: The purpose of this review was to evaluate the role of community pharmacists in provision of screening with/without subsequent management of undiagnosed chronic obstructive pulmonary disease (COPD) and uncontrolled asthma. METHODS: An extensive literature search using four databases (ie. Medline, PubMed, International Pharmaceutical Abstracts (IPA) and Scopus) with search terms pharmacy, screening, asthma or COPD was conducted. Searches were limited to the years 2003-2013, those in English and those reporting research with humans. Data retrieval, analysis and result presentation employed a scoping review method. RESULTS: Seventeen articles met the inclusion/exclusion criteria, of which fifteen studies were based on people with asthma and two were based on people with COPD. Only seven asthma studies and one COPD study involved screening followed by subsequent management. More than half of the people screened were found to be poorly controlled and up to 62% of people were identified at high risk for COPD by community pharmacists. The studies varied in the method and type of asthma control assessment/screening, the type of intervention provided and the outcomes measured. The limitations of the reviewed studies included varying definitions of asthma control, different study methodologies, and the lack of long-term follow-up. While many different methods were used for risk assessment and management services by the pharmacists, all the studies demonstrated that community pharmacists were capable of identifying people with poorly controlled asthma and undiagnosed COPD and providing them with suitable interventions. CONCLUSIONS: The literature review identified that community pharmacists can play an effective role in screening of people with poorly controlled asthma and undiagnosed COPD along with delivering management interventions. However, there is very little literature available on screening for these chronic respiratory conditions. Future research should focus on development of patient care delivery model incorporating a screening protocol followed by targeted management interventions delivered by the community pharmacist.

The role of community pharmacists in screening and subsequent management of chronic respiratory diseases: a systematic review / Papel de los farmacéuticos comunitarios en rastreo y posterior manejo de enfermedades crónicas respiratorias: revisión sistemática

Objective: The purpose of this review was to evaluate the role of community pharmacists in provision of screening with/without subsequent management of undiagnosed chronic obstructive pulmonary disease (COPD) and uncontrolled asthma. Methods: An extensive literature search using four databases (ie. Medline, PubMed, International Pharmaceutical Abstracts (IPA) and Scopus) with search terms pharmacy, screening, asthma or COPD was conducted. Searches were limited to the years 2003-2013, those in English and those reporting research with humans. Data retrieval, analysis and result presentation employed a scoping review method. Results: Seventeen articles met the inclusion/exclusion criteria, of which fifteen studies were based on people with asthma and two were based on people with COPD. Only seven asthma studies and one COPD study involved screening followed by subsequent management. More than half of the people screened were found to be poorly controlled and up to 62% of people were identified at high risk for COPD by community pharmacists. The studies varied in the method and type of asthma control assessment/screening, the type of intervention provided and the outcomes measured. The limitations of the reviewed studies included varying definitions of asthma control, different study methodologies, and the lack of long-term follow-up. While many different methods were used for risk assessment and management services by the pharmacists, all the studies demonstrated that community pharmacists were capable of identifying people with poorly controlled asthma and undiagnosed COPD and providing them with suitable interventions. Conclusion: The literature review identified that community pharmacists can play an effective role in screening of people with poorly controlled asthma and undiagnosed COPD along with delivering management interventions. However, there is very little literature available on screening for these chronic respiratory conditions. Future research should focus on development of patient care delivery model incorporating a screening protocol followed by targeted management interventions delivered by the community pharmacist (AU)

Objetivo: El propósito de esta revisión fue evaluar el papel de los farmacéuticos comunitarios en la provisión de rastreos con/sin posterior manejo de enfermedad pulmonar obstructiva crónica (EPOC) no diagnosticada y asma no controlada. Métodos: Se realizó una extensiva búsqueda bibliográfica usando cuatro bases de datos (ie. Medline, PubMed, International Pharmaceutical Abstracts (IPA) and Scopus) con términos de búsqueda farmacia, rastreo, asma o EPOC. Las búsquedas se limitaron a los años 2003-2013, a las escritas en inglés, y a las que comunicaban investigación en seres humanos. La recuperación, y análisis de datos y la presentación de resultados se realizaron mediante un método de determinación del alcance. Resultados: 17 artículos cumplieron los criterios de inclusión/exclusión, de los cuales, 15 eran de personas con asma y 2 con EPOC. Sólo 7 de los estudios de asma y uno de los de EPOC envolvían rastreos seguidos del consiguiente manejo. Más de la mitad de las personas rastreadas estaban pobremente controladas y hasta un 62% de las personas fueron identificadas como en alto riesgo de EPOC por los farmacéuticos. Los estudios variaban en el método y tipo de evaluación/rastreo del control de asma, el tipo de intervención realizada y los resultados medidos. Las limitaciones de los estudios revisados incluyeron la diversidad de definiciones de control de asma, las diferentes metodologías de estudio, y la falta de seguimiento a largo plazo. Aunque se utilizaron muchos métodos diferentes de evaluación del riesgo y de servicios de manejo de la enfermedad por los farmacéuticos, todos los estudios demostraron que los farmacéuticos comunitarios eran capaces de identificar personas con asma pobremente controlada y EPOC no diagnosticada y de realizar con ellos las intervenciones apropiadas. Conclusión: La revisión de la literatura identifico que los farmacéuticos comunitarios pueden jugar un papel efectivo en el rastreo de personas con asma pobremente controlado y EPOC no diagnosticada así como realizarles las intervenciones de manejo. Sin embargo, hay muy poca literatura disponible sobre el rastreo de estas enfermedades respiratorias crónicas. La investigación futura debería centrarse en el desarrollo de modelos de atención a pacientes que incorporen un protocolo de rastreo seguido de intervenciones de manejo de la enfermedad proporcionadas por los farmacéuticos comunitarios (AU)

Discrete choice experiments in pharmacy: a review of the literature.

OBJECTIVE: Discrete choice experiments (DCEs) have been widely used to elicit patient preferences for various healthcare services and interventions. The aim of our study was to conduct an in-depth scoping review of the literature and provide a current overview of the progressive application of DCEs within the field of pharmacy. METHODS: Electronic databases (MEDLINE, EMBASE, SCOPUS, ECONLIT) were searched (January 1990-August 2011) to identify published English language studies using DCEs within the pharmacy context. Data were abstracted with respect to DCE methodology and application to pharmacy. KEY FINDINGS: Our search identified 12 studies. The DCE methodology was utilised to elicit preferences for different aspects of pharmacy products, therapy or services. Preferences were elicited from either patients or pharmacists, with just two studies incorporating the views of both. Most reviewed studies examined preferences for process-related or provider-related aspects with a lesser focus on health outcomes. Monetary attributes were considered to be important by most patients and pharmacists in the studies reviewed. Logit, probit or multinomial logit models were most commonly employed for estimation. CONCLUSION: Our study showed that the pharmacy profession has adopted the DCE methodology consistent with the general health DCEs although the number of studies is quite limited. Future studies need to examine preferences of both patients and providers for particular products or disease-state management services. Incorporation of health outcome attributes in the design, testing for external validity and the incorporation of DCE results in economic evaluation framework to inform pharmacy policy remain important areas for future research.

Patient preferences for community pharmacy asthma services: a discrete choice experiment.

BACKGROUND: Specialized community pharmacy services, involving the provision of disease state management and care by pharmacists, have been developed and trialled and have demonstrated very good health outcomes. Most of these services have been developed from a healthcare professional perspective. However, for the future uptake and long-term sustainability of these services as well as for better and sustained health outcomes for patients, it is vital to gain an understanding of patients' preferences. We can then structure healthcare services to match these preferences and needs rather than around clinical viewpoints alone. OBJECTIVE: The aim of this study was to elicit patient preferences for pharmacy-based specialized asthma services using a discrete choice experiment and to explore the value/importance that patients place on the different attributes of the asthma service. The existence of preference heterogeneity in the population was also investigated. METHODS: The study was conducted with asthma patients who had recently experienced a specialized asthma management service at their pharmacy in New South Wales, Australia. Pharmacists delivering the asthma service mailed out the discrete choice questionnaires to participating patients at the end of 6 months of service provision. A latent class (LC) model was used to investigate each patient's strength of preference and preference heterogeneity for several key attributes related to asthma service provision: frequency of visits, access to pharmacist, interaction with pharmacy staff, availability of a private area for consultation, provision of lung function testing, type and depth of advice provision, number of days with asthma symptoms and cost of service. RESULTS: Eighty useable questionnaires (of 170 questionnaires sent out) were received (response rate 47.1%). The study identified various key elements of asthma services important to patients. Further, the LC analysis revealed three classes with differing patient preferences for levels of asthma service provision. Patients in the Minimalistic Model class valued provision of lung function testing and preferred more frequent service visits. Cost of service had a negative effect on service preference for patients in this class. Patients in the Partial Model class mainly derived utility from the provision of lung function testing and comprehensive advice at the pharmacy and also wanted more frequent service visits. The Holistic Model class patients considered all attributes of the service to be important when making a choice. While the majority of the service attributes had a positive effect on preference for patients in this class, cost of service and days with symptoms of asthma had a negative effect on service preference. These patients also preferred fewer service visits. CONCLUSION: The study identified various key attributes that are important to patients with respect to community pharmacy-based asthma services. The results also demonstrate the existence of preference heterogeneity in the population. Asthma service providers need to take these findings into consideration in the design and development of future service models so as to increase their uptake and ensure their long-term sustainability.

Patients' value of asthma services in Australian pharmacies: the way ahead for asthma care.

OBJECTIVE: Long-term sustainability of health services requires an understanding of patients' values and preferences. The aim of this study was to evaluate patients' preferences as well as their willingness-to-pay (WTP) for a community pharmacy-delivered specialized asthma service using a discrete choice experiment (DCE). METHODS: Patients with asthma in New South Wales, Australia, who had recently experienced a specialized asthma management service at their pharmacy were mailed DCE questionnaires. Patients were asked to choose between two hypothetical service models with varying attributes. Multinomial logit models estimated patients' marginal WTP. RESULTS: The study had a response rate of 47%. Patients greatly valued various aspects of the pharmacy-based specialized service and had marginal WTP values of AUD$18.00 for a private area, AUD$44.50 for lung function testing, AUD$9.18 for appointments with pharmacists, and AUD$22.80 for provision of comprehensive advice on asthma and its medications. The marginal WTP for the overall service was AUD$94.86. CONCLUSIONS: The findings of the study indicate that patients greatly value and are willing to pay for asthma services in pharmacies. The study results will help pharmacists and policy advisors in the development of individualized asthma services that patients will use, are willing to pay for, and thus are economically viable in the future.

Community pharmacy-based asthma services--what do patients prefer?

BACKGROUND: Patient preferences can influence the outcomes of treatment and so understanding and organizing health-care services around these preferences is vital. OBJECTIVE: To explore patient preferences for types of community pharmacy-based asthma services, to investigate the influence of "experience" in molding preferences for such services, and to identify aspects of the services that patients prefer over others. METHODS: Semistructured face-to-face interviews were conducted with a convenience sample of two types of asthma patients: (1) those naïve to a specialized asthma service and (2) those who had experienced a specialized asthma service. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed. RESULTS: Eighteen interviews were conducted (8 experienced patients, 10 naïve patients). The majority of the patients wanted the pharmacist to play a greater role in their asthma management. Patients experiencing increased levels of service had increased levels of expectations as well as more specific preferences for various aspects of the service. The key aspects of an asthma service that all patients wanted their pharmacists to provide were the provision of information about asthma and its medications, lung function testing and monitoring of their asthma, and checking/correcting their inhaler technique. Patients also expressed a desire for skilled communication and behavioral aspects from the pharmacist such as friendliness, empathy, attentiveness, and dedicated time. Patients highlighted the importance of privacy in the pharmacy. There was a high level of satisfaction toward the currently delivered asthma service among both naïve and experienced patients. The provision of the specialized service was associated with increased patient loyalty to the particular pharmacy. All patients indicated a willingness to participate in future pharmacy-delivered specialized asthma services. DISCUSSION: Elements of the specialized pharmacy-based asthma services important from a patient's perspective were identified. It would be important to identify the strength and magnitude of patient's preferences for different elements of such services. Future pharmacy-based services should incorporate patient preferences and tailor services to patient's needs to ensure their long-term viability.

Measurement of patient satisfaction with community pharmacy services: a review.

AIM OF THE REVIEW: The aim of this review is to conduct an in-depth analysis of the available literature in order to identify and evaluate studies measuring patient satisfaction with pharmacy services delivered by pharmacists in a community setting. METHOD: An extensive literature search was conducted in five databases (Medline, Scopus, Embase, Psychinfo, International Pharmaceutical Abstracts) using the search terms "patient/client/consumer satisfaction" AND "community pharmacy/pharmacies" AND "pharmacy service/pharmaceutical services/pharmacy program/intervention/intervention studies". Only those articles where the main focus was measuring patient satisfaction with services delivered in community pharmacies were included in the review. Patient satisfaction was explored with three different levels of pharmacy services -- general services, intervention services and cognitive services. RESULTS: Twenty-four articles measuring patient satisfaction with community pharmacy services were retrieved. Of these, eleven measured patient satisfaction with general services, six measured satisfaction with intervention services and seven measured satisfaction with cognitive services. The majority of studies reviewed had adopted and measured satisfaction as a multidimensional construct. None of the studies reviewed tested any theoretical models of satisfaction. Further a lack of consistent instruments measuring patient satisfaction was observed, with most of the reviewed studies using self developed, non-validated or ad hoc instruments with items from various previously published papers. The review also observed high levels of patient satisfaction with pharmacy services be they general, intervention or cognitive services. CONCLUSION: This review found that patient satisfaction has been measured within the community pharmacy context to a certain degree. Further research is needed to develop and test instruments based on theoretical frameworks, to test satisfaction pre and post hoc and in well designed randomized controlled trials and to measure changes in satisfaction over time. Novel approaches involving an understanding of expectations and preferences of patients and matching these to the services provided also need to be explored.