Healthcare expenditure and its socio-demographic and clinical predictors in Australians with poorly controlled asthma.

INTRODUCTION: Asthma has substantial and increasing health and economic burden worldwide. This study aimed to estimate healthcare expenditure and determine the factors that increase expenditure in Australians with poorly controlled asthma. METHODS: Individuals ≥18 years of age with poorly controlled asthma, as determined by a score ≥1.5 on the Asthma Control Questionnaire, were included in the study. Healthcare utilization costs from medical services and medications were estimated over an average follow-up of 12 months from administratively linked data: the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. A generalized linear model with gamma distribution and log link was used to predict participants' key baseline characteristics associated with variations in healthcare costs. RESULTS: A total of 341 participants recruited through community pharmacies were included. The mean (standard deviation, SD) age of participants was 56.6 (SD 17.6) years, and approximately 71% were females. The adjusted average monthly healthcare expenditure per participant was $AU386 (95% CI: 336, 436). On top of the average monthly costs, an incremental expenditure was found for each year increase in age ($AU4; 95% CI: 0.78, 7), being unemployed ($AU201; 95% CI: 91, 311), one unit change in worsening quality of life ($AU35; 95% CI: 9, 61) and being diagnosed with depression and anxiety ($AU171; 95% CI: 36, 306). CONCLUSIONS: In a cohort of Australian patients, characterized by poor asthma control and co-morbidities individuals impose substantial economic burden in terms of Medicare funded medical services and medications. Programs addressing strategies to improve the quality of life and manage co-morbid anxiety and depression and encourage asthma patients' engagement in clinically tolerable jobs, may result in significant cost savings to the health system.

Patient uptake and outcomes following pharmacist-initiated referrals to general practitioners for asthma review.

Uptake and outcomes of pharmacist-initiated general practitioner (GP) referrals for patients with poorly controlled asthma were investigated. Pharmacists referred at-risk patients for GP assessment. Patients were categorized as action takers (consulted their GP on pharmacist's advice) or action avoiders (did not action the referral). Patient clinical data were compared to explore predictors of uptake and association with health outcomes. In total, 58% of patients (n = 148) received a GP referral, of whom 78% (n = 115) were action takers, and 44% (n = 50) reported changes to their asthma therapy. Patient rurality and more frequent pre-trial GP visits were associated with action takers. Action takers were more likely to have an asthma action plan (P = 0.001) at month 12, and had significantly more GP visits during the trial period (P = 0.034). Patient uptake of pharmacist-initiated GP referrals was high and led to GP review and therapy changes in patients with poorly controlled asthma.

Integrating Pharmacy and Registry Data Strengthens Clinical Assessments of Patient Adherence.

Background: Accurate clinical assessment of patient adherence using reliable and valid measures is essential in establishing the presence of adherence issues and support practices for pharmacists. Objective: This investigation aims to conduct a novel assessment of patient adherence to asthma controller therapy by combining 1) patient-specific dosage data found in pharmacy dispensing data with 2) centrally collected administrative claims records, to determine the added value of using both sources of data. Methods: A total of 381 clinically uncontrolled asthma patients, from 95 community pharmacies across three Australian States were recruited and provided consent for the retrieval of their claims records and pharmacy dispensing data. Patients were stratified as multiple or single pharmacy users and adherence scores were calculated via the proportion of days covered (PDC) method using 1) patient claims records, 2) patient pharmacy dispensing data, and 3) combined claims records and pharmacy dispensing data. Cohort and subgroup adherence estimates were then compared. Results: Low levels of adherence were evident amongst the cohort irrespective of the data source used. PDC estimates based on claims records alone or combined claims records and pharmacy dispensing data were significantly higher than estimates based on pharmacy dispensing data for the total cohort (56%, 52%, 42% respectively, p < 0.001) and more noticeably for multiple pharmacy users (67%, 64%, 35% respectively, p < 0.001). PDC estimates based on combined claims records and pharmacy dispensing data were significantly lower than estimates based on claims records alone, indicating that perhaps standard daily dose is not a robust proxy for prescribed dosage to inhaled respiratory devices in adherence approximations. Poorer adherence was found amongst single pharmacy users than multiple pharmacy users when combined claims records and pharmacy dispensing data (46% compared to 64% respectively, p < 0.001) or claims records alone (51% compared to 67% respectively, p < 0.001) were compared. Conclusion: Access to routine collected data increases clinical acuity over patient adherence to asthma controller medications and is a valuable resource for health care professionals. A policy of secure accessibility of such data at the patient-pharmacist or patient-GP interface may allow real-time intervention and assist in decision making across numerous therapeutic areas.

Rethinking the gold standard - The feasibility of randomized controlled trials within health services effectiveness research.

BACKGROUND: An evidence-based randomized controlled trial for a novel Pharmacy Asthma Service was tested in 3 Australian states. Positive asthma outcomes were achieved after the 12-month intervention, albeit in both the intervention and comparator arms. The current investigation uses a mixed methods approach to 1) qualitatively explore how comparator arm pharmacists implemented the trial protocol and 2) quantitatively examine how this may have impacted patient outcomes in this trial. METHODS: Post-intervention semi-structured qualitative interviews were conducted with 20 pharmacists, representing 21 of 37 (57%) comparator arm pharmacies that completed the trial. Based on these interviews, pharmacies were classified as 'adherent' to the trial protocol (reporting no interventions other than general practitioner referral) or 'non-adherent' (reporting at least one extra intervention to the trial protocol), or 'inconclusive'. These subgroups were compared descriptively in relation to patient outcomes. RESULTS: Overall, 33% (n = 8/24) of the comparator pharmacies who were interviewed (n = 21) or determined to have monitoring by a project officer to ensure adherence to the protocol (n = 3) were classified as adherent), 58% (n = 14/24) as non-adherent, 8% inconclusive (n = 2/24). While all patients commenced with uncontrolled asthma (Asthma Control Questionnaire score (ACQ) > 1.5), after 12 months the mean ACQ score for patients from adherent comparator pharmacies ('true control') was 1.8 (still uncontrolled asthma) compared to a score of 1.4 (controlled asthma) in the non-adherent comparator group. Quality of life significantly improved in the non-adherent comparator group over the 12 months of the trial. CONCLUSION: The majority of pharmacists in the comparator arm who were interviewed, introduced their own interventions, which may have influenced the outcomes of the trial. The naturalistic setting of the study was not protective against these confounders. These findings question the feasibility of comparator arms within primary care settings and that alternative study designs should be considered when designing future intervention studies in pharmacy practice.

Pharmacist-delivered asthma management services-what do patients think?

BACKGROUND: Evaluating pharmacy services from the perspective of the end user-patients-is imperative for ensuring the sustainability of services. OBJECTIVES: This study evaluated patient feedback regarding an evidence-based community pharmacist-delivered Pharmacy Asthma Service (PAS), in terms of overall satisfaction, satisfaction with PAS delivery, and perceived impact, and explored determinates of satisfaction. METHODS: All patients who received the 12-month PAS (n = 143) were invited to provide feedback via a project-specific patient evaluation survey upon completion of the final consultation. The survey included a mix of 5-point Likert-type scale items, multiple-choice questions, and free-text response questions. Overall satisfaction was determined by a single 5-point Likert-type scale question. Satisfaction with service delivery and overall impact were assessed using a 4-item and 8-item Likert-type scale, respectively, and a summative score computed for each section. Patient PAS data including demographics and management outcomes were then cross tabulated against overall satisfaction, satisfaction with PAS delivery, and impact. RESULTS: Feedback was received from 71% (n = 101) of patients who completed the PAS. The results indicated high overall patient satisfaction, with 86% of respondents very satisfied with the service. Patients identified positive impacts of the PAS including improved understanding and management of asthma and allergic rhinitis. Similarly, almost all patients were satisfied with service delivery including the pharmacist's knowledge and their ability to assist (98%) and the privacy of the pharmacy setting (91%). Patients who had controlled asthma at the end of the trial had higher levels of overall satisfaction (χ2 = 9.584, df = 5, P = 0.048) and reported greater overall impact on asthma and allergic rhinitis management (U = 1593.5, P = 0.004). CONCLUSION: The diffusion of health services within community pharmacy practice is dependent upon patient receptivity and how the services align with patient needs. The positive satisfaction received indicates that the PAS would be welcomed by patients with asthma in future.

A Multi-Mode Education Program to Enhance Asthma Care by Pharmacists.

Objective. To provide optimal asthma care, community pharmacists must have advanced, contemporary knowledge, and the skills to translate that knowledge into practice. The development and evaluation of an innovative multi-mode education program to enhance pharmacists' clinical knowledge and practical skills is described.Methods. The online education modules were collaboratively developed alongside asthma and pharmacy organizations. The education program was comprised of five evidence-based education modules delivered online and a skills review conducted either in-person with real-time feedback (urban pharmacists) or via video upload and scheduled video-conference feedback (regional and remote pharmacists). A mixed methods approach was used to evaluate the feedback obtained from pharmacists to assess the content, efficacy, and applicability of the education.Results. Ninety-seven pharmacists opted into the program and successfully completed all education requirements. A larger proportion of pharmacists did not pass trial protocol-based education modules on their first attempts compared to the number that passed the asthma and medication knowledge-based modules. Prior to skills review, the proportion of pharmacists demonstrating device technique competency was suboptimal. Pharmacists rated the education modules highly in both quantitative and qualitative evaluations and reported that the program adequately prepared them to better deliver care to asthma patients.Conclusion. We developed, implemented, and evaluated a novel multi-mode asthma education program for community pharmacists that supports knowledge and practical skill development in this crucial area of patient care. The education program was well received by pharmacists. This form of education could be used more broadly in international collaborative trials.

An electronic decision support-based complex intervention to improve management of cardiovascular risk in primary health care: a cluster randomised trial (INTEGRATE).

OBJECTIVES: To determine whether a multifaceted primary health care intervention better controlled cardiovascular disease (CVD) risk factors in patients with high risk of CVD than usual care. DESIGN, SETTING: Parallel arm, cluster randomised trial in 71 Australian general practices, 5 December 2016 - 13 September 2019. PARTICIPANTS: General practices that predominantly used an electronic medical record system compatible with the HealthTracker electronic decision support tool, and willing to implement all components of the INTEGRATE intervention. INTERVENTION: Electronic point-of-care decision support for general practices; combination cardiovascular medications (polypills); and a pharmacy-based medication adherence program. MAIN OUTCOME MEASURES: Proportion of patients with high CVD risk not on an optimal preventive medication regimen at baseline who had achieved both blood pressure and low-density lipoprotein (LDL) cholesterol goals at study end. RESULTS: After a median 15 months' follow-up, primary outcome data were available for 4477 of 7165 patients in the primary outcome cohort (62%). The proportion of patients who achieved both treatment targets was similar in the intervention (423 of 2156; 19.6%) and control groups (466 of 2321; 20.1%; relative risk, 1.06; 95% CI, 0.85-1.32). Further, no statistically significant differences were found for a number of secondary outcomes, including risk factor screening, preventive medication prescribing, and risk factor levels. Use of intervention components was low; it was highest for HealthTracker, used at least once for 347 of 3236 undertreated patients with high CVD risk (10.7%). CONCLUSIONS: Despite evidence for the efficacy of its individual components, the INTEGRATE intervention was not broadly implemented and did not improve CVD risk management in participating Australian general practices. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616000233426 (prospective).

COPD Management in Community Pharmacy Results in Improved Inhaler Use, Immunization Rate, COPD Action Plan Ownership, COPD Knowledge, and Reductions in Exacerbation Rates.

PURPOSE: To evaluate the effectiveness of a pilot community pharmacy care model for patients with chronic obstructive pulmonary disease (COPD) to improve: 1) inhaler technique; 2) medication adherence; and 3) uptake of non-pharmacological treatment and prevention activities. PATIENTS AND METHODS: Forty "host" pharmacies in Sydney were invited to recruit eligible patients and to provide a counselling room/area in their pharmacy for service provision. Eligible patients were referred to two "consultant" pharmacists, specifically trained to deliver a specialized pharmacy COPD service which involved 3 in-pharmacy visits and 2 follow-up phone calls over a 6-month period. The service consisted of 1) inhaler technique assessment; 2) medication adherence assessment; and 3) referrals to the patient's general practitioner (GP) to facilitate the uptake of non-pharmacological resources as well as to review COPD medications/devices, as required. Pre-post analyses were conducted using paired Student's t-test and Wilcoxon Signed Rank Test for independent variables and chi-squared tests for proportional data. RESULTS: Nine "host" pharmacies recruited 40 patients, of whom 37 completed the baseline Visit and 27 completed all Visits. A total of 270 interventions were provided by the "consultant" pharmacists with most provided at Visit 1 (176). The most common interventions were addressing patient gaps in COPD knowledge and inhaler technique. A total of 119 referrals were made to GPs for various reasons, the most common being for a COPD action plan, pulmonary rehabilitation, or pneumonia vaccination. There were significant improvements pre-post intervention in inhaler use competence, COPD knowledge, immunization rate for pneumonia, exacerbation rate and COPD plan ownership. CONCLUSION: In this pilot study, the specialized pharmacy-based COPD care model delivered by "consultant" pharmacists in community pharmacies provided significant health benefits for patients. Further research is needed to assess the model's effectiveness in a larger population as well as when measured against standard care.

Perspectives of pharmacists about collaborative asthma care model in primary care.

BACKGROUND: The newly recognized General Practice Pharmacist (GPP) model in Australia, where non-dispensing pharmacists work in collaboration with general practitioners (primary care physicians) within their general practice/clinics represent an efficient yet novel approach for the management of chronic diseases. In chronic conditions, such as asthma, these models can help achieve optimal health outcomes, given current gaps between guidelines and practice. OBJECTIVE: The aim of this study was to elicit pharmacists' views and recommendations about pragmatic models of collaboration between GPPs and general practitioners in providing asthma management services in future service delivery models. METHODS: Community pharmacists were recruited via convenience sampling and passive snowballing techniques. Qualitative, semi-structured, in-depth interviews were conducted. Recorded interviews were transcribed verbatim and analyzed utilizing NVivo® 11 software. Obtained data were content analyzed for emergent themes using the Braun and Clarke framework. RESULTS: Twenty-five interviews were conducted. Asthma management challenges in current practice and the implementation practicality of asthma care GPP models comprised the two major emerging themes. Pharmacists' time and workload constraints and patients' reluctance to seek pharmacists' assistance to dispel misconceptions about asthma control were reported to be major barriers for the implementation of optimal asthma management services in community pharmacy. While a GPP dependent on several criteria. The development of specified channels for inter-professional communication for sharing of patient information and the willingness of stakeholders to accept and access such a model were reported. Funding and remuneration were considered critical factors by most participants. The professional self-autonomy of each healthcare professional involved in the GPP model was also highlighted as pertinent issue. CONCLUSIONS: This study provides significant insights to create pragmatic scalable versions of a GPP care model that could facilitate better asthma care after key barriers and facilitators identified by participants are carefully addressed.

A Targeted Approach to Improve Asthma Control Using Community Pharmacists.

Background: Building on lessons learnt from evidence-based community pharmacy asthma management models, a streamlined and technology supported Pharmacy Asthma Service (PAS) was developed to promote the integration of the service into routine practice. Objective: This study investigates the efficacy of the PAS in improving asthma symptom control and other health outcomes. Methods: A two-arm pragmatic cluster randomized controlled trial was implemented in 95 pharmacies across three Australian States. Participants were adults with poorly controlled asthma as per the Asthma Control Questionnaire (ACQ), with or without allergic rhinitis. Patients within the PAS arm engaged in four consultations with the pharmacist over a 12-month period. An evidence-based algorithm guided pharmacies, via a trial specific software, to deliver a series of interventions targeting three issues underpinning uncontrolled asthma (medication use and adherence, inhaler technique, and allergic rhinitis management) to patient clinical asthma status and patient need. Comparator arm patients received a minimal intervention likened to usual practice involving referral of eligible patients to the GP and two follow-up consultations with their pharmacist to collect comparative data. Results: In total, 143 of 221 PAS patients (65%) and 111 of 160 comparator patients (69%) completed the trial. Improvements in asthma control were achieved in both the PAS (mean difference (MD) in ACQ from baseline = -1.10, p <.0001) and comparator (MD in ACQ from baseline = -0.94, p <.0001) arms at the trial end; however, there were no significant differences between the two arms (MD = -0.16, 95% CI -0.41 to 0.08, p = 0.19). Patients' quality of life in the PAS arm improved significantly when compared with the comparator arm (MD in Impact of Asthma on Quality-of-Life Questionnaire (IAQLQ) = -0.52, 95% CI -0.89 to -0.14, p = 0.0079). Conclusion: Despite the PAS achieving a greater improvement in patients' quality of life, the pharmacist-led service and usual practice arm produced comparable improvements in asthma control. These results ask us to reflect on current standards of usual care, as it appears the standard of asthma care in usual practice has evolved beyond what is reported in the literature.

Perspectives of general practitioners about a collaborative asthma care model in primary care.

INTRODUCTION: Asthma affects 2.7 million people in Australia and is predominantly managed by general practitioners (GPs) within primary care. Despite national focus on this condition, asthma control in the population is suboptimal, with many preventable hospitalizations. In the light of robust evidence supporting the role of pharmacists in the management of chronic diseases including asthma, the Australian Medical Association (AMA) proposed a General Practice Pharmacist (GPP) model in 2015. In this proposal, a non-dispensing pharmacist, co-located within the primary care setting and collaborating with GPs and allied health professionals, can make a positive impact on patients' health and minimize costs due to medication misadventure. The aim of this study was to obtain the views of GPs regarding the GPP model for better management of asthma in a qualitative study. METHODS: Semi-structured interviews were conducted with 23 GPs, audio-recorded, transcribed verbatim, and later analyzed for emergent themes. The GPs support the idea of a GPP as time and task pressures restrict them in adhering to asthma management guidelines. RESULTS: Support from another health professional in such a pressured environment can positively impact patient's health. Funding, clear role delineation within general practice, training of pharmacists working as GPPs, and effective communication systems were described as the potential catalysts for the success of the model. CONCLUSION: Sustainable funding and the willingness of practice owners/managers were described as the barriers. The GPs agreed that pharmacists can make a positive difference in patient's asthma management once the barriers were effectively addressed.

Pharmacists experience of and perspectives about recruiting patients into a community pharmacy asthma service trial.

BACKGROUND: Research trials testing the impact of community pharmacy services require adequate and appropriate recruitment of patients by participating pharmacists, however, this step presents an ongoing challenge. OBJECTIVE: To identify factors affecting recruitment of patients in community pharmacies participating in a multi-center trial of a pharmacy asthma service in Australia (Pharmacy Trial Program - Asthma and Rhinitis Control (PTP-ARC). METHODS: The PTP-ARC protocol required identification and recruitment of seven eligible asthma patients per pharmacy. Pharmacists responsible for sites that failed to recruit or retain any patients into the PTP-ARC trial participated in a semi-structured telephone interview about their experiences with these elements of the trial. The interviews were recorded, transcribed and coded using QSR International's NVivo 11 software. The analysis was conducted with reference to the COM-B framework (Capability, Opportunity, Motivation). RESULTS: Pharmacists from 47 of 50 eligible pharmacies were interviewed. Seventeen factors were isolated and mapped to the COM-B framework. Psychological capability (recruitment hesitancy, research literacy and health literacy), physical capability (technological barriers, staffing issues and pharmacy busyness), physical opportunity (patient busyness, trial timing, study protocol, support and location), social opportunity (health literacy and supportive milieu), reflective motivation (incentive for participation, simplification) and automatic motivation (patient attitudes and pharmacist-felt experience) were factors affecting pharmacists' participation. Challenges identified included: issues with the software, unfamiliarity with research procedures generally (and specifically with the PTP-ARC protocols), the patients' lack of interest and pharmacists' lack of time. CONCLUSIONS: To the best of our knowledge, this is the first study to focus on issues affecting patient recruitment into a pharmacy health services (asthma) trial in real time. To propel evidence-based trials towards practice implementation, user-friendly software, pharmacists' training on research and patient-engagement and adequate remuneration to address pharmacist time issues need to be key foci for health services design and implementation research.

Medication Adherence in a Community Population with Uncontrolled Asthma.

It is well documented that the use of medications in asthma and allergic rhinitis is often suboptimal, and consequently, patients remain symptomatic. This study aimed to determine the extent and type of medication-related issues contributing to poor asthma control by profiling medication management in those most at risk-a population with clinically uncontrolled asthma. Participants (n = 363) were recruited from Australian community pharmacies, and a dispensed medication history report for the previous 12 months was collected to examine medication adherence and factors affecting adherence. Information was also collected regarding participant asthma control and asthma/allergic rhinitis (if applicable) management. The participants' mean asthma control score was 2.49 (± 0.89 SD, IQR = 1.20) (score ≥ 1.5 indicative of poorly controlled asthma), and 72% were either non-adherent or yet to initiate preventer therapy. Almost half had been prescribed high doses of inhaled corticosteroid and 24% reported use of oral corticosteroids. Only 22% of participants with concomitant allergic rhinitis were using first line treatment. A logistic regression model highlighted that participant health care concession status and hospital admissions were associated with better adherence. Suboptimal medication management is evident in this at-risk population.

The role of pharmacists in the pharmaceutical care of asthma patients in Yogyakarta, Indonesia: the patients' views.

Introduction: Community pharmacists are one of the most frequently accessed health professionals who can be involved in the provision of ongoing asthma management within the primary care setting. The aim of this study was to identify patients' views regarding current asthma care provided by their pharmacists and their perspectives on future pharmacy-based asthma services.Methods: This is a qualitative approach with an interview guide. Asthma patients were purposively selected. Interviews were conducted from April to June 2017. Patient's opinions about asthma and its management and their experiences regarding asthma care provided by pharmacists were collected. Data were analyzed using content analysis.Results: Thirty-three interviews were conducted. Asthma literacy was low. There was dis-engagement with the health care system, with only a few participants trusting conventional health care professionals. Alternative medicine systems and practitioners were better trusted and participants had strong preferences for family/peer involvement in their asthma care. Participants also had misunderstandings regarding their asthma disease and medications. Participants had experienced little pharmaceutical care provided by pharmacists but would welcome it in the future.Conclusion: Given the accessibility of community pharmacy venues and readiness of the profession for more involved care of chronic disease patients, it may be recommended that Indonesian community pharmacists should adopt the provision of pharmaceutical care models for asthma. Such pharmaceutical care models need to incorporate patients' unique sociocultural health beliefs, preferences for alternative medicines and family/social peer involvement as well as stronger collaboration between pharmacists and physicians.

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.

Patient Perceptions of Treatment Delivery Platforms for Cognitive Behavioral Therapy for Insomnia.

OBJECTIVE: Stepped care has given rise to the proliferation of abbreviated CBT-I programs and delivery formats. This includes interventions delivered by allied health professionals and those delivered electronically through the Internet. This article aims to explore patient perceptions between electronic and face-to-face (FTF) delivery platforms for (abbreviated) CBT-I. PARTICIPANTS: Patients with insomnia from specialist sleep or psychology clinics and those from the general community in Sydney, Australia. METHOD: Semistructured interviews were conducted with patients with insomnia, guided by a schedule of questions and a choice task to explore patient perceptions of the different CBT-I treatment delivery platforms (e.g., perceived advantages and disadvantages or willingness to engage with either platform). Interviews were transcribed verbatim and analyzed using Framework Analysis. Participants also completed a battery of clinical mood and insomnia measures. RESULTS: Fifty-one interviews were conducted with patients with insomnia from specialist sleep or psychology clinics (n = 22) and the general community (n = 29). Synthesis of the qualitative data set revealed three themes pertinent to the patients' perspective toward electronic and FTF CBT-I delivery: Concepts of Efficacy, Concerns About Treatment, and Treatment on My Terms. Participants' choice to engage with either platform was also informed by diverse factors including perceived efficacy of treatment, personal commitments, lifestyle, and beliefs about sleep and insomnia. CONCLUSION: Clarifying patient treatment priorities and allaying potential concerns about engaging with an electronic treatment platform represent important steps for disseminating eCBT-I into mainstream practice.

Physicians' perspectives on communication and decision making in clinical encounters for treatment of latent tuberculosis infection.

The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice. 20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically. The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds) and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk-benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances. In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.

Patient Preferences for Managing Insomnia: A Discrete Choice Experiment.

BACKGROUND: Despite the rapid development of effective treatments, both pharmacological and non-pharmacological, insomnia management remains suboptimal at the practice interface. Patient preferences play a critical role in influencing treatment outcomes. However, there is currently a mismatch between patient preferences and clinician recommendations, partly perpetuated by a limited understanding of the patients' decision-making process. OBJECTIVES: The aim of our study was to empirically quantify patient preferences for treatment attributes common to both pharmacological and non-pharmacological insomnia treatments. METHOD: An efficient dual-response discrete choice experiment was conducted to evaluate patient treatment preferences for managing insomnia. The sample included 205 patients with self-reported insomnia and an Insomnia Severity Index ≥ 14. Participants were presented with two unlabelled hypothetical scenarios with an opt-out option across 12 choice sets. Data were analyzed using a mixed multinomial logit model to investigate the influence of five attributes (i.e. time, onset of action, maintainability of improved sleep, length of treatment, and monthly cost) on treatment preferences. RESULTS: Treatments were preferentially viewed if they conferred long-term sleep benefits (p < 0.05); had an ongoing, as opposed to a predefined, duration of treatment course (p < 0.05); required some, as opposed to no, additional time commitment (p < 0.05); and had lower monthly out-of-pocket treatment costs (p < 0.001). However, treatment onset of action had no influence on preference. Age, help-seeking status, concession card status and fatigue severity significantly influenced treatment preference. CONCLUSION: Participants' prioritization of investing time in treatment and valuing the maintainability of therapeutic gains suggests a stronger inclination towards non-pharmacological treatment, defying current assumptions that patients prefer 'quick-fixes' for managing insomnia.

Pharmacists' views on the development of asthma pharmaceutical care model in Indonesia: A needs analysis study.

BACKGROUND: Over recent years the pharmacy profession in Indonesia has adopted a stance of pharmaceutical care to expand their scope of practice. Asthma management presents a key opportunity for pharmacists to test expanded roles in health service provision. There is however no exploratory work on the willingness, experience or future practice needs of Indonesian pharmacists in the realm of specialised asthma service provision. OBJECTIVES: The objectives of this study were to explore Indonesian pharmacists' experiences, perspectives, and needs regarding the provision of pharmaceutical care for asthma patients in Indonesia. METHODS: The study utilised conventional qualitative content analyses with two stages, i.e.: deductive analyses and inductive concept development. Data were collected using Focus Group Discussion (FGD) Method. FGDs were conducted using a topic guide and by facilitators trained in FGD conduct. FGDs were audio-recorded and transcribed verbatim prior to analysis. A maximum variation sampling methods targeted pharmacist across various settings of practice within Yogyakarta Indonesia. RESULTS: Nine focus groups with 103 pharmacist participants were conducted, with an average of 11 participants in each group. Inductively derived concepts that emerged included: willingness to adopt asthma service provision roles, pragmatism in recognising essential barriers/facilitators in adopting such roles, reflections regarding practice gaps and barriers to interprofessional collaboration mainly in relation to doctors. Inductive data analysis indicated clear differences in responses between hospital and non-hospital pharmacists. Key barriers to service provision included lack of training, lack of supportive professional frameworks, time and lack of reimbursement channels for services. Participants urged for a visionary leadership to facilitate pharmacists' role expansion into health services provision in Indonesia. CONCLUSIONS: Indonesian pharmacists were willing to adopt change and reported universally recognised barriers and facilitators to changing roles, especially in the provision of asthma care. Given this universality of pharmacists expressions, it may be suggested that the experience of researchers and academics who have expended time and effort in developing and implementing asthma care models in other countries should be, to some extent, transplanted to regions where pharmacy organisations are now considering adopting roles additional to medicines supply.