This study provided valuable information regarding the perceptions of GPs, community pharmacists and patients towards a community pharmacy-based asthma intervention. The acceptance and support of these key stakeholders is vital to ensure adequate uptake and effectiveness of future interventions. Although there have been a number of community pharmacy-based asthma interventions published which report improved patient outcomes,301,303,331,332 this seems to be the first data reported on the views of GPs, pharmacists, and patients of such an intervention.
There was a general acceptance of the intervention process by participants. Both GPs and patients expected pharmacists to intervene when patients’ therapies could be suboptimal or detrimental to their health. Indeed, the patients were very accepting of the intervention as it provided both positive attention and reassurance that their medications were being actively monitored.
The acceptance by GPs of pharmacy interventions seemed dependent on the existing relationships with pharmacists. If the relationship was professionally cordial and respectful then any information provided to GPs was generally well received. GPs were sometimes reluctant to accept pharmacist input resulting from interventions if they perceived this as an encroachment on their own area of responsibility. This finding is in
line with previous studies, which have shown that GPs tend to express concerns about pharmacists assuming roles they considered to be general practice activities.333-335 It has previously been reported that GPs may sometimes be offended by the introduction of a pharmacist-led health service, feeling that it implied shortcomings in their existing level of care.336 This means that pharmacists need to ensure that perceived boundaries in patient care are approached with caution in order to reduce the risk of misinterpretation about the intent of these types of interventions. Another concern was the credibility of pharmacists, and the potential conflict of interest of promoting health in a retail environment. Previous studies have demonstrated that many GPs see community pharmacists as business-people, shopkeepers or specialist retailers, and believe that this represents a conflict of interest in healthcare.333,337,338 Interestingly, a previous study of patients’ perceptions suggested that this conflict may, in practice, not be overly significant; many of the participants were able to recall experiences of their own where a pharmacist had clearly put patients before profit, not just in respect of their health, but also in terms of convenience and financial gain for the patient.339
GPs would welcome advice from pharmacists at the time of interventions, so they could make notes to raise the issue with patients at subsequent visits. With this change to the procedure, it is likely that the number of asthma reviews would increase, as the onus on the patient to initiate action would be reduced. The researchers discouraged this initial pharmacist/GP contact in the original intervention due to concerns about privacy and patient consent. If direct notification of GPs is to be used at the time of asthma interventions then there will be a need to advise GPs easily and efficiently, and patient consent in this process needs to be taken into account. This could involve some form of electronic notification, as GPs, in most cases, would not want to receive a phone call from pharmacists given the perceived non-urgency of the review. Thus, a business practice change may be required to accommodate electronic communication with GPs by pharmacists.
Pharmacists believed that a national roll-out of the asthma intervention would be a positive move towards improved asthma management in the community. It was encouraging to learn that community pharmacists implemented the intervention very
community practice is such that research is perceived as having a low priority because it would have to be taken on as an additional role.13 Academic researchers should be sensitive to time constraints and responsibilities of community-based investigators when they develop study procedures. If community pharmacists are to become involved in pharmacy practice research, it is necessary to develop a strategy that recognises the workload issues in community pharmacy practice.
Patients’ general satisfaction with pharmacy services was high, but their perceived benefit of the intervention was lower. This is in line with previous results from satisfaction studies, confirming satisfaction ratings with pharmacy services are generally high, although patients’ expectations of pharmacists’ capabilities are low.338,342-345 It is apparent that patients expect their pharmacist to process prescriptions rapidly and provide basic medication information, and that pharmacists are effective in meeting these expectations. However, most consumers apparently do not expect to consult with their pharmacist or receive pharmaceutical care services.343 These comments convey the important message that much work still needs to be done to educate the public about the training and roles of the pharmacist.343 Unfortunately, the public’s poor knowledge and low expectations can justify a reduced desire for an extended role of the pharmacist in the community.342
Patients were reluctant to adopt suggestions from pharmacists to make GP appointments for asthma reviews, or when they did make an appointment, they may not have raised any issues with their asthma. While there is an appreciation of pharmacists’ interest in patient health, this did not necessarily translate into compliance with the suggestions made at the time of the intervention. The reason for this related primarily to patients’ optimistic views of their asthma control. All patients seemed to accept they would have asthma symptoms throughout their life, and they did not expect that an improvement in their asthma management was possible. This is in keeping with the substantial evidence that patients with asthma tend to under-estimate their asthma severity,46,51,52,55,281,282 and it represents a major barrier to the uptake of asthma interventions. It was interesting that despite these perceptions and reluctance to comply with the suggestions made at the time of the intervention, patients were pleased that ‘something was being done’ to help patients with asthma. This suggests that patients may be failing to recognise their own role in managing their asthma, and more education may be required to encourage patients to take a more proactive approach with their asthma management. Furthermore,
patients need to be made aware that putting up with their symptoms may actually be detrimental to their health,18 and that complete control of asthma is achievable in the majority of patients.27
It is possible that patients’ under-estimation of their symptom severity may have influenced the reported success of the intervention, as patients who considered their asthma as well controlled were unlikely to have sought further medical advice. Most interviewed patients assumed their asthma was well controlled because any symptoms were alleviated with relievers, and they did not want to ‘bother’ their busy GPs. This means that few GP appointments were made and even fewer asthma discussions ensued, thus reducing the beneficial outcomes of the program. Despite this low number, the quantitative data indicated a three-fold increase in the preventer-to-reliever ratio after the intervention.5 Clearly those patients who did attend the GP for medication review had a positive outcome in terms of improved preventer usage and a decreased reliance on reliever medication. It also suggests that the educational material provided by the pharmacist may have had some impact on asthma management. The positive outcome when patients were reviewed by the GP underscores the importance of the review process. Nevertheless, the main limitation to the uptake and effectiveness of asthma interventions may be patients’ views and acceptance of their asthma symptoms. More research may be required to further explore patients’ beliefs and perceptions about asthma in order to determine the best way to target health behaviours amenable to an intervention.
There are limitations to the qualitative component of this study. Whereas a large number of GPs, pharmacists and patients with asthma were approached, many failed to respond to the request for their involvement or stated that they were unable to participate. The absence of these opinions may have resulted in biases within the data. It should also be noted that the respondent sample is inherently biased for two reasons. Firstly, these participants had already demonstrated willingness to participate in such research. Secondly, the interviews were administered after participants learned of the positive results of the intervention. Furthermore, the study was conducted by selecting a sample of respondents from northern and southern Tasmania. Thus, the findings may not be
work even though they are unable to test hypotheses and are not automatically generalisable. To explore the extent and prevalence of views expressed a quantitative approach is needed. However, the findings may be generalised as the attitudes expressed here have been reported elsewhere for patients, GPs and pharmacists.11-14,333-345 Nevertheless, the results provide valuable information regarding the perceived feasibility of a community pharmacy-based asthma intervention. It allowed for exploration of participants’ views and experiences of the intervention, and the findings provide impetus for future research in this area.