Patient-Centered Care: Metrics to Measure Quality of Care in the Community Setting for Patients with Asthma

Improving medication use and management is a complex process. There are a variety of external factors that can influence a pharmacist/patient exchange of information (counseling session), including how the patient interprets the information, or even the attentiveness of the patient during the counseling session. These factors will impact each patient differently.

Think of the situation where a parent is working with a pharmacist because their child has just been diagnosed with asthma. Each parent (and child) may react differently to the information they receive, and this can be challenging in terms of medication use and management. Providing information on how to properly use an inhaler is not an easy skill that patients can master just from hearing about breathing in and coordinating the dose of the medication.
To make matters worse, if a chamber and/or a mask are also needed for a young child, this can add to the complexity of the appropriate skills needed by the patients. Of course, this challenge does not only apply to parents and children; adult patients with asthma (those new to therapy and those who have been on therapy) also need information regarding the appropriate use of their medications, management of the disease, and progression of the disease.

The Role of Pharmacists
What should pharmacists add to the workflow process to assist patients with asthma and their caregivers? What metrics can we examine in the community setting to help determine how our patient’s therapy is working? To address these questions, let us review areas that pharmacists can impact and what experts are indicating pharmacists can do.

The National Heart, Lung, and Blood Institute National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma recommends that educational interventions be performed by pharmacists.¹ The expert panel concluded “that use of interventions provided by pharmacists is feasible, may help improve self-management skills and asthma outcomes, and merits more clinical studies of pharmacists’ providing education interventions.”¹

The panel also stated that an important part of patient education is the pharmacist’s encouragement of adherence.1 In addition, we are aware that for many patients, education needs to run across a variety of topics, including disease-management counseling, disease-progression discussions (and prevention of progression), demonstration of appropriate techniques for inhaled medication use, periodic review of the techniques, and the review of medication use both in long-term maintenance and rescue (short-acting beta agonist [SABA]) medications.¹

Measuring Therapy and Outcomes
It is important to understand that we have the tools, knowledge, and skills to communicate with our patients. In addition, we can look for metrics that we can easily measure in the community pharmacy setting.

The Pharmacy Quality Alliance (PQA), a nonprofit organization that develops medication management and use metrics,² has developed 2 metrics that can assist pharmacists in reviewing medication use and management for patients with asthma.³ PQA metrics include the following:

• The percentage of patients with asthma who were dispensed more than 3 canisters of a SABA inhaler over a 90-day period and who did not receive controller therapy during the same 90-day period
• Suboptimal control: the percentage of patients with persistent asthma who were dispensed more than 3 canisters of a SABA inhaler during the same 90-day period
• Absence of controller therapy: the percentage of patients meeting the numerator for the “suboptimal control” rate who did not receive controller therapy during the same 90-day period.

Although individual pharmacies may have difficulty gathering the data across the aggregate of patients with asthma they serve, there are ways we can use these measures in the community setting and follow individual patient’s adherence and medication use. A pharmacy would need to review claims data and medication history to determine how well they are doing across the metric and all patients with asthma. However, if pharmacists look at individual patient’s use of SABA inhalers over time, they can use this as an intermediary outcome metric on suboptimal control and possible absence of controller therapy or controller therapy that needs adjustment.

Of course, we need to also look at the adherence rate on controllers if the patient is on a controller medication before making recommendations of therapy changes. Recommending a change for a maintenance medication without checking for adherence to the regimen may only exacerbate the problem with an alternative therapy.

Working Toward Patient-Centered Care
We can use the following example of how we can track this at the pharmacy on an individual patient level. By alerting our technicians that anytime a SABA is dispensed—they should also review the last 2 refill dates—pharmacists can quickly see who may be overusing the inhaler. If a patient is using 3 canisters over a 90-day period, the pharmacy could establish a process whereby the technician highlights this usage for the pharmacist indicating the need for a counseling session. The pharmacist can determine how the patient is doing through a couple of questions, discuss the frequency use of the inhaler, and why/when/how the patient is using the inhaler.

This way, we can use our educational background and professional judgment to make recommendations to the patient and/or contact their prescriber about any concerns. This example provides us the opportunity to practice patient-centered care and review a patient’s medication use for all SABAs. This is one way to identify which patients need additional therapy. Recommendations could include reviewing the techniques the patient is using to verify that they are actually getting the medication, discussing possible triggers, and emphasizing the importance of reviewing their asthma to get it under control.

There are numerous patient education materials that are available from manufacturers. Many have nonproduct-specific materials that highlight disease state facts and general medication use of a rescue inhaler, including understanding that the number of times an inhaler is used is an indication of asthma control for some patients.

A recent study by Slejko and colleagues suggests that in the United States, patients with asthma overuse quick-relief inhalers and underuse control medications.⁴ The investigators surveyed 9782 patients with lifetime asthma and 8837 patients with reported current asthma. Overall, 4521 patients used a quick-relief inhaler for asthma symptoms, and approximately 15% used more than 3 canisters of this type of medication in the past 3 months. In addition, among these patients using quick-relief inhalers, 60% were using daily control medication, whereas 28% had never used long-term control medication. Of those who had a recent exacerbation, 29% were using daily preventive medication, whereas 54% had never used long-term control medication.⁴ The question is: do you know if your patients fit with the study results? If they do, can you help them regulate their asthma more appropriately?

We can practice patient-centered care for all our patients and take time to focus on patients with asthma. The process discussed here is a relatively efficient way of providing care to patients with asthma by reviewing their use of SABAs as a means to help them understand the importance of appropriate medication use and management of their medications.

References

1. National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed April 17, 2014.
2. Pharmacy Quality Alliance. PQA mission and strategic objectives. http://pqaalliance.org/about/default.asp. Accessed April 17, 2014.
3. Pharmacy Quality Alliance. PQA measures. http://pqaalliance.org/measures/default.asp. Accessed April 17, 2014.
4. Slejko JF, Ghushchyan VH, Sucher B, et al. Asthma control in the United States, 2008-2010: indicators of poor asthma control. J Allergy Clin Immunol. 2013 Dec 9. Epub ahead of print.