Section 4:

The importance of structured medicines reviews

Patients with asthma are a target group for structured medicines use reviews (SMRs) because:

  • In the UK, 5.4 million people receive treatment for asthma.1
  • Only around 40% of people with asthma in England are compliant with treatment.2
  • In 2017, 1,484 people in the UK died from an asthma attack.1

Community pharmacists who carry out structured review with patients with asthma can have a beneficial impact on patients’ asthma control.3

Structured interviews between pharmacists and patients, carried out in private in the pharmacy, looked at five areas: asthma symptoms; medicines use; attitude towards medicines; adherence; and identification of pharmaceutical care issues. After 3 months, patients who had had review were 76% more likely to have achieved good asthma control test scores, compared with patients who did not.3

Pharmacists can play an integral role in helping patients to achieve the ideal ratio of reliever to ICS inhalers – approximately one SABA to every six ICS inhalers but currently thought to be 2:1.4,5 Using medication records to identify patients, pharmacists can initiate conversations about SABA over-reliance and ICS under-use. They can spend time educating, answering questions and checking that Personal Asthma Action Plans (PAAP) are up to date.5

Pharmacists also have an important role in ensuring that patients know how to use their inhalers, and should familiarise themselves with good inhaler technique so they can coach patients on using inhaler devices (and spacers).5 You can access information about inhalers and demonstration videos, or download the free RightBreathe app, at https://www.rightbreathe.com. The New Medicine Service (NMS) for recently diagnosed patients, or those whose medication has been changed, is an ideal opportunity to confirm that patients’ inhaler technique is satisfactory.

Payments under the Pharmacy Quality Scheme are available for pharmacies that can demonstrate that:

  • Patients with asthma, for whom more than six SABA inhalers were dispensed without any ICS in a 6 month period have been referred to an appropriate healthcare professional for an asthma review.6
  • All children aged 5-15 prescribed ICS for asthma have a spacer device, where appropriate, and have a personalised asthma action plan (PAAP), and have been referred to an appropriate healthcare professional where this is not the case.6

Components of an asthma SMR

Ask the patient if they have had an asthma review with their GP/asthma nurse in the last 12 months
Ask the Royal College of Physicians ‘3 Questions’7 as a general question, e.g. ‘How’s your asthma today?’ is likely to produce a non-specific answer such as ‘I’m OK’.8
In the last month:

  • Have you had difficulty sleeping because of your asthma symptoms (including cough)?
  • Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
  • Has your asthma interfered with your usual activities (e.g. work/housework/school)?
Does the patient have a Personal Asthma Action Plan?
Smoking status. If patient is a current smoker:
Offer stop smoking advice
Refer to stop smoking service
Check inhaler technique.

  • Does patient have MDI and DPI inhalers?
  • Can they use them appropriately?
  • Do they use MDI with a spacer?

If issues identified refer to GP/asthma nurse

Inhaler adherence

  • Check dates of dispensing
  • Does dose of ICS taken correspond to prescribed dose?* If under-use of ICS identified refer to GP practice
  • Over-use of SABA (e.g. >6 salbutamol inhalers in last 6 months), recommend urgent review by GP/asthma nurse
If any issues identified, complete suggested GP actions on MUR form.
*Patients on high dose ICS with a low asthma control test (ACT) score and no exacerbations in last 3 months should be referred to GP with a view to stepping down treatment

Job code: UK/RES-19014c DOP: February 2020

References

  1. Asthma UK. Asthma facts and statistics. https://www.asthma.org.uk/about/media/facts-and-statistics/ [Accessed February 2020]
  2. York Health Economics Consortium, and School of Pharmacy, University of London. Evaluation of the scale, causes and costs of waste medicines; 2010. https://discovery.ucl.ac.uk/id/eprint/1350234/1/Evaluation_of_NHS_Medicines_Waste__web_publication_version.pdf [Accessed February 2020]
  3. Manfrin A, Tinelli M, Thomas T, Krsja J. A cluster randomised control trial to evaluate effectiveness and cost-effectiveness of the Italian medicines use review (I-MUR) for asthma patients. BMC Health Services Research 2017;17:300. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2245-9 [Accessed February 2020]
  4. O’Byrne PM, Jenkins C, Bateman ED. The paradoxes of asthma management: time for a new approach? Eur Respir J 2017;50:1791103
  5. Attar-Zadeh D. UK asthma mortality is too high, but pharmacy can help. Clinical Pharmacist, 1 February 2019. https://www.pharmaceutical-journal.com/opinion/insight/uk-asthma-mortality-is-too-high-but-pharmacy-can-help/20206055.article?firstPass=false [Accessed February 2020]
  6. Pharmaceutical Services Negotiating Committee. PSNC Briefing 041/19: The Pharmacy Quality Scheme 2019/20. September 2019.
  7. Pearson MG, Bucknall CE, editors. Measuring clinical outcome in asthma: a patient-focused approach. London: Royal College of Physicians of London; 1999
  8. British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) British Guideline on the Management of Asthma; 24 July 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Accessed February 2020]