Date: 30 May 2018
Chronic obstructive pulmonary disease, or COPD as it is commonly referred to, is a growing problem across the globe with the World Health Organization predicting it will become the third leading cause of death by 2030. Community pharmacies are playing an increasingly important role in helping patients manage COPD, with scope to increase the role.
Chronic obstructive pulmonary disease, or COPD as it is commonly referred to, is a growing problem across the globe and in 2012 was the fourth largest cause of morbidity worldwide. In that year alone it is estimated it was the cause of some 3.1 million, or 6 per cent of global deaths.
Worldwide, more than 210 million people have COPD, according to the World Health Organization.
The organisation predicts that COPD will become the third leading cause of death worldwide by 2030.
The figures are reflected in this country with the Lung Foundation Australia reporting 14.5 per cent or one in seven Australians aged 40 years or over have airflow limitation of their lungs, with this figure increasing to 29.2 per cent in Australians 75 years or over.
COPD is the general term used to describe long-term lung conditions which are characterised by a shortness of breath and which are not fully reversible through the use of medicines. This include chronic bronchitis and emphysema. The Lung Foundation reports that while each condition can occur on its own, people can suffer from a combination of conditions. Asthma is not COPD but some people with have both conditions which is called Asthma-COPD Overlap (ACO).
COPD usually occurs in people who have smoked or continue to smoke cigarettes or other tobacco products while exposure to irritants like dust and fumes can also increase the risk of developing COPD. Childhood respiratory infections and/or chronic asthma may also lead to COPD.
People with COPD may have a persistent cough with sputum due to excessive mucus production in the airways (known as chronic bronchitis) or evidence of lung tissue destruction, enlargement of the air sacs and further impaired lung function (known as emphysema). The terms COPD, emphysema and chronic bronchitis are often used interchangeably.
If left untreated, COPD symptoms will gradually worsen leading to further complications and eventually possibly to death. Therefore effective and early management of the condition is critical and patients are increasingly looking to community pharmacies for assistance, guidance and advice.
Researchers at the School of Pharmacy at the University of East Anglia have examined the role of community pharmacies in COPD and published their findings in a paper titled Community pharmacy COPD services: what do researchers and policy makers need to know?
“Until recently, pharmacists’ main role in patients with COPD centred on prescription supply and counselling on medicines, including inhaler technique,” they wrote.
“However, with the recent development of more patient facing, clinical and public health roles for pharmacists’ new approaches to care being investigated largely centre on identifying people who are currently undiagnosed or providing support and education to those with established COPD.”
The authors concluded: “This review has shown that community pharmacists can identify people with undiagnosed COPD and provide support to their ongoing care and this can be cost-effective to the health service.”
Chair of Lung Foundation Australia’s COPD Pharmacy Committee Peter Guthrey agrees community pharmacies are playing an increasingly important role in helping patients manage COPD and sees potential for an even greater role.
“At present one of the primary roles of community pharmacists is educating consumers about the correct use of devices and in providing screening for COPD,” Mr Guthrey said.
A member of the committee, Debbie Rigby, said the issue of people using their devices correctly was critical.
“Statistics show 90 per cent of patients don’t use them correctly, and 50 per cent of health professionals don’t know how to use them correctly,” she said.
“There is a real opportunity for pharmacists to make device technique a core focus and to do it well and do it consistently.
“It is not enough to just ask the patient to show us how they use the devices; we have to demonstrate how to use these devices, and demonstrate them correctly.
“I give a lot of lectures around the country on correct techniques and I encourage pharmacies to have a box of placebo devices that they can use to demonstrate to the patients.
“We also need to regularly repeat technique education as the evidence shows people need to have their techniques checked regularly as we all get a bit slack over certain steps and need to have this pointed out. As pharmacists we need to be able to demonstrate the use of devices correctly.”
Just how important the correct use of inhalers is can be seen from National Asthma Council data reinforcing that up to nine out of ten Australians use their life-saving inhalers incorrectly.
The council says this increases “their risk of hospitalisation by 50 per cent for asthma and chronic obstructive pulmonary disease (COPD). Even people who have been using their inhalers for years are likely to need help with inhaling properly, with an Australian study finding that six out of seven confident inhaler users were mistaken in thinking they had the correct technique.”
National President of the Pharmacy Guild of Australia, George Tambassis, said the education in the correct use of inhalers was clearly one where community pharmacists played a central role
“It is surprising how many patients are not properly educated in how to use their inhaler correctly,” Mr Tambassis said.
“The incorrect use of an inhaler means that you may not be getting the benefit from the medicines you are taking and while most of us are confident we have the techniques mastered, clinical studies show that up to a surprising 90 per cent of patients do not use their inhalers correctly.
“Your community pharmacist can help you in this area. A visit to your local pharmacy and a talk with the pharmacists there can result in some significant benefits for you.
“Your pharmacist can show you some of the simple steps you need to undertake to improve your inhaler technique so that your medicine gets the chance to do its work for you.”
He said the tips patients could get from their community pharmacy included working on their inhaler breathing technique so the medicines actually reached their lungs rather than just hitting the back of the throat.
“It might sound simple but the importance of using your inhaler correctly cannot be underestimated,” he said.
Another important service provided through community pharmacies is screening for COPD which is pivotal in early detection and management.
A paper published in the International Journal of Pharmacy Practice found that pharmacist-delivered COPD screening “potentially provides cost-savings and improves quality of life.”
The paper, Chronic obstructive pulmonary disease case finding by community pharmacists: a potential cost-effective public health intervention, published in 2014, looked at a COPD screening service in UK pharmacies, with the aim of estimating potential costs and effects associated with its delivery.
The researchers reviewed 21 community pharmacies that screened 238 patients over nine months. Of the patients, 135 were identified with potentially undiagnosed COPD, and 88 of those were smokers.
Significantly, the authors reported with the 88 smokers at risk of COPD, smoking cessation initiation provided a project gain of 38.62 life years, 19.92 quality-adjusted life years, and a cost saving of more than $655 per patient screened.
“This evaluation shows that community pharmacists can effectively undertake case finding of COPD and that a method of targeted screening identifies one patient with moderate severity COPD for every two screened,” the authors wrote.
Peter Guthrey sees COPD playing a greater role in the services community pharmacies can offer patients.
“We do it well but I believe we can do it even better and the Lung Foundation has developed fantastic resources to improve pharmacists’ skills in supporting people living with COPD,” he said.
“We need to offer these services in a more structured way to increase the early detection of COPD and help delay onset of symptoms and associated impact on quality of life.”
The Guild’s George Tambassis said prevention was perhaps one of the best forms of self-management.
“Community pharmacies providing COPD risk assessment and screening to alert consumers to possible risks and likelihood of developing COPD are incredibly important services for the community,” he said.
“This screening includes lifestyle questions such as whether you’re a smoker or a former smoker, whether you have worked where you are exposed to dust, gas or fumes, and whether you get out of breath more easily than others of a similar age. Lifestyle questions such as how much exercise you get can form part of this screening.
“Community pharmacies conducting these assessments will refer you for further examination and diagnosis if they believe this is necessary.”
Mr Guthrey also pointed to ensuring medicines adherence as being critical for people living with COPD.
The importance of compliance was highlighted in the Community pharmacy COPD services: what do researchers and policy makers need to know? study.
“Pharmacists can help people with COPD understand their condition and improve their management of their condition.
“If patients are not able to do this, then this will also result in further contact with health services as their condition deteriorates.
“All of these result in a greater number of general practitioner (GP) appointments, greater number of prescribed medicines, increased hospitalisations and decreased quality of life and productivity.”
Debbie Rigby also sees the role in ensuring adherence to medicine regimens as an essential part of the pharmacists’ role.
“There is the issue of adherence and taking their medicine and this is critical. This is how we help to keep COPD patients out of hospital and also give them a better quality of life.
“I would like to see pharmacists include adherence with device education as core roles.”
An area of improvement in the future was for pharmacists to be better at device education.
Ms Rigby said many manufacturers’ representatives did not visit pharmacies very often and a lot more could be done in this area.
“I work in a GP clinic and one my roles is fostering greater collaboration between doctors and pharmacists. Reps come into surgeries and demonstrate the devices and I can act as a liaison with the community pharmacists,” she said.
“Pharmacists often never see the reps and are not familiar with the new devices, more and more of which are coming onto the market but they need to know how to use them correctly.
“Pharmacists should ‘own’ asthma and COPD devices. We should be the experts in them and not assume a GP is going to demonstrate them to patients.
“We also need to work on our strategies to start the conversation with patients and get them to demonstrate how they use their devices so we can help them with their techniques.
“Consultation rooms can be important. As part of the education process it would be good to show one of the videos, hand the patient printed material and get them to demonstrate how they use their device.
“A consult room makes this much easier as many people might not be comfortable demonstrating in the middle of the pharmacy. It would be a bit like a clinical intervention and the separate area takes away the barrier a patient may have about demonstrating in a public area.”
Peter Guthrey says he would also like to see pharmacies increase the availability of screenings services to help improve rates of early detection.
“Pharmacists are the most accessible health professionals and we see our patients more often than most other healthcare professionals,” he said.
“If we increase the rate of screening, we can make a big impact on the burden of COPD across Australia.
“There are also opportunities for greater linking of patients to resources and support networks such as Lung Foundation Australia’s patient support hotline; 1800 654 301.
“Screening is just the first step. Patients need follow-up and referral. Community pharmacists can only refer to services and support appropriate for their individual patients if they know what is available out there.”
Mr Guthrey urged all pharmacist involved in COPD education and screening to visit Lung Foundation Australia’s website to ensure they are abreast of the latest developments and guidelines.
He said the COPD-X Plan, available on the Lung Foundation of Australia website, provided the Australian and New Zealand online management guidelines for COPD and had been developed jointly by The Thoracic Society of Australia and New Zealand and the Lung Foundation.
Mr Guthrey said the COPD-X Plan was regularly updated as new evidence is published. “Health professionals can have confidence that the COPD-X guidelines are current and based on the best information available.
The guidelines aim to:
The key recommendations are summarised in the “COPDX Plan”:
C: Confirm diagnosis
O: Optimise function
P: Prevent deterioration
D: Develop support network and self-management plan
X: Manage eXacerbations
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