Physician's perspective regarding asthma guided self-management: directives or guidance?

INTRODUCTION: Asthma guided self-management enhances patients' control of their condition under the guidance of the treating physician. The aim of the present study was to understand how physicians perceive, endorse, uptake, and support asthma guided self-management. METHODS: We conducted a secondary supplementary analysis of data originally collected as part of a multicenter collective case study in which physicians treating patients with asthma were interviewed. Using reflective thematic analysis, we aimed to explore physicians' understanding of guided asthma self-management as related to four ideas, namely: (a) understanding of the disease management and treatment goals; (b) defining medical frame and guidance; (c) describing the importance of patient-physician relationship; and (d) implementing asthma guided self-management. RESULTS: Evidence indicates that physicians perceived optimal guided self-management as related to patients' adherence to physician's instructions and recommendations, supported by the adjustment of prescribed pharmaceutical therapy contingent upon patient's symptoms. Some physicians also perceived behavior change and environmental control along with the medical recommendations. While physicians' perception of asthma and its treatment were aligned with the recommended guidelines-i.e., patient-centered care approach based on guided self-management, the actual guidance offered to patients remained primarily directive and paternalistic. Non-pharmacological approaches, such as exercise, smoking cessation, patient self-monitoring, and self-management supported by education and written self-management plans, were given little consideration in the context of the recommended treatment plan.

Entre l'arbre et l'écorce : l'évolution de la profession de pharmacien au Québec aux XIXe-XXe siècles.

In Quebec's historiography, the history of pharmacies and pharmacists straddles the history of medicine, doctors and health, on the one side, and the history of small business and consumerism, on the other. Too much of a hybrid to fit neatly in either of those fields of study, it has largely flown under the historians' radar. This duality is nonetheless fascinating. Not only is it at the very heart of pharmacies' trajectory and evolution in Quebec, but it explicitly highlights the fact that health, medication, and consumerism have historically close ties. Having given the background to an important investigation held in 1899, the paper illustrates the tension between commerce and profession from the mid-19th century to the economic and identity crisis facing pharmacists in the Sixties and Seventies.

Dans l'historiographie québécoise, l'histoire de la pharmacie et des pharmaciens se situe en quelque sorte entre l'histoire de la médecine, des médecins et de la santé, d'un côté, et l'histoire du petit commerce et de la consommation de l'autre. Sans doute trop hybride pour s'inscrire fermement dans l'un ou l'autre de ces champs d'études, elle n'a que très peu attiré l'attention des historiens à ce jour. Cette hybridité n'en demeure pas moins fascinante. Non seulement est-elle au cœur de la trajectoire et de l'évolution de la pharmacie au Québec, mais elle met en évidence de manière explicite le fait que santé, médicament et consommation sont historiquement étroitement liés. Après avoir brossé le contexte qui mène à une importante enquête menée en 1899, l'article déroulera le fil rouge de cette tension entre commerce et profession du milieu du XIXe siècle jusqu'à la crise économique et identitaire à laquelle feront face les pharmaciens dans les années 1960 et 1970.

Development of an electronic tool (e-AdPharm) to address unmet needs and barriers of community pharmacists to provide medication adherence support to patients.

BACKGROUND: Community pharmacists are best placed to improve medication adherence because they frequently interact with patients and have been trained to manage medication-related problems. Therefore, it is essential to equip pharmacists adequately to detect non-adherent patients quickly and intervene to improve medication adherence. OBJECTIVE: To design e-AdPharm, a tool that addresses unmet needs and barriers of community pharmacists to provide medication adherence support to patients with chronic diseases. METHODS: A qualitative study using 4 focus group discussions with community pharmacists was conducted with a semi-structured interview guide and discussions lasting for 1-2 h. The discussions covered the barriers and needs of pharmacists related to medication adherence support provided to patients, their expectations of an electronic tool based on prescription refills to help them provide this support, and the design of the tool. Focus group data were coded and analyzed using an iterative process, with thematic and descriptive analyses. RESULTS: Twenty-six community pharmacists participated. Lack of time and motivation from pharmacists and patients were common barriers to the provision of medication adherence support. Accordingly, community pharmacists wished to measure medication adherence quickly, provide easily interpretable data to patients on their medication use, and raise the patient's awareness of non-adherence. The pharmacists expressed their need to have an electronic tool to share medication adherence information with the treating physician. Regarding the design of e-AdPharm, the pharmacists wanted a table displaying medication adherence with a color code representing adherence level. They also stressed the importance of a structured section enabling them to continuously document the interventions made and the need for patient follow-ups. CONCLUSIONS: e-AdPharm meet the needs and overcome the barriers of community pharmacists to provide medication adherence support to their patients. Future studies should examine the feasibility of implementing e-AdPharm in community pharmacies and test its efficacy for improving medication adherence.

Monitoring and managing medication adherence in community pharmacies in Quebec, Canada.

BACKGROUND: Community pharmacists have direct access to prescription refill information and regularly interact with their patients. Therefore, they are in a unique position to promote optimal medication use. OBJECTIVES: To describe how community pharmacists in Quebec, Canada, identify nonadherent patients, monitor medication use and promote optimal medication adherence. METHODS: An invitation to complete a web-based survey was published online through different platforms, including a Facebook pharmacists' group, an electronic newsletter, a pharmacy network forum and e-mail. The survey included questions on participant characteristics, methods used by pharmacists to identify nonadherent patients and monitor medication use and interventions they used to promote medication adherence. RESULTS: In total, 342 community pharmacists completed the survey. The participants were mainly women (71.6%), staff pharmacists (56.7%) and aged 30 to 39 years (34.2%). The most common method to identify nonadherent patients was to check gaps between prescription refills (98.8%). The most common intervention to promote adherence was patient counselling (82.5%). The most common barriers to identifying nonadherent patients were lack of time (73.1%) and lack of prescription information (65.8%), whereas the most common barriers to intervening were anticipation of a negative reaction from their patients (91.2%) and lack of time (64%). CONCLUSION: Lack of time and lack of prescription information are frequent challenges encountered by community pharmacists regarding effective monitoring and management of patients with poor medication adherence. Pharmacists could benefit from electronic tools based on prescription refills that would provide quick and easily interpretable information on their patients' medication adherence. Can Pharm J (Ott) 2020;153:xx-xx.

Guided asthma self-management or patient self-adjustment? Using patients' narratives to better understand adherence to asthma treatment.

PURPOSE: The purpose of this study was to better understand patients' perspective of asthma self-management by focusing on the sociocultural and medical context shaping patients' illness representations and individual decisions. PATIENTS AND METHODS: We conducted a secondary analysis of semi-structured interviews carried out as part of a multicentered collective qualitative case study. In total, 24 patients, aged 2-76 years with a confirmed diagnosis of asthma (or were parents of a child), who renewed the prescription for inhaled corticosteroids in the past year, participated in this study. The thematic analysis focused on asthma-related events and experiences reported by the patients. Consistent with narrative inquiry, similar patterns were grouped together, and three vignettes representing the different realities experienced by the patients were created. RESULTS: The comparison of experiences and events reported by the patients suggested that patients' perceptions and beliefs regarding asthma and treatment goals influenced their self-management-related behaviors. More specifically, the medical context in which the patients were followed (ie, frame in which the medical encounter takes place, medical recommendations provided) contributed to shape their understanding of the disease and the associated treatment goals. In turn, a patient's perception of the disease and the treatment goals influenced asthma self-management behaviors related to environmental control, lifestyle habits, and medication intake. CONCLUSION: Current medical recommendations regarding asthma self-management highlight the importance of the physicians' guidance through the provision of a detailed written action plan and asthma education. These data suggest that while physicians contribute to shaping patients' beliefs and perceptions about the disease and treatment goals, patients tend to listen to their own experience and manage the disease accordingly. Thus, a medical encounter between the patient and the physician, aiming at enhancing a meaningful conversation about the disease, may lead the patient to approach the disease in a more effective manner, which goes beyond taking preventative paths to avoid symptoms.

[The enhanced medication: The use of medicine in transhumanistic discourses and its social meanings]. / Le médicament augmenté : l'usage du médicament dans les discours transhumanistes et ses significations sociales.

Though NBICs and their overlap are at the heart of transhumanist claims in favour of human enhancement, medication also occupies a central place. In many of the movement's writings and lectures, it is one of the primary means systematically considered to extend human biological boundaries and improve physical, intellectual and emotional performance. Taking a sociological perspective, this article aims to explore the role and meaning medication holds in transhumanist discourse. Declared the tool for true human emancipation, the non-therapeutic use of medication for which transhumanists advocate is actually carried out against a heightened biomedicalization of many contemporary social issues. After having explored this ambivalence, our article demonstrates that, hardly specific to this fringe movement, transhumanists' aspirations of pharmacologically reaching ?better than well? fits more broadly into contemporary biomedical pretentions, of which transhumanism is just one extreme example.

[Not Available]. / Entre médecine, culture et pensée sociopolitique: le concept de dégénérescence au Québec (1860-1925).

In The Mind of Modernism, Mark Micale demonstrates the ubiquity of the concept of hysteria in the French imagination at the turn of the century. Taking this approach as our starting point, our study attempts to determine if the notion of degeneration played a similar role in the interactions of psychiatry, culture and politics in Quebec. Our analysis of a variety of historical sources demonstrates that the concept of degeneration did indeed penetrate aspects of psychiatric nosology, medical literature, news media, fiction, and political discourse in Quebec.

Prescription Psychostimulant Use Among Young Adults: A Narrative Review of Qualitative Studies.

BACKGROUND: Within the last decade, the nonmedical use of prescription drugs has raised concern, particularly among young adults. Psychostimulants, that is to say amphetamine and its derivatives, are pharmaceuticals, which contribute to what has come to be known in Canada and the United States as the "prescription drug crisis." Research in the fields of public health, addiction studies, and neuroethics has attempted to further understand this mounting issue; however, there is a paucity of data concerning the underlying social logics related to the use of these substances. OBJECTIVES: The objective of this article is to provide an overview of the current literature related to the social context of prescription psychostimulant use among young adults, and to discuss theoretical considerations as well as implications for future research. METHODS: A narrative review of the literature was performed. RESULTS: We found that research efforts have chiefly targeted college students, yet there is a lack of knowledge concerning other social groups likely to use these pharmaceuticals nonmedically, such as persons with high strain employment. Three main emerging patterns related to prescription psychostimulant use were identified: (1) control of external stressors, (2) strategic use toward the making of the self, and (3) increasing one's performance. CONCLUSIONS: Prescription psychostimulant use among young adults is anchored in contemporary normativity and cannot be separated from the developing performance ethic within North-American and other Western societies. We suggest that pharmaceuticalization and Actor-Network Theory are useful conceptual tools to frame future research efforts.

On social plasticity: the transformative power of pharmaceuticals on health, nature and identity.

This article proposes a theoretical framework on the role of pharmaceuticals in transforming perspectives and shaping contemporary subjectivities. It outlines the significant role drugs play in three fundamental processes of social transformation in Western societies: medicalisation, molecularisation and biosocialisation. Indeed, drugs can be envisaged as major devices of a pharmaceutical regime, which is more akin to the notion of dispositif, as used by Foucault, than to the sole result of high-level scheming by powerful economic interests, a notion which informs a significant share of the literature. Medications serve as a key vector of the transformation of perspective (or gaze) that characterises medicalisation, molecularisation and biosocialisation, by shifting our view on health, nature and identity from a categorical to a dimensional framework. Hence, central to this thesis is that the same underlying mechanism is at work. Indeed, in all three processes there is an evolving polarity between two antinomic categories, the positions of which are constantly being redefined by the various uses of drugs. Due to their concreteness, the fluidity of their use and the plasticity of the identities they authorise, drugs colonise all areas of contemporary social experiences, far beyond the medical sphere. A video abstract of this article can be found at: https://www.youtube.com/watch?v=djIBY7DHKW4&feature=youtu.be.

Patients' perspective of barriers and facilitators to taking long-term controller medication for asthma: a novel taxonomy.

BACKGROUND: Although asthma morbidity can be prevented through long-term controller medication, most patients with persistent asthma do not take their daily inhaled corticosteroid. The objective of this study was to gather patients' insights into barriers and facilitators to taking long-term daily inhaled corticosteroids as basis for future knowledge translation interventions. METHODS: We conducted a collective qualitative case study. We interviewed 24 adults, adolescents, or parents of children, with asthma who had received a prescription of long-term inhaled corticosteroids in the previous year. The one-hour face-to-face interviews revolved around patients' perceptions of asthma, use of asthma medications, current self-management, prior changes in self-management, as well as patient-physician relationship. We sought barriers and facilitators to optimal asthma management. Interviews were transcribed verbatim and transcripts were analyzed using a thematic approach. RESULTS: Patients were aged 2-76 years old and 58% were female. Nine patients were followed by an asthma specialist (pulmonologist or allergist), 13 patients by family doctors or pediatricians, and two patients had no regular follow-up. Barriers and facilitators to long-term daily inhaled corticosteroids were classified into the following loci of responsibility and its corresponding domains: (1) patient (cognition; motivation, attitudes and preferences; practical implementation; and parental support); (2) patient-physician interaction (communication and patient-physician relationship); and (3) health care system (resources and services). Patients recognized that several barriers and facilitators fell within their own responsibility. They also underlined the crucial impact (positive or negative) on their adherence of the quality of patient-physician interaction and health care system accessibility. CONCLUSIONS: We identified a close relationship between reported barriers and facilitators to adherence to long-term daily controller medication for asthma within three loci of responsibility. As such, patients' adherence must be approached as a multi-level phenomenon; moreover, interventions targeting the patient, the patient-physician interaction, and the health care system are recommended. The present study offers a potential taxonomy of barriers and facilitators to adherence to long-term daily inhaled corticosteroids therapy that, once validated, may be used for planning a knowledge translation intervention and may be applicable to other chronic conditions.

Resistance and mutations of non-specificity in the field of anxiety-depressive disorders in Canadian medical journals, 1950-1990.

Pharmaceuticalisation is a complex phenomenon, co-constitutive of what scholars identify as a pharmaceutical regime, comprised of networks of actors, institutions and artefacts as well as cognitive structures that underlie the production, promotion and use of medications. The aim of this paper is to explore the linkages between different components of this pharmaceutical regime through the analysis of psychotropic drug advertising in Canadian medical journals between 1950 and 1990. Advertisements stand at the nexus of macro-level processes related to the development, regulation and marketing of new drug treatments and of micro-level processes related to the use of these drug treatments, both by clinicians and lay persons. We thus examine advertisements from the angle of the mental and classificatory universes to which doctors were exposed through direct-to-prescriber advertisement strategies implemented during this period. Furthermore, we explore to what extent the rationale behind advertisements was permeated by both scientific/professional and popular narratives of mind-body connections. This paper demonstrates that, although this period was marked by paradigm shifts in the classification of mental diseases, the development of modern psychopharmacology, and the questioning of the scientific legitimacy of psychiatry, advertisements unveil a remarkable continuity: that of the mass management of anxiety-depressive disorders by primary care physicians through psychotropic drugs. Also, despite the effective resistance to specificity as shown by the constant redefinitions of diagnostic categories and therapeutic indications, our analysis suggests that the language of specificity used in the promotion of new drugs and in the various narratives of mind-body connection may have been appealing to general practitioners. Finally, our study of the classes of psychoactive medications that have been in use for over half a century reveals a complex, non-linear dynamic of pharmaceuticalisation and de-pharmaceuticalisation.

Universal cures for idiosyncratic illnesses: A genealogy of therapeutic reasoning in the mental health field.

Over the past decades, there has been a significant increase in prescriptions of psychotropic drugs for mental disorders. So far, most of the explanations of the phenomenon have focused on the process of medicalization, but little attention has been cast towards physicians' day-to-day clinical reasoning, and the way it affects therapeutic decision-making. This article addresses the complex relationship between aetiology, diagnosis and drug treatment by examining the style of reasoning underlying prescribing practices through an historical lens. A genealogy of contemporary prescribing practices is proposed, that draws significant comparisons between 19th-century medicine and modern psychiatry. Tensions between specific, standardized cures and specific, idiosyncratic patients have been historically at play in clinical reasoning - and still are today. This inquiry into the epistemological foundations of contemporary drug prescription reveals an underlying search for scientific legitimacy.

Facilitators and solutions for practicing optimal guided asthma self-management: the physician perspective.

OBJECTIVE: To identify key solutions that facilitate the prescription of long-term asthma controller and provision of written self-management plans by physicians. METHODS: One hour individualized semistructured interviews were conducted with physicians. Interviews were transcribed verbatim and analyzed independently by two trained qualitative researchers. A taxonomy of facilitators (contemplated solutions) and experienced solutions was achieved by consensus within the research team. RESULTS: Forty-two physicians (family physicians, pediatricians, emergency physicians, pulmonologists and allergists) were interviewed. The 867 facilitators and solutions, grouped in 10 categories, addressed three physician needs: support physicians in delivering optimal care (guideline dissemination, workplace culture, physician training and experience, physician attitudes toward optimal practice, tools and resources supporting physicians' decision making); assist patients with following recommendations (patient characteristics, experiences and attitudes; physician behaviour; and tools and resources supporting patient self-management); and offer efficient services (reorganization of care; interprofessional patient management). Suggestions pertaining to the latter two categories were most frequently cited to optimize asthma management and use of self-management plans (e.g., access to self-management plans; education by allied health care professionals). The most cited suggestions to support prescribing long-term controller pertained to physician behaviour (e.g., involvement in patient education, personalization of prescriptions, feedback to patients of the benefits of long-term controller). The distribution of facilitators and solutions varied across specialties. CONCLUSIONS: Physicians proposed multiple facilitators and solutions to support optimal practice, leading to the development of a novel taxonomy. Key suggestions varied across physician specialties and behaviours sought, emphasizing the need to carefully select the most promising knowledge translation interventions.

The multiple anxieties of getting older: tranquilizers and the ambivalence of effect.

Most studies on benzodiazepines emphasize overconsumption and warn of addiction, especially by older adults. This article is about the avoidance of benzodiazepine medications by 'aging' women living in a Brazilian village. This case study helps to support our central concern: to call attention to the ambiguities that exist in discussing these medications, and to stress the importance of a multilayered understanding of effect. We argue that benzodiazepines, like other psychopharmaka, induce bodily sensations that, at least in part, correspond to and are shaped by the situated self-image of individuals in distress.

[Drug therapy and hypertension in the newspapers]. / Médicaments et hypertension dans les journaux.

OBJECTIVE: The most recent country-wide Canadian data have revealed that only 33% of people with hypertension take medication and fewer than half of them have their blood pressure under control. One of the most important reasons for difficulty in controlling blood pressure is lack of drug treatment compliance. In addition, media coverage of health facts has an impact on beliefs, attitudes and behaviours related to health. Our goal was to analyze newspaper coverage of drugs related to hypertension. METHOD: We conducted a thematic content analysis of newspapers covering medications related to hypertension. The study comprised 104 articles drawn from three of the most important francophone daily newspapers in Canada--a reference one, a general broadsheet and a tabloid. RESULTS: We identified three major themes: 1) drugs as an effective treatment, 2) specific problematic cases, and 3) problems with the pharmacological approach in general. We noted a gradual change from positive to negative as we moved from the most serious newspaper to the most popular. We discuss the Fiske hypothesis which suggests that tabloid-format newspapers are a repository of popular opposition to the discourse of groups who hold power in society. CONCLUSION: In the tabloid, the most widely-read newspaper in Quebec, medications are often presented in negative fashion in articles on hypertension. However, further studies are required to determine if there is a causal association between media discourse and the phenomenon of lack of drug treatment compliance.

Risk perception and reasons for noncompliance in pharmacovigilance: a qualitative study conducted in Canada.

BACKGROUND: The postmarketing safety evaluation of drugs relies on the spontaneous reporting of adverse reactions to authorities. Under-reporting is a known issue, with only 3% of all adverse reactions that occur actually being reported. Therefore, the postmarketing safety evaluation of medications is compromised. OBJECTIVE: This investigation aimed to identify determining factors that influence reporting as well as corrective actions. We specifically wanted to define the perceptions physicians and pharmacists have of pharmacovigilance, of the local and national reporting systems, of their role and that of other players in reporting adverse reactions, and of its consequences in their clinical practice. METHODS: Three focus groups with pharmacists and 16 semi-structured interviews with physicians from four different clinical services were conducted. RESULTS: Four major obstacles to reporting adverse reactions were identified: (i) pharmacovigilance is seen as an unrealistic ideal; (ii) the reporting authority is perceived as a virtual and remote entity; (iii) healthcare professionals do not feel concerned by the risks associated with the medications used in their practice; and (iv) healthcare professionals are uncertain about the scope of their role in reporting adverse effects. CONCLUSION: In order to promote reporting and a greater awareness of the system, a redefinition of its expectations and targeted feedback seem to be essential. Increased reporting can also be achieved by the presence of an onsite professional dedicated to reporting and educating others. Several definite measures are proposed in order to achieve this goal.

Quantitative evaluation of a clinical intervention aimed at changing prescriber behaviour in response to new guidelines.

RATIONAL, AIMS AND OBJECTIVES: The objective of the study was to assess prescribers' compliance with guidelines for acute community-acquired pneumonia management in a paediatric university hospital centre before and after its dissemination. METHOD: This quasi-experimental study without a control group was conducted before and after new community-acquired pneumonia management guidelines were disseminated in a tertiary care paediatric hospital. The pre-intervention (baseline) period was from October 2004 to March 2005. The intervention period was divided into two phases: (1) October 2005 to January 14, 2006 (consultation by peer leaders and networking) and (2) January 15, 2006, to March 2006 (dissemination of official guidelines and of a pre-printed prescription sheet, an educational session led by a peer leader for residents and further networking). We used a compliance score to assess prescriptions written by prescribers who practised in the units where the guidelines had to be followed. RESULTS: The study included a total of 1151 prescriptions. The prescription compliance with the guidelines increased from 131/652 (20.1%) in the pre-intervention period to 264/499 (52.9%) in the post-intervention intervention period: a difference of 32.8% (CI 95% 27.4-38.0). Similar results were found if analysed according to affiliation (emergency department or wards). An inappropriate choice of antibiotic agent represented 347/521 (66.6%) of the causes of non-compliance in the pre-intervention period and 99/235 (42.1) in the intervention period: a difference of -24.5% (95% CI -31.8, -16.8). CONCLUSION: Guideline dissemination for the management of acute community-acquired pneumonia significantly increased prescriber compliance in the emergency department and on wards.

Community pharmacists' interventions in asthma care: a descriptive study.

BACKGROUND: Factors influencing community pharmacists' interventions have been identified, but little information is available regarding these factors in asthma care. OBJECTIVE: To describe the type and frequency of pharmacists' asthma care interventions and to identify factors influencing those interventions. METHODS: A pretested, self-administered questionnaire was mailed to all community pharmacists registered with the Ordre des pharmaciens du Québec in 2006. The form included questions about the pharmacists' interventions in asthma care in the community setting (21 questions), factors influencing the provision of those interventions (13 questions), and the responders' characteristics (17 questions). RESULTS: A total of 4587 questionnaires were sent; 917 pharmacists returned the questionnaires (response rate 20%), and 877 were eligible for analysis. Overall, community pharmacists who completed the questionnaire appeared to intervene frequently when the initial prescription for asthma medication was filled. About 98% of responders reported providing verbal information always or often on new asthma medication prescriptions. Furthermore, checking for overuse of rescue medication and underuse of maintenance therapy always or often was reported by 91% and 85.8% of responders, respectively. Other interventions at follow-up were not as frequently reported. For example, only 8.4% of pharmacists reported reassessing inhalation technique always or often. Lack of time was reported to be an important barrier to the type and frequency of intervention, while interest on the part of the patient appeared to be a significant facilitator. About 99% of pharmacists agreed with the statement that they have an important role in asthma care. CONCLUSIONS: Community pharmacists appear to intervene with patients with asthma mostly at the initiation of treatment, but some interventions at follow-up are not frequently done, which could be attributed to organizational factors.