NHS Doncaster Community Pharmacy Inhaler
Check Service Evaluation
involves discussion about diagnosis, pattern of use of
different medicines and review of inhaler technique.
May 2014
The In-Check DialTM device is used to help
demonstrate to patients the optimum IR required to
maximise use of their prescribed inhaler device.
Background
Asthma and Chronic Obstructive Pulmonary Disease
(COPD) are common respiratory conditions. Asthma
affects up to 5.4 million people in the United Kingdom
(UK) and is still killing people. The number of reported
deaths in the UK is the highest in Europe.1 COPD is
estimated to affect 3 million people in the UK, with
deaths in England double the European average.2
Aims of the Service
To help patients to optimise the use of inhaled
medication and improve respiratory management.
Service Evaluation
Aim and Objectives: To evaluate a community
pharmacy inhaler check service. To identify the
number of patients using the service, inhaler use
issues and interventions provided by community
pharmacists, exploring patient satisfaction with the
service and ideas for service development.
Between April 2013 and February 2014 there were
313 emergency admissions for asthma with an
inpatient cost of £306,127 and 869 emergency
admissions due to COPD at a cost of £1,871,651.3
Setting: Twenty-nine community pharmacies across
Doncaster.
The mainstay of treatment for both asthma and COPD
is inhaled therapy. Short-acting bronchodilators
(‘reliever’ inhalers) are used to relieve breathlessness.
Maintenance treatment is with ‘preventer’ inhalers e.g.
inhaled corticosteroids. There are many different
inhaler devices e.g. metered dose inhalers (MDIs) and
dry powder inhalers (DPIs). Different devices require
different inspiration rates (IRs).
Methods: A mixture of research methods were used
for data collection: audit of 616 consultations and
analysis of 577 patient satisfaction questionnaires.
Audit and questionnaire results were analysed using
descriptive statistics, qualitative comments using a
thematic approach.
Limitations: Information and investigator bias, and
poor piloting and design of the data collection tools
limited the methods used.
Rationale for the service
Suboptimal inhaler use can result in poor condition
control (leading to increased prescribing costs for
reliever inhalers and unnecessary hospital admissions)
as well as medicine waste. Community pharmacists
are taught as part of their undergraduate course about
different inhaler devices and there are examples of
community pharmacy respiratory projects across the
country demonstrating the role of community
pharmacists in optimising inhaled medicine use.
Evaluation Results
Overall Scheme Cost and Period Covered
Total cost of the service from January-March 2014
including initial set-up/training costs and evaluation:
£7561.50
A&E Attendances and Admissions Avoided
The pilot Pharmacy Local Professional Network for
NHS South Yorkshire & Bassetlaw developed a
respiratory support service that ran from September
2012 until the March 2013. Service evaluation found
that community pharmacists helped over 1000 patients
who were not using their inhaler correctly achieve the
optimum IR during one consultation.4
The short time period the service has been running for
make it difficult to identify whether or not the service
has had an impact on A&E attendances/admissions.
Doncaster Local Pharmaceutical Committee (LPC)
secured funding from NHS Doncaster to recommission this service from January to March 2014
using Winter funding. This report provides a summary
of the findings from evaluation of the service.
Previous Inhaler Technique Instruction
Diagnosis
Two-thirds of patients reported asthma as their
condition with nearly a quarter reporting COPD. A
significant minority were unsure of their diagnosis.
Most patients had received previous instruction.
Inhaled Therapy
The majority of patients (82.2%, n=616) were
prescribed a MDI. Sixty percent were using one type of
inhaler only. The range was from 1-3 types.
Community Pharmacy Inhaler Check Service
Patients presenting in the pharmacy to collect a
prescription for an inhaled medicine are targeted for a
consultation with a community pharmacist trained in
the use of the In-Check DialTM device. The consultation
Patient Performance – Inspiration Rate Change
400 patients had an initial inspiration rate out of the
target range for their device. Over 98% of patients
achieved target range by the end of their consultation.
1
MDI inspiration rate results
Patient Questionnaire Results
Patient feedback was positive.
Patient Evaluation
Would recommend service…
Advice given was useful
Use of inhaler has improved
More confident about meds
Understand more about meds
Explained how medicines worked
Understand more about cond
0% 20% 40% 60% 80% 100%
The majority of patients using a MDI were over the
target range regardless of diagnosis.
Percentage
of Patients
Uncertain
Strongly Agree
Agree
Disagree
Strongly Disagree
“Thought I was good using inhalers but learnt a lot
from the pharmacist that will help me” Patient
MDI use and previous inhaler instruction
Recommendations for development/improvement
This service should be continued and developed
further to empower the pharmacist to supply a spacer
with/without mask, include full assessment of condition
control, follow-up consultations to monitor performance
and
outcomes,
see
patients
after
asthma
attacks/exacerbations and develop an exacerbation
management service.
The data collected should be reviewed and recorded
electronically and the tool thoroughly piloted to
improve data collection for future evaluation. The
service should be promoted.
Conclusion
The evaluation demonstrates the need for regular
inhaler technique checks. Many patients had not
achieved optimum IR for their inhaler device on initial
assessment, however the community pharmacists
were able to support almost all these patients to
achieve the optimum IR by the end of their
consultation. Community pharmacists have a key role
in improving inhaler technique and inhaled medicines
use, complying with recommendations made in current
guidelines for asthma and COPD.
A statistically significant relationship (p>0.001) was
found between patients prescribed MDIs not achieving
the optimum IR rate on initial assessment and
reporting that they had not had any previous
instruction.
Condition Control
There were high reports of regular preventer use from
the majority of patients. Almost half of patients
reported needing to use their reliever inhaler once or
twice daily or more, which can be an indicator of poor
condition control.
The service is beneficial to patients and the wider
NHS; improving inhaler use can improve condition
control improving quality of life, reducing hospital
admissions and even deaths, funding should continue.
Interventions Provided by the Pharmacist
References
Sixty-three percent of patients (n=388) were given at
least one intervention by the pharmacist. The most
common intervention provided was inhaler instruction.
There was little need to contact the GP/practice nurse.
1. Royal College of Physicians. Why Asthma Still Kills. NRAD. 2014.
2. NHS. An Outcomes Strategy for COPD & Asthma. NHS 2012. 3.
NHS Doncaster CCG. 4. N.Gray NHS South Yorkshire & Bassetlaw
Community Pharmacy Respiratory Project. 2013 For further
information contact: doncasterlpc@gmail.com
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