| Abstract |
2.1 Introduction
On the occasion of the death of 195 patients suffering from asthma within
a year in England, in the period 2012-2013, the possible causes were
investigated and excessive prescribing for certain types of bronchodilators
(SABA), reduced prescribing of others (LABA), inadequate administration
and compliance with the prescription of corticosteroids (ICS) and the wrong
dosage of individual or combinations of the above formulations for the
treatment of asthma attacks were found. In addition, it was found that there
was no continuity in the medical monitoring and training for asthma
management of these patients, so that there was no documented picture of
their condition and the risk they are at. Thus, the need arose to create a
methodology for informing and highlighting the problems, guiding and
improving the way asthma is managed by patients, with the contribution of
all health professionals who have a direct or indirect influence on the
management of the disease, e.g. doctors, health professionals and
pharmacists, in primary/secondary health care.
2.2 Aim - Methodology
The aim of the study was to determine whether health professionals
(Pharmacists, General Practitioners) know basic principles in the therapeutic
Δημόσια Υγεία-Πρωτοβάθμια Φροντίδα Υγείας-Υπηρεσίες Υγείας
Ιατρική Σχολή–Πανεπιστήμιο Κρήτης
11
approach of asthma management, with particular emphasis on the frequent
use of inhaled SABA. It should also assess the intention and the ability of
health professionals to influence and shape a new perception in patients and
by extension in society-state about the necessity of the right way to use
inhaled medicines and the general philosophy of Proper Asthma
Management (Asthma Right Care-ARC).
The methodology of the research project was based on the initiative of
IPCRG (International Primary Care Respiratory Group). An attempt was
made to record views and practices, groups of health professionals and the
possibility of adjusting these views and practices in line with the proposals
of the ARC initiative was investigated. ARC is an initiative born through
IPCRG creating a European network of people related to primary health care
(doctors, nursing staff and pharmacists). They try to influence and shape the
proper management of asthma, reducing the misuse of inhaled SABA.
Asthma should no more be treated as an emergency and only acute symptoms
should be managed, but a model for its management as a chronic disease
should be established.
In our study we used a sample of convenience consisting of ten Doctors
(General Practitioners) and thirty Pharmacists of the region of Heraklion,
Crete. The criterion for the selection of the respondents was only their
capacity (Gen. Doctors, Pharmacists), and concerned those operating in
Heraklion, Crete.
A questionnaire created by Professor Tsiligianni Ioanna and Anna
Manidaki (associate) was used. The questionnaire is structured in 3 sections.
In the first section there are questions where the participant should choose
from a series of graded answers on a Likert scale, while in the second and
third sections the participant gives a supplementary interview. The first two
question sections are common to both groups of respondents (Gen.
Practitioners - Pharmacists). The third unit is specialized according to the
specialty of the respondent (General Practitioner or Pharmacist).
Δημόσια Υγεία-Πρωτοβάθμια Φροντίδα Υγείας-Υπηρεσίες Υγείας
Ιατρική Σχολή–Πανεπιστήμιο Κρήτης
12
The aim of the questionnaire is to assess the degree of understanding of
the importance of proper asthma management and the accessibility that health
professionals may have in their workplace, so that they can influence the
patient with asthma and be able to direct them to a more correct and longterm stable behaviour in terms of asthma management.
Then the tools of the ARC initiative were presented: The Ruler for the
Proper Management of Asthma and the Questions and Challenges Cards. The
tools of the ARC initiative and the questionnaire are translated and weighted
by Professor Tsiligianni Ioanna and Anna Manidaki (associate). Their use in
this research has been licensed by IPCRG.
Ruler for the Proper Management of Asthma
Questions and Challenges Cards
The answers and interviews were recorded and their quantitative and
qualitative analysis accordingly. Content analysis was applied for the quality
Δημόσια Υγεία-Πρωτοβάθμια Φροντίδα Υγείας-Υπηρεσίες Υγείας
Ιατρική Σχολή–Πανεπιστήμιο Κρήτης
13
part. Categories / subcategories derived from the content of the material
under analysis were created. For the analysis the results were captured
according to the qualitative answers in the form of frequencies (N, %) and
selected variables are depicted in the form of diagrams.
2.3 Results
Of the answers to the common classified questions, 18 out of 30
pharmacists (60%) believe that guidelines are not followed in our country
while 6 out of 10 General Practitioners (60%) believe that they are followed.
We saw that while all the Gen. Practitioners (100%) are aware of
national/international guidelines, 17 out of 30 pharmacists (56.57%) are not.
Also, only 5 out of 30 pharmacists (16.67%) consider that they devote time
to the education of asthma patients, as opposed to 15 out of 30 pharmacists
(50%) who believe that they do not devote at all while all Gen. Practitioners
believe that they spend enough time (100%). We saw that 7 out of 10 Gen.
Practitioners (70%) and 13 out of 30 pharmacists (43.33%) do not believe
that patients can search for asthma information on their own, while 10 out of
30 pharmacists (33.33%) agree with this position.
3 of the 10 Gen. Practitioners (30%) and 18 out of 30 pharmacists (60%)
have not crystallized an opinion on how to prescribe the combination of
corticosteroids with SABA, 3 out of 10 Gen. Practitioners (30%) and 5 out
of 30 pharmacists (16.67%) consider the correct ratio of 6:1 (ICS: SABA)
when prescribing expected, while 4 out of 30 pharmacists (13.33%) and 4 out
of 10 Gen. Practitioners (40%) believe that the usual prescribing ratio is 2:1.
6 out of 10 Gen. Practitioners (60%) and 14 out of 30 pharmacists
(46.67%) do not agree with the position that excessive use of Aerolin is a
problem in asthma but not in COPD (Chronic Obstructive Pulmonary
Δημόσια Υγεία-Πρωτοβάθμια Φροντίδα Υγείας-Υπηρεσίες Υγείας
Ιατρική Σχολή–Πανεπιστήμιο Κρήτης
14
Disease), in contrast to 10 out of 30 pharmacists (33.33%) and 4 out of 10
Gens. Doctors (40%) who agree.
The front against the abuse of SABA and in favor of proper information
and management should be the subject of the Gen. Practitioners according to
the opinion of 3 of the 10 Gen. Practitioners (30%) and 15 out of 30
pharmacists (50%), while 7 out of 10 Gen. Practitioners (70%) and 26 out of
30 pharmacists (86.67%) believe that it should be the subject of
pneumonologists. Finally, 18 out of 30 pharmacists (60%) consider that the
management of asthma also concerns pharmacists, while 4 out of 30
(13.33%) disagree, while 7 out of 10 Gen. Practitioners (70%) disagree up to
thoroughly and only 3 out of 10 (30%) seem undecided.
From the interviews section we see an "isolation" between the different
branches of health professionals that comes from the difficulty or avoidance
of communication between them, resulting in a small degree of substantial
combined intervention in the proper management of asthma. Of the health
professionals surveyed, pharmacists believe they have a lack of information
about asthma while the Gen. Practitioners have a good level of awareness.
The Gen. Practitioners rely on the typical diagnostic modes (clinical
examinations, clinical picture, retesting) without much individualization,
while recognizing the value of ICS and the need to control SABA. They also
consider the workload and lack of intention by the patients themselves as the
main cause of the patients' lack of education in the treatment of asthma
attacks and the use of inhalation devices. They find it difficult to approach
patients for further counseling and education.
Pharmacists are not aware of GINA's initiative, they are aware of the
legislation regarding the restriction on the availability without prescribing of
SABA but they find it difficult to implement it in practice. They believe that
the modern way of operation of the Greek pharmacy is not appropriate for
the proper information and education of the patient with asthma while they
Δημόσια Υγεία-Πρωτοβάθμια Φροντίδα Υγείας-Υπηρεσίες Υγείας
Ιατρική Σχολή–Πανεπιστήμιο Κρήτης
15
also express the possible inadequacy to offer such a service, asking for some
education – information.
All of the above shows that the health professionals surveyed do not have
the interventional power and willingness to modify the way asthma is
managed
2.4 Conclusion
While national/international guidelines from health professionals
regarding the management of asthma are quite well-known, they are
nevertheless partially implemented. Also, some health professionals, mainly
pharmacists, report a lack of information about asthma and its management.
The time devoted to educating patients about the correct technique of
application of inhalation devices is not enough either because of workload or
because of lack of mood by the patients themselves. It is not always possible
to communicate two-way between health professionals, resulting in
insufficient coordination in monitoring the course of the patient's disease.
However, it is accepted that the front for the proper treatment and
management of the way SABA is disposed of should be broadened either to
other medical specialties apart from pneumonologists but also to other
disciplines such as pharmacists.
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