Symptom Control and Adherence are Major Issues for Asthmatic Patients: Can they be Improved and are They Linked?

Background

Italy has a population of 61 million people where the percentage of asthmatic patients has increased to 6.2%1. The cost of asthma is linked to its control2,3 and adherence to treatment could be below 50%4. Pharmacists can play an important role in this context because they are health care professionals close to their community. The objectives of this work were to determine whether pharmacist intervention could improve adherence to treatment and asthma control and to assess the association between these variables.

Method

A cluster randomized controlled trial involving 15 out of the 20 Italian regions was conducted between September 2014 and July 2015 with data collection before, during and after pharmacists’ intervention; every 3 months (T0, T3, T6, T9). Pharmacists were randomly allocated to different groups after stratification by region: A (n=104) were trained to provide the Italian Medicines Use review (I-MUR) immediately after completion of the baseline Asthma Control TestTM (ACT) score; B (n=112) received training and provided this service 3 months later. The primary outcome measure was asthma control, assessed using the ACT scores, before and after the I-MUR intervention, defined by the international guidelines (ACT?19 = not controlled; ACT ?20 = controlled). Secondary outcome was adherence to treatment before and after the intervention assessed using the Morisky scale.

Results

Pharmacists in group A recruited 428 patients and in group B, 456. Patients were well distributed among regions; the percentage of female was 58.6%. Baseline ACT score showed that 56% of patients had asthma not fully controlled.

In group A, after the I-MUR intervention, asthma control showed both a statistically significant difference (p<0.0001) and a clinically valid difference, with the median ACT score changed from 19 to 20. In group B patients, who had not received the I-MUR when their asthma control was assessed at T3, there was also a statistically significant change in control (p<0.001), with the median value increasing from 18 to 19. However as both values indicate that asthma was only partially controlled, this cannot be regarded as clinically significant. A further improvement in asthma control was achieved in group B at T6, after the I-MUR intervention, which was again both statistically significant (p<0.0001) and clinically significant, with the median ACT score increasing from 19 to 20. Comparing the proportion of patients with asthma not controlled at baseline, to the proportion with asthma control after the I-MUR intervention, the overall proportion rose by 25% (X2, P<0.0001). Adherence improved overall by 38% (X2, p<0.0001). Correspondence analysis identified a relationship between adherence and asthma control showing that, patients who were more adherent, were more likely to have their asthma controlled.

Conclusion

This is the first trial ever conducted in Italy of pharmacist intervention in asthma. Results not only show an improvement of both asthma control and adherence following pharmacists’ intervention, but also underline the link between these two variables.

References

1 European Lung White Book. The burden of lung disease.European Respiratory Society. Available at http://www.erswhitebook.org/chapters/adult-asthma/. Accessed 24 Jun 2014

2 Vervloet D, Willians A. E., Llyod A., Clark T.J.H. Costs of managing asthma as defined by a derived Asthma Control Test score in seven European countries. Eur. Respir Rev 2006; 15:98, 17-23

3 Accordini, S., A. G. Corsico, et al. (2013). "The cost of persistent asthma in Europe: an international population-based study in adults." Int Arch Allergy Immunol 160(1): 93-101

4 Manfrin A, Thomas T, Krska J. Randomised evaluation of the Italian medicines use review provided by community pharmacists using asthma as a model (RE I-MUR). BMC Health services research (2015) 15:171