Our study explored the assessment of asthma control in a community pharmacy setting, using the ACT instrument, a standardized and validated five-item questionnaire measuring asthma control [10]. Although being easy-to-use and accurate in providing immediate disease control evaluation, ACT is still underused by general practitioners (GPs) and medical consultants [11].
In the present study local pharmacies detected an unsatisfactory asthma control in the general population of the study area. In particular, based upon ACT score, 50.5% patients had controlled disease, 22.3% poorly controlled and 27.2% uncontrolled. A variable proportion of patients with uncontrolled asthma was observed at every level of severity of the disease, although more frequently among those affected by mild persistent asthma. Most patients (92%) reported regular compliance with prescribed treatment. Nonetheless, the main determinant of poor asthma control (ACT<16) was treatment adherence, after removing the effect of all other factors (including disease severity).
Although this result may be intuitive, asthma control still represents a challenge worldwide [7,8] and the community pharmacies have been identified as a potential relevant partner in sharing this challenge with the other health care providers, monitoring treatment compliance for asthma, a critical aspect to control the disease [16]. Pharmacists can in fact offer patients a first point of contact with the health care services, easy to access for disease counselling. In his way, community pharmacies somehow compensate the obstacles of patients to access hospital care as well as the limited time for consultations dedicated in GPs settings [16,18]. The local pharmacy could also play a unique role in the assessment of asthma control by combining the ACT and asthma medicine records as a proxy of treatment compliance.
Although the involvement of primary care (particularly pharmacists) in asthma control is recommended by current international guidelines [20], only a few studies have been conducted on this topic and none has been carried out in Italy [21-24].
According to our results the level of asthma control assessed by ACT was overall higher in comparison with studies using the same tool but conducted in a medical setting in Italy [5-8] or in community pharmacies of other European countries [21-24]. Some reasons may account for this discrepancy. The mean age of our study population is >50 years, whilst in previous studies reporting a worse asthma control, a higher proportion of younger patients was recruited. It has been previously found that the prevalence of uncontrolled asthma is higher among young adults and adolescents [25].
Adult or elderly patients tend to be more familiar and comfortable with the local pharmacists, hence they receive more frequent advice on the need of regular asthma therapy.
However, the older age of our patients raises plausible concerns of the differential diagnosis with other chronic respiratory conditions, particularly chronic obstructive pulmonary disease (COPD); in which case the ACT may provide an unreliable score as it is not a validated instrument for obstructive respiratory syndromes other than asthma. The inclusion of the exemption code specific for asthma (007-493) among patients’ selection criteria allowed us to overcome this confounding factor [26,27].
Although low treatment adherence was the only determinant of poorly controlled asthma, patients recruited in the present study showed a surprisingly high overall crude rate (92%) of treatment adherence. This finding is quite unexpected, when considering the actual data from the Italian Medicine Agency (AIFA), reporting an overall poor treatment adherence [27]. Furthermore, the adherence rate, when objectively evaluated, seems to be independent from the disease severity [28, 29], so that the prevalence of patients with moderate to severe persistent asthma in our study population cannot be used to explain the above figure. More likely it may reflect the typical overestimation of patients when interviewed about their compliance with therapy, as already reported in the open literature [26].
Lack of asthma control was more common among patients with mild persistent asthma in the present study. This finding is not surprising, as in our previous pilot study we reported a 31% prevalence of uncontrolled asthma in a GP setting [8]. It is plausible that the presence of intermittent symptoms led these patients to a treatment on demand, with a consequent overuse of beta-2 short agonists and underuse of inhaled steroids. Moreover, these patients usually prefer self-medication than regular follow-up by their GPs or by specialist medical consultants. However, the risk of fatal asthma is still possible with mild persistent disease, as recently reported [30].
Whilst the positive results of this study suggest the feasibility of asthma control assessment at the local pharmacy level, an overall inclusion of the community pharmacist is a challenging target, as not all of them may be keen in being involved in a similar health plan, rating it demanding and time consuming, particularly in periods of the year of high morbidity and intense access to pharmacies [31]. Therefore, in addition to careful selection of well trained, motivated community pharmacists, within a structured health plan, value-based incentives (VBI) programs may also be considered. Similar to other health care settings (e.g. GP practices), financial incentives could be granted to pharmacies to accomplish quality health outcomes in patients [17]. In addition of being an accessible setting for asthma control assessment, the local pharmacies could also provide counselling on disease control outside health care settings. Trained pharmacists would have also the opportunity to teach patients about the disease and the proper use of medical devices, thus facilitating enrolled patients’ [32]. Moreover, the local pharmacy could also be an optimal setting to deliver spirometry tests for a fee. However, despite charging patients for spirometry could further motivate the participation of pharmacists in asthma control plans, similar measures are still open to debate, since the interpretation of spirometry entails specific competences that should be limited to trained and certified pharmacies [33]. Finally, community pharmacies could also provide counselling on smoking cessation, as in our study population one out of five asthmatic patients was a smoker.