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Pharmaceutical care for asthma patients: A community pharmacy-based pilot

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Article  in  Allergy and Asthma Proceedings · January 2008

DOI: 10.2500/aap2008.29.3083 · Source: PubMed

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SYMPOSIUM: Allergic Rhinitis in Children: Complications and Treatment
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l Late phase allergic reaction in nasal provocation with fungal allergens Niedoszytko et al.
l Dust mite avoidance measures in patients on immunotherapy White et al.
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" Exhaled breath condensate pH in the evaluation of asthma Coop et al.
a Pharmaceutical care for asthma patients: A community pharmacy based project Petkova
, Emergency dept utilization by patients not meeting HED1Scriteria for persistent asthma Hsu et al.
a Mycobacterium vaccae ameliorates airway histo1?athology in asthma Yazi et al.
l Serum 19Elevels in pregnant women and their infants De Amici et al.
l Antigenic extracts from pollen & seeds of mustard (brassica) Shahi et al.
l Causes of moderate to severe angioedema Banerji et al.
l POPs Case: A is-year old girl with recurrent pneumonia DiDario et al.
 armaceutical care for asthma patients: A community
harmacy-based pilot proj ect
alentina B. Petkova, Ph.D.

. Asthma is a clinical problem with social, psychological, and economic burdens. To improve patient disease management and
quality of life (QOL), different education programs have been developed. The purpose of this study is to adapt and implement
. (? community-based educational program for patients with asthma. A prospective, randomized, controlled trial was performed.
Fifty individuals with mild asthma (aged 18-40 years) that have been attending pharmacies were included in the sample. The
duration of the disease was 9 :!:: 4.21 years. A 4-month study was conducted on essence of asthma and factors that can intensify
;1; nourishing facts, allergens, and physical activities; self-management and use of tobacco;and pharmacotherapy, inhalation
technique, and possible adverse drug reactions. Patient's health-related QOL was assessed in the beginning and at the end of
the survey. Parameters assessed during the four stages of the program were patients' peak expiratory flow (PEF); inhaler
technique; severe asthma symptoms, including breathlessness, hospitalization rates,frequency of urgent medical aid calls, and
frequency of general practitioner visits; compliance with therapy; and satisfaction with pharmacy services. Health-related QOL
of the intervention patients was improved at 4 months and there was improvement in the PEF rate, decrease in patients'
breathlessnessand wheezing rate, decreasein the reported hospitalizations rate becauseof the disease, decreasein the physician's
visits, and increase in satisfaction with pharmacist-provided information. The positive results from the educational approach
show a potential to decreaseasthma disease complications and show a positive impact on patients' inhaler technique, patients'
opinions about the pharmacy services, and information obtained.
(Allergy Asthma Proc 29:55-61,2008;doi: 10.2500/aap2008.29.3083)
Key words: Asthmatic quality of life, bronchial asthma, Bulgaria, educational program for asthma patients, patient
knowledge, pharmaceutical care, pharmaceutical education '

here has been a significant increase in the prev-
T alence of allergy and especially of bronchial
asthma in the past 20 years. Asthma seems to be
associated with an enormous social, psychological,
and economic burden as it is responsible for many
deaths and expenditure of health care expenses. 1,2
Despite the innovations in the availability and effi-
cacy of asthma drug treatment, the quality of health
care provided to this group of chronic patients seem
to be suboptimal, and asthma mortality and morbid-
ity rates remain unacceptably high.3-5 There are
many reports of noncompliance to asthma treatment,
which leads to poor quality of asthma care and in-
creases in asthma exacerbations that lead to hospi-
talizations, GP visits, extra use of drugs, and increase
in asthma treatment cost.6,7
There are many educational programs for patients
with asthma, provided by different health care pro-
From the Faculty of Pharmacu, Department of Social Pharmacy, Medical University-
Sofia, Sofia, Bulgaria
Address correspondenceand reprint requests to Valentina Petkoua, Ph.D., Faculty of
Pharmacy, Department of Social Pharmacy, Medical Uniocreitv-Sofia, 2-Dunav sir.,
Sofia-lOOO,Bulgaria
E-mail address:petkovav1972@yahoo.com
Copyright © 2008, OceanSide Publications, Inc., U.S.A.
viders.8-10 But community pharmacists are consid-
ered to be in a unique position to support asthma
patients with the management of their chronic illness
because of their permanent contact with the patients
and their drug knowledge, authority, and easy ac-
cessibility. The pharmacists are well educated and
can be trained easily, especially in asthma, to be able
to provide specialized care to asthmatic patients.
Training provided to pharmacists has a long-term
effect on their knowledge and proficiency and can
improve patient drug knowledge, inhaler technique,
and level of compliance. In the United States, phar-
macists' instructions in metered-dose inhalers im-
proved patient skills.ll,12Pharmacists play an impor-
tant role in asthmatic patients' treatment, focused on
the safe and effective use of drugs.13 According to
the European Therapeutic Outcome Monitoring
studies, pharmacists not only improved patients'
drug knowledge, inhalator skills, and patients' com-
pliance with the prescribed therapy, but they also
work and improve the drug therapy together with
the general practitioner (GP)Y-16 The pharmacist's
contribution to patient care through education and
monitoring and through assessing and optimizing
the drug therapy leads, in general, to improvement
in patient quality of life (QOL).12,17,18

Allergy and Asthma Proceedings 55

MATERIALS AND METHODS
The aim of this study was to develop and implement
education programs for moderate and severe asthma
patients at a community pharmacy setting and to eval-
uate its influence on the patients' QOL. The study
design was a prospective and randomized study with
a control group.
Patients registered as having asthma were invited to
participate in the study during their pharmacy visit.
The inclusion criteria were diagnosis of bronchial
asthma, aged> 14 years, and understanding of spoken
and written Bulgarian. Exclusion criteria were pres-
ence of other significant pulmonary disease (e.g., car-
cinoma), presence of any condition that would hinder
completion of questionnaires (e.g., poor eyesight or
literacy), and age of <14 years. Fifty asthmatic patients
were included, and they were diagnosed between 1991
and 2003. Twenty-two of these patients were assigned
to the educational group and 28 were assigned to the
control group. They were assigned based on the prin-
ciple of random numbers. All of the participants were
informed of the objectives of the investigation and
were asked to sign a basic consent form. The groups
were identical with regard to disease severity param-
eters, inhaler technique, and QOt. Patient condition
and asthma severity were assessed by their physicians
and the information was part of their personal medical
records. The control group was treated as usual at the
pharmacy, with no additional information, while the
educational group attended educational sessions for a
period of 4 months.
The pharmacies were selected through a list of pri-
vate community pharmacies, located in Sofia, Bulgaria,
provided by the Bulgarian Ministry of Health (1134
private pharmacies). Ten pharmacies with the highest
number of asthma patients were selected. These phar-
macies were invited to take part in the study. The
education session was performed by the author and by
10 pregraduating students that have passed their exam
in Pharmaceutical care. Patient's diaries consisted of
information about patient's peak flow value, smoking
history, disease complications, and prescribed drugs. If
there were any problems encountered with treatment
they also were included in the diary. Patients were
asked not to change their pharmacy during the study.
The educational program included information
about asthma, instruction on the appropriate use of
medication, training in the inhaler technique, adverse
drug reactions during treatment, recognition of early
signs of exacerbation, information about the identifica-
tion and control of asthma attacks, and tobaccoism and
efficacy of different methods on smoking cessation. All
of the materials were developed by the authors. They
were based on the information provided by the Asso-
ciation of the Bulgarian with Asthma and from the
56
National Asthma Education Program Office of Preven-
tion, Education, and Control, National Heart, Lung
and Blood Institute, National Institute of Health (Be-
thesda, MD)_l9The educational leaflets were prepared
in the form of a self-study program that includes in-
formation on one of the topics. After the educational
session the leaflets were given to the patients. The
applied materials included 22 information leaflets on
different education sessions, 22 patient health diaries,
and 100 QOL assessment questionnaires.
In the beginning of the second, third, and forth ses-
sions interviews on the previous topics were provided
to assess the level of the newly achieved knowledge
and to clarify any doubt or illegibility (n = 66). There
was a direct interview with the observed patients dur-
ing which specific questions on the previous education
subjects were cleared. The interviewer used a list with
questions, and took notes on the patients' answers.
This type of interview is impersonal and seeks to re-
veal the real level of knowledge achieved. The follow-
ing parameters were assessed at baseline and once a
month:
Patient's peak expiratory flow (PEF) rate, determined
with a peak flowmeter. There was appropriate
equipment in the pharmacy for measurement of PEF
with a MicroPeak peak flowmeter (MIC Global, Ltd.,
London, U.K.) and the highest PEF was selected each
time from each set of three spirometric maneuvers
for each of the patients.
Patient inhaler technique. The patient was observed
while using the inhaler and a score (1 = correct and
o = incorrect) was given for each step according to
standard instructions.?" If a patient forgot a step,
such as shaking the inhaler, removing the cap, etc., a
score of 0 was assigned.
Patient asthma self-monitoring. Patients were asked
how often they have suffered from any asthma com-
plication-the severity and duration of the crisis,
were they admitted to the hospital, and, if hospital-
ized, the length of their hospitalization and how
often they forgot to take their prescribed drugs. Pa-
tients also were asked about their visits to the doctor.
The hospitalizations and GP visits were verified
through their medical records.
Patients' subjective opinions of the patient's health-
related QOL were assessed through an adapted dis-
ease-specific instrument Asthma Assessment forrn'"
that was translated into Bulgarian using conven-
tional backtranslation procedures. The questionnaire
includes eight questions on the duration of the dis-
ease, severity of asthma, reasons for triggering of
asthma, application of inhaler during the past 4
weeks, availability of shortness of breath during the
past 4 weeks, fully experienced day at work or at
home in the past 4 weeks, frequency of hospitaliza-
January-February 2008, Vol. 29, No. 1
Table 1 Main characteristics of the population sample
Demographics
Age
Sex
Female
Male
Female/male ratio
Education (%)
Primary
Secondary
High
Cigarette smoker (%)
Duration of disease since diagnosis (yr)
Severity of asthma (according to EPR-2)
Mild intermittent (n)
Mild persistent (n)
Moderate persistent (n)
Severe persistent (n)
EPR-2 = Expert Panel Report 2: Guidelines for diagnostic and management of asthma, 1997.
tions, and urgent medical aid (UMA) calls in the past
4 weeks. That information was obtained in the be-
ginning and at the end of the study.
Patient satisfaction with the services provided by phar-
macists was assessed by a directed interview. It was
provided in the beginning of the project and after the
education process.
PEF rate measurements, inhaler technique assess-
ments, and data obtained from QOL instruments were
analyzed using repeated-measures analysis of variance
(ANOVA). In addition, changes between baseline and
4 months for the various measures were compared
within and between the two groups of patients using
t-tests and the Mann-Whitney U-test (between-group
analysis), as appropriate. A value of p < 0.05 was
considered statistically significant. Statistics were per-
formed by using SPSS/version 12.0 (SPSS Inc., Chi-
cago,IL).
RESULTS
Fifty patients were eligible to participate in the
study, 22 in the intervention group (group 1) and 28 in
the control group (group 2). The separation is based on
patient willingness to take part in the education pro-
gram. Table 1 gives demographic information about
the two groups.
The number of women is equal in the two groups
and statistically there is no significant difference be-
tween the number of men in the intervention and
control groups (p > 0.05). The intervention group also
had a significantly younger mean age compared with
the control group. All of the patients had health insur-
Allergy and Asthma Proceedings
Group 1 (n = 22) Group 2 (n = 28)
35.14 ± 17.4 40.82 ± 17.7
9 9
13 19
0.69 0.47
18.2 10.7
40.9 39.3
40.9 50.0
22.7 21.4
9.55 ± 4.0 10.04 ± 3.5
9 8
10 8
2 7
1 5
ance coverage and were educated-the secondary and
higher education predominates in both groups. Five
patients from group 1 and six patients from group 2
were current cigarette smokers. The duration of the
asthma since diagnosis is comparatively equal in both
groups. The severity of patients' asthma is shown in
the Table 1.
Table 2 represents the influence of the education on
the studied parameters: PEF rate, inhaler technique,
asthma self-monitoring, quality of services provided,
and patients' QOL. It is clear that there are some dif-
ferences between the two groups at baseline: the hos-
pitalization rate and the frequency of UMA calls are
lower in the intervention group than in the control
group. Although the results for asthma self-monitor-
ing, shortness of breath, and availability of cough are
nearly equal in the two groups. The purpose of the
study was to assess if there was any alteration in the
results between the two groups because of the educa-
tion program.
The results of the PEF rate from the patient's diaries
show that at baseline, the mean PEF of the patients in
both groups were comparatively equal (335.45 ± 15.73
L/minute for group 1 versus 332.14 ± 14.49L/minute
for group 2). After ANOVA analysis with gender and
age as covariates (predictors), it was proven that PEF
was not significantly different in the two groups (p >
0.05). These PEF values are the mean for both groups
without taking in mind the influence of patients' age
and height.
During the education process fluctuation still is ob-
served in the control group PEF values whereas after
57
Table 2 Education effect
Parameters Baseline After 4 mon
Group 1 Group 2 Group 1 Group 2
(n = 22) (n = 28) (n = 22) (n = 28)

PEF rate (L/min) 335.45 ± 15.73 332.14 ± 14.49 338.64 ± 12.55 333.57 ± 14.00
Inhaler technique 0.41 ± 0.5 0.46 ± 0.5 0.55 ± 0.51 0.46 ± 0.51
Asthma self-monitoring
Availability of cough, shortness of 90.9% 96.4% 68.2% 96.4%
breath
Hospitalization rate 36.4% 85.7% 13.6% 78.6%
Frequency of UMA calls 54.5% 89.3% 18.2% 78.6%
Visit to GP
<2-3 times 63.7% 17.9% 86.4% 21.4%
>6 times 9.1% 3.6% 4.5% 3.6%
QOL 3.55 ± 1.335 3.39 ± 0.685 3.77 ± 1.020 3.00 ± 0.903
Quality of health services provided
Information provided from the 1.45 ± 0.510 1.71 ± 0.460 1.23 ± 0.429 1.57 ± 0.504
pharmacist
Satisfaction from the services provided 1.55 ± 0.510 1.71 ± 0.460 1.27 ± 0.456 1.75 ± 0.441
Necessity of additional information 1.18 ± 0.395 1.36 ± 0.488 1.45 ± 0.510 1.29 ± 0.460

Table 3 PEF rate alterations (L/min) At baseline, both groups had similar inhaler scores,
and a relatively low percentage of patients was as~
Group 1 Group 2 sessed with "correct" for their inhaler techniques (9
Baseline 335.45 ± 15.73 332.14 ± 14.49 [40.9%] for group 1 and 13 [46.4%] for group 2). After
After 1 mon 336.59 ± 14.09 326.07 ± 12.86 the education session the patients in group 1 showed a
After 2 mon, 338.86 ± 12.53 331.61 ± 13.95 trend to improve their techniques (12 [54.5%]).There is
After 3 mon 338.41 ± 12.19 322.32 ± 12.36 no improvement observed in the control group. The
After 4 mon 338.64 ± 12.55 333.57 ± 14.00 difference between the 4-month score and the baseline
score was significantly higher in the intervention
group than in the control group (,1-test).
During the study, patient self-monitoring was pre-
the second month and especially after the third month sented, which included patient's report about the exis-
there are stable values of the PEF rate in group 1. After tence, duration, and severity of asthma crisis; hospital-
the education process, stable values of the PEF rate are ization and duration of hospitalization if needed; and
observed for group 1 (338.64 ± 12.55)and there are still compliance with the drug treatment. Patients reported
fluctuations in the PEF rate of the patients in group 2 frequency of cough, chest tightness, and shortness of
(333.57 ± 14.00; Table 3) breath. Over 90% of patients inboth the control and the
For the patients in the control group the mean PEF at intervention groups reported that they have experi-
baseline (332.14. ± 14.49 L/minute) was almost equal enced these symptoms most of the time. Up to 50%
to the mean PEF after 4 months (333.57 ± 14.00 reported feeling these symptoms three to six times a
L/minute). The corresponding comparison for the in- week or more frequently. After the education session
tervention group shows improvement in the PEF rate significantly more patients in the intervention group
after the program (335.45 ± 15.73 in the beginning and than in the control group (32% versus 4%) reported no
338.64 ± 12.55 at the end of the project). The difference availability of these symptoms at all (p = 0.013;,1-test).
between the 4-month PEF and the baseline PEF was A significant part of the control group (85.7%) in
significantly higher in the intervention group than in comparison with the intervention group (36.4%) was
the control group (ANOVA with gender and age as hospitalized because of asthma crisis and the length of
covariates). hospital stay was from 2-5 days. They reported that
The inhaler technique scores were calculated based they were hospitalized once (57.1% versus 18.2%) or
on observation of patients' skills. Their inhaler tech- more then once (28.6%versus 18.2%). After the educa-
niques were ranked with "1" for correct and "0" for tion process there was a decrease in the hospitalization
incorrect. rate in the intervention group. The patients reported

58 January-February 2008, Vol. 29, No.1

Table 4 Asthma interference in patients' daily routines
Answers Baseline
Group 1 Group 2
Frequency Percent Frequency
All of the time (1) 2 9.1 0 0
Most of the time (2) 4 18.2 1 3.6
Some of the time (3) 2 9.1 17
A little of the time (4) 8 36.4 8 28.6
None of the time (5) 6 27.2 2 7.1
Total 22 100 28
that during the observed period they were hospitalized
only once (13.6%). The rest of the patients from this
group were not hospitalized. Although the results in
the control group show a decrease in the rate of the
polyhospitalizations from 28.6 to 21.4%, there is con-
stant rate of 57.1% in the single hospitalizations. There
is an increase in the number of patients from this group
that were not hospitalized (from 14.3 to 21.4%). The
self-reported hospitalization rates were significantly
different between the two groups (p = 0.001; paired
t-test). All of the patients claimed that they were com-
pliant with the prescribed therapy and all of the pa-
tients said that they strictly followed the physicians'
instructions.
A significant decrease in the frequency of UMA calls
was observed. Inthe beginning of the study ~45.5% of
patients from the intervention group were not calling
for UMA, and the remaining patients needed UMA
once (27.3%)or more then once (27.2%);only 10.7% of
the patients from the control group did not need UMA.
The rest called UMA only once (71.4%)or more times
(17.9%). After the education process there was a de-
crease in the UMA calling rate in the intervention
group. The patients reported that during the observed
period they needed their services only once (18.2%).
The rest of the patients from this group did not have
any disease complications that called for UMA inter-
vention. The results in the control group showed a
decrease in the rate of the calls from 89.3 to 78.6%.The
difference between the 4-month results and the base-
line was not significant in the two groups (p > 0.05;
Mann-Whitney U-test).
After the education process there was no significant
difference in the results of the control group regarding
the frequency of GP visits-3.6% declared that they
have visited their physician more then six times and
21.4% visited their physician less then two to three
times. Although there are significant differences in the
intervention group, 86.4% have visited their physician
less then two to three times and only 4.5% visited their
physician more then six times for the last 4 weeks (p =
0.018; _i-testt
Allergy and Asthma Proceedings
After 4 mon
Group 1 Group 2
Percent Frequency Percent Frequency Percent
0 0 2 7.1
2 7.1 4 14.3
60.7 8 28.6 15 53.6
5 17.9 6 21.4
7 25.0 1 3.6
100 22 100 28 100
Analysis of the Asthma Assessment form showed no
significant differences in the patients' QOL over the
4-month period. Approximately 27.2% of the interven-
tion group and only 7.1% of the control group said that
they had fully experienced day most of the time and
their disease did not interfere in their daily routine.
After the program, there is no significant change ob-
served in the answers of the patients: ~25.0% of the
intervention group and 3.6% of the control group an-
swered that they have had fully experienced days most
of the time for the last 4 weeks (Tables 2 and 4).
From the analysis of the data of each group over
time, it is evident that for the 22 patients in the inter-
vention group who completed the study, the mean
score at the end of the program (3.77 ± 1.020) was
significantly higher than at baseline (3.55 ± 1.355;P <
0.0001;paired t-test), indicating that there is improve-
ment in the QOL over the duration of the study (the
scoring was from I, "interference all of the time," to 5,
"interference none of the time"). The corresponding
comparison for the control group showed that there
was worsening in the patients' QOL: from 3.39 ± 0.685,
the results decreased to 3.00 ± 0.903 (p = 0.039;paired
t-test).
Data regarding patient satisfaction with the services
provided by pharmacists were collected by interview.
It was provided in the beginning of the project and
after the education process. The patients' responses
were based on the services provided by the private
community pharmacists included in the project phar-
macies.
The intervention group was more satisfied with the
information that was provided by their pharmacists in
the beginning of the program, whereas the patients
from the control group were not so satisfied (54.5%
from the intervention group were positive vs. 28.6%for
the control group). After the education process both
groups showed increase in their satisfaction (77.3%for
the intervention group vs. 42.9%for the control group).
After the analysis of the data for each group, over
time, it is evident that for the intervention group, the
mean score at 4 months (1.23 ± 0.429)was significantly
59
lower than at baseline (1.45 :±: 0.510; P = 0.021; paired
t-test), indicating that there was improvement in the
patient's opinion about the pharmacy information ser-
vices during the study. The corresponding comparison
for the control group showed equivalent results: the
mean score at 4 months (1.57 :±: 0.460) was lower than
at baseline (1.71 :±: 0.504; P = 0.043; paired t-test).
At baseline, the two groups classified the pharmacy
service provided as poor (54.5% for the intervention
group versus 71.4% for the control group). After the
education, the responses obtained from the interven-
tion group showed positive increase: 72.7% of the pa-
tients assessed the services as satisfactory, and the
patients from the control group were still assessing the
pharmacy services as poor (75.0%). The difference be-
tween the 4-month results and the baseline was signif-
icantly higher in the intervention group than in the
control group (p = 0.011; paired t-test).
When assessing the necessity from additional infor-
mation, nearly all of patients at baseline declared that
they needed additional information from their phar-
macist about their asthma or their prescribed drugs
(81.8% of the intervention group versus 64.3% of the
control group). After the 4-month assessment period,
control patients (71.4%) rated this need as great
whereas intervention patients were more satisfied
from the provided contact regarding their condition
and its management (54.5%;p < 0.017; paired t-test).
DISCUSSION
Today, acute severe asthma and the risk of exacer-
bations are major individual and public health and
economic burden. The pharmacy practice in asthma
management is a relatively new approach that inte-
grates disease and drug management, patients' com-
pliance assessment, PEF monitoring, inhaler technique
training, prospective and retrospective drug use re-
view, adverse drug reaction, and toxicity screening and
education of the patients? These skills as a system-
atized approach in everyday pharmacy practice should
correspond to the introduction of the pharmaceutical
care principles for all chronic diseases.
The results from our study confirm the evidence
from the literature that education of patients with
asthma can be effective and beneficial. It proves that
pharmaceutical care provision is well received by asth-
matic patients.l" Of course, the study size is small and
the observed results can not lead to general conclu-
sions about all asthmatic patients in Bulgaria. There are
differences between the two groups at the start of the
pilot project; however, the aim of this study, as previ-
ously stated, was to see if there is any alteration in
patient results and the study shows some positive re-
sults in the intervention group. At the end of the study,
the education· group showed significant differences
60
when compared with the control group (education/
control [mean values]) with respect to improvement in
the PEF rate 338.64/333.57 (p < 0.05); decrease of the
patients' breathlessness and wheezing rate, 4.09/2.82
(p < 0.05); decrease in the rate of reported hospitaliza-
tions because of the disease, 2.73/1.64 (p < 0.05); and
decrease in the physician visits, 1.59/3.18 (p < 0.05).
Improvements also were observed in inhaler tech-
nique, QOL, satisfaction with pharmacy services, and
information obtained and although it is not statistically
significant it must be taken into account that the edu-
cation process was for only 4 months. The continuation
of the process will most likely increase the satisfaction.
The value of inhaler training is evident from the results
and it coincides with other studies. The better results of
the intervention group suggest that the education in
proper application of inhalers at pharmacy sites is
beneficial. 16
The results show that the pharmacist services had an
effect on patients' QOL. Although the improvement
was small, it was better than the intervention provided
by other health care providers as in the nurse care for
asthmatic patients in Creenwich.F The greater acces-
sibility to the pharmacists and the lack of most of the
psychological obstacles made the pharmacy a good
place for additional education of asthmatic patients.
It can be concluded that the educational program at
pharmacy sites is performed easily and can signifi-
cantly improve asthma morbidity. The obtained results
confirm the need for constant patient education for
asthma patients as an essential part of asthma care in
the pharmacy that will result in a decrease in exacer-
bations of the disease.12,13 The results show that such
an approach has the potential to improve the QOL of
asthmatic patients and that it can be implemented in
the daily pharmacy routine. The pharmacists need to
be well trained to cope with all of the drug- and dis-
ease-related problems that can arise during chronic
disease management. This study, as a pilot program,
only outlines the directions in which the pharmaceuti-
cal care for asthmatic patients must develop and shows
that education at the pharmacy site can lead not only to
better disease ma:t:lagement but also to pharmacoeco-
nomical benefits due to a decrease in hospitalizations,
decrease in disease exacerbations, and better drug
management. 16
REFERENCES
1. Jarvis D, and Burney P. The epidemiology of allergic disease.
BMJ 316:607-610, 1998.
2. Murphy A. Management of acute asthma. In Asthma in Focus.
London: Pharmaceutical press, 57-73, 2006.
3. Garg V, Bidani R, Rich E, et al. Asthma patients' knowledge,
perception, and adherence to the asthma guidelines. J Asthma
42:633-638, 2005.
4. Piecoro LT, Potoski M, Talbert [C, et al. Asthma prevalence, cost
and adherence with expert guidelines on the utilization of
January-February 2008, Vol. 29, No.1
 health care services and costs in a state Medicaid population.
Health Serv Res 36:357-371, 2001.
5. Scarfone RJ, Zore JJ, and Capraro GA. Patient self-management
of acute asthma: Adherence to national guidelines a decade
later. Pediatrics 108:1332-1336, 2001.
6. Scherer YK, and Bruce S. Knowledge, attitudes, and self-efficacy
and compliance with medical regimen, number of emergency
department visits and hospitalizations in adults with asthma.
Heart Lung 30:250-257, 2001.
7. Legoretta AP, Christian Herman J, O'Connor RD, et al. Com-
pliance with national asthma management guidelines and spe-
cialty care: A health maintenance organization experience. Arch
Intern Med 158:457-464, 1998.
8. Green LW, and Frankish C], Theories and principles of health
education applied to asthma. Chest 1064:2195-230S, 1994.
9. Pauley TR, Magee MJ, and Cury JD. Pharmacist-managed, phy-
sician-directed asthma management program reduces emer-
gency department visits. Ann Pharmacother 29:5--9, 1995.
10. Ignacio-Garcia JM, and Gonzalez-Santos P. Asthma self-man-
agement education program by home monitoring of peak expi-
ratory flow. Am J Respir Crit Care Med 151:353--359, 1995.
11. Roberts RJ, Robinson JD, Doering PL, et al. A comparison of
various types of patients instructions in the proper administra-
tion of metered inhalers. Drug Intell Clin Pharm 16:53--55, 59,
1982.
12. De Tullio PI, and Corson E. Effect of pharmacist counseling on
ambulatory patients' use of aerosolized bronchodilators. Am J
Hosp Pharm 44:1802-1806, 1987.
13. Hunter KA, and Bryant BG. Pharmacist provided education
and counselling for managing pediatric asthma. Patient Educ
Allergy and Asthma Proceedings
Couns 24:127-134,1994.
14. Herborg H, Soendergaard B, Froekjaer B, et al. Improving drug
therapy for patients with asthma-Part 1: Patient outcomes.
JAm Pharm Assoc 41:539-550, 2001.
15. Narhi U, Airaksinen M, and Enlund H. Pharmacists solving
problems in asthma management-experiences from a one-year
intervention programme in Finland. Int J Pharm Pract 10:55-59,
2002.
16. Cordina M, McElnay JC, and Hughes CM. Assessment of a
community pharmacy-based program for patients with asthma.
Pharmacotherapy 21:1196-1203, 2001.
17. Hepler CD, and Strand LM. Opportunities and responsibilities
in pharmaceutical care. Am J Hosp Pharm 47:533--543, 1990.
18. Pauley TR, Magee MJ, Cury JD. Pharmacist-managed, physi-
cian-directed asthma management program reduces emergency
department visits. Ann Pharmacother 29:5-9, 1995.
19. National Asthma Education Program Office of Prevention,
Education, and Control. National Heart, Lung and Blood Insti-
tute, National Institute of Health, Bethesda, MD, 20892. Avail-
able online at www.asthma-bg.com/index.htrnl; www.
meddean.luc.edu/lumen/meded/medicinel Allergy I Asthma I
asthtoc.html: last accessed Sept. 2007.
20. Asthma audit. RPSGB 1998, 7. Available online at www.rpsgb.
org.uk/pdfs/asthma.pdf; last accessed Sept. 2007.
21. Asthma Assessment Form 2002. Available online at www.
naperville203.orgl assets/ asthma-assessment. pdf; last accessed
Sept. 2007.
22. Premarante UN, Sterne J, Marks G, et al. Clustered randomized
trial of an intervention to improve the management of asthma:
Greenwich asthma study. BMJ 318:1215-1255, 1999. D·
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