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. 2016 Oct 24;25(5):335–342. doi: 10.1111/ijpp.12320

Physician agreement regarding the expansion of pharmacist professional activities in the management of patients with asthma

Audrey Tilly-Gratton 1, Alexandrine Lamontagne 1, Lucie Blais 2, Simon L Bacon 3,4, Pierre Ernst 5,6, Roland Grad 7, Kim L Lavoie 4,8, Martha L McKinney 9, Eve Desplats 10, Francine M Ducharme 1,8,11,✉
PMCID: PMC7938947  PMID: 27774739

Abstract

Background

Asthma control remains suboptimal in Canada. Expansion of pharmacist’s professional activities offers the opportunity to improve the interdisciplinary management of patients with asthma.

Objective

The aim of this study was to determine the level of agreement of physicians regarding the expansion of pharmacists’ professional activities in the management of asthma patients.

Methods

We conducted a survey of randomly selected Quebec physicians in family medicine, paediatrics and emergency medicine. A 102-item questionnaire, including 10 questions regarding pharmacist’s expanded professional activities, was sent using the Tailored Design Method. Questions were answered on a 6-point Likert-like scale (0 — strong disagreement to 5 — strong agreement).

Results

With a 56% response rate, 421 (250 family medicine, 115 paediatric and 56 emergency medicine) physicians participated; the median years of practice (25%, 75%) was 13 (5–21) years and 69% of respondents were women. Physicians were in favour of the expansion of pharmacist’s professional activities with strong endorsement rates (rating of ≥4 on a maximum of 5) exceeding 60% for all but three activities: suggesting a written action plan to the physician (55%), adjusting the dose of prescribed asthma medication to achieve a therapeutic target (52%) and offering spirometry testing in pharmacies (45%). Emergency physicians, physicians with fewer years of practice, and those with a favourable perception of an interprofessional approach were associated with higher endorsement of these activities.

Conclusion

Physicians are favourable to the expansion of pharmacist activities in the management of patients with asthma. More complex activities were less frequently endorsed. The characteristics of strong intenders have been identified.

Keywords: asthma, pharmacist, physician agreement, survey

Introduction

Asthma remains uncontrolled in most patients in Canada and abroad leading to preventable impaired quality of life, acute care visits and a large economic burden.[1,2] National[3] and international guidelines[4–6] regular monitoring of asthma control, patient asthma education, use of written self-management, plans and daily asthma controller medication in individuals with persistent asthma.[3] Yet, only a minority of patients have received asthma education, own a self-management plan, or have benefited from spirometric testing.[7,8] Patient management is clearly improved by a multidisciplinary team approach in the context of a chronic care model. Indeed, interdisciplinary asthma management has been shown to be effective in increasing the possession of a self-management plan, drug adherence, monitoring of lung function via peak flow metres and raising patient quality of life.[9]

As the most accessible primary healthcare professional, pharmacists are uniquely positioned to play a central role in assessing, monitoring and addressing the gap between medications taken and prescribed.[10] Face-to-face pharmacist interventions clearly increase patient adherence to asthma controller therapy.[11] The effectiveness of pharmacy-based education, counselling and monitoring of drug adherence to reduce hospitalisations and improve disease control has been demonstrated in several conditions, including asthma.[12] Led by Australia,[13] Finland[14] and the Netherlands,[15] there is currently a global movement to expand pharmacist’s professional activities beyond drug dispensing and monitoring, towards acting as case managers coordinating asthma care.[16] In Quebec, Canada, as of June 2015 a legal change to the law (bill 41) enables pharmacists to extend a prescription, prescribe medications for minor conditions, prescribe laboratory tests and interpret results.[17] Furthermore, pharmacists may adjust a prescription, more specifically change the form of the drug, dosage, the quantity of drugs and the dose of the medication prescribed to the patients with an established diagnosis. Of note, prescribing of a device including a holding chamber was allowed before Bill 41.[10] Documentation of the incomplete understanding by physicians and pharmacists of each other’s respective roles[18] underscores the need to strengthen communication for the successful expansion of pharmacists’ activities. Moreover, while physicians have requested greater interdisciplinary approaches for the management of asthma,[19] few studies have focused specifically on physician’s perception of pharmacists taking an enhanced role in shared patient asthma management.

The objective of this study was to ascertain physicians’ level of agreement regarding the expansion of pharmacist’s professional activities in the management of patients with asthma and to identify potential determinants of physician perception.

Methods

The study design was a quantitative survey of physicians in the Province of Quebec. The research project was approved by the research ethics board of Sainte-Justine University Health Centre who waived consent of this low-risk study, considering that completing the questionnaire attested to the participants’ consent. The study was endorsed by the Institut national d'excellence en santé et services sociaux (INESSS), the Association des pédiatres du Québec, the Association des spécialistes en médecine d'urgence du Québec and the Fédération des médecins omnipraticiens du Québec.

The main survey has been published elsewhere.[20] Briefly, physicians were eligible if they were registered in July 2013 as family physicians, paediatricians, or emergency physicians with the Collège des médecins du Québec and held an active practice licence. A stratified random sample of physicians from each of these three specialties was invited to participate. Physicians were excluded if they were in training, not practicing, not seeing patients with asthma, or participated in the pre-test of the study documents or had obtained their diploma more than 30 years ago; the latter criteria meant to exclude physicians most likely to be retired by the time an asthma-specific intervention would be funded to be tested.

A questionnaire was developed based on the results of a qualitative study in which 42 physicians were interviewed individually to identify physician-proposed facilitators to promote the optimal asthma management.[19] The 102-item questionnaire pertaining to asthma management included questions about physician demographics, practice characteristics, beliefs, knowledge, reported behaviour, perceived facilitators to and comfort level regarding, the prescription of long-term inhaled corticosteroids (ICS), and 10 questions on the expansion of the pharmacist’s role as it would apply to the management of patients with asthma. The latter questions were revised and approved by two pharmacists members of the Ordre des pharmaciens du Québec. Each question was answered on a 6-point Likert-like scale (0 – strongly disagree to 5 – strongly agree; Table 1). Based on the Tailored design method, we mailed an invitation letter followed[21] by the questionnaire with 25$ in compensation, a thank you/reminder postcard, and for non-respondents, a second questionnaire was mailed, followed by up to three phone calls.

Table 1.

Questions regarding physicians’ endorsement of pharmacists’ expanded professional activities

I am comfortable with the professional activities of pharmacists enabling them to: Strongly disagree Strongly agree
Prescribe a holding chamber if omitted 0 1 2 3 4 5
Extend my prescription of inhaled corticosteroids if it has expired (for a maximal period equivalent to my initial prescription, or until a maximum of 12 months) while ensuring a medical follow-up 0 1 2 3 4 5
Prepare a written action plan for the patient according to my prescription 0 1 2 3 4 5
Prescribe medications to treat certain minor conditions associated with asthma (e.g. allergic rhinitis), its treatment (e.g. oral moniliasis) and to help smoking cessation 0 1 2 3 4 5
Adjust the form (Diskus versus metered-dose inhaler) or the posology (frequency per day) of a prescribed medication to facilitate the patient’s compliance 0 1 2 3 4 5
Manage the monitoring of my patient’s medication therapy (effectiveness, safety, adherence) and notify me if necessary in the event of a problem 0 1 2 3 4 5
Adjust the dosage of a prescribed medication to ensure the patient’s safety (e.g. to decrease side effects of a medication) 0 1 2 3 4 5
Suggest me a written action plan for my patient in the context of a pharmaceutical opinion 0 1 2 3 4 5
Adjust the dose of a prescribed medication to achieve therapeutic targets agreed with me (e.g. spirometry values, symptoms’ control), while notifying me of any changes within a reasonable amount of time 0 1 2 3 4 5
Offer pulmonary function tests (e.g. spirometry) in the pharmacy to monitor my patient’s therapy 0 1 2 3 4 5
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A sample size of 500 physicians was required to obtain a 95% confidence interval of ±0.10 for endorsement proportions of 50%, with increasing precision for endorsements below or above 50%. Aiming for a sufficient number of respondents in each specialty to explore between-specialty differences, we performed a stratified sampling on specialty, over-sampling paediatricians and emergency physicians compared to family physicians. Assuming a 60% response rate, we aimed to send questionnaires to 800 physicians.

The distribution of endorsement of pharmacists’ new professional activity was reported as the median (25%, 75%), after adjustment for the stratified sampling by specialty that is greater weight was given to the responses of family physicians (91%), than those of paediatricians (7.6%) and emergency physicians (1.4%), to reflect the actual distribution of these specialties in the Province of Quebec. We displayed results with diverging stacked bars charts. We classified physicians as being in strong agreement if they responded 4 or 5 on the 6-point scale (0 to 5). We further explored physician characteristics to identify possible determinants for low levels of endorsement of pharmacist’s professional activities and used bivariate and multivariate logistic regression models to identify potential determinants of the responses. As sampling was stratified by specialty, specialty was forced into all models. Potential determinants included: physician demographics, practice characteristics, as well as comfort level about, hesitation level regarding and perception of proposed facilitators to, the initiation of long-term ICS. All tests were two-sided with estimates presented with 95% confidence intervals. Analyses were performed on SAS software (version 9.3, SAS Institute Inc. Cary, NC 27513, USA). An odds ratio (OR) with a 95% confidence interval between 0.9 and 1.1 was deemed indicative of equivalence. P-values <0.05 indicated statistical significance, with no correction for multiple testing.

Results

Of the 838 surveyed physicians, 90 were ineligible. Of the remaining 748 potentially eligible physicians, 421 (56%) completed the questionnaire, namely 250 family physicians, 115 paediatricians and 56 emergency physicians. Non-respondents were similar to respondents in practice setting (urban versus rural) and specialty, but differed significantly in sex (43% versus 31% males, P < 0.001) and years of practice (20 versus 13, P < 0.001). Respondents were predominantly female, in family medicine, and in practice for a median of 13 (5–21) years.

Physicians were generally in favour of the 10 proposed expansions of pharmacists’ professional activities. High agreement, that is a rating of 4 or 5, varied between 100% and 60% (Figure 1). Most (≥60%) physicians showed high agreement for pharmacist’s prescribing a holding chamber, extending an expired prescription of ICS, preparing a written action plan following physician’s recommendations, adjusting the form or posology of a prescribed medication, prescribing medications for minor conditions associated with asthma, monitoring of medication with communication of information to physician, and adjusting dosage to ensure patient’s safety. However, less than half of physicians were in high agreement with pharmacists proposing to physicians an action plan, adjusting dosage of a prescribed medication to achieve therapeutic targets, and offering in-pharmacy pulmonary function tests.

Figure 1.

Figure 1

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Physician’s level of agreement regarding the expansion of pharmacists professional activities. This histogram depicts the physicians’ endorsement of each pharmacist’s professional activities on a 6-point Likert scale ranging from 5 indicated strong agreement (vertical bars); 4, (diagonal grey bars), 3 (white), 2 (light grey), 1 (medium grey) to 0 indicating strong disagreement (black). The proportion of participants with strong endorsement, that is, answering 4 or 5, is identified by a dark box in the histogram and displayed in the right column.

Determinants of high physician agreement with the three least endorsed activities are displayed in Tables 2, 3 and 4. In all cases, those in high agreement were more likely to be emergency physicians than family physicians, whereas paediatricians were least likely to be comfortable with pharmacists’ expanded roles. Every additional year of practice reduced, by 4–5%, the likelihood of physicians showing high agreement. Those in practice for a shorter period were more enthusiastic. Physicians in high agreement with pharmacists suggesting to them an action plan in the context of pharmaceutical opinion, were also significantly more likely to believe that a paramedical health care professional explaining the action plan increased patients’ adherence to long-term ICS (Table 2). Those in high agreement with pharmacists adjusting the dosage of a prescribed medication to achieve agreed upon therapeutic targets were also more likely to have access to a paramedical healthcare professional providing on-site asthma education (Table 3). Finally, physicians who identified access to oscillometry in preschool children as an important facilitator to prescribe long-term ICS were 22% more likely to be highly favourable to pharmacists offering pulmonary function testing for therapy monitoring (Table 4).

Table 2.

Determinants of physician agreement with pharmacists suggesting to physicians a written action plan for their patient

Determinants High agreement* (N = 205) No to fair agreement* (N = 215) Odd ratios† (95% CI)
Years of practice – Median (25–75%) 9.0 (4.0–20.0) 16.0 (8.0–23.0) 0.95 (0.93–0.97)
Specialty – n (%)
Family medicine 137 (60.9) 112 (57.4) Reference
Paediatrics 49 (21.8) 66 (33.9) 0.57 (0.36–0.91)
Emergency medicine 39 (17.3) 17 (8.7) 2.26 (1.20–4.56)
Physician believing access to paramedical increases compliance to long-term ICS – Median (25–75%) 5.0 (4.0–5.0) 4.0 (4.0–5.0) 1.32 (1.01–1.73)
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*

‘High agreement’ refers to responses of 4 or 5 and ‘no to fair agreement’ refers to rating of 0 to 3 on the 6-point Likert scale (0-strong disagreement to 5-strong agreement).

†

Odds ratio adjusted for years of practice, specialty, and access to a paramedical healthcare professional providing patient guidance.

Table 3.

Determinants of physician agreement with pharmacists adjusting the dose of a prescribed medication to achieve agreed-upon therapeutic targets

Determinants High agreement* (N = 205) No to fair agreement* (N = 215) Odd ratios† (95% CI)
Years of practice – Median (25–75%) 11.0 (4.0–20.0) 16.0 (7.0–23.0) 0.96 (0.94–0.98)
Specialty – n (%)
  Family medicine 130 (63.4) 119 (55.4) Reference
  Paediatrics 43 (21.0) 72 (33.5) 0.51 (0.32–0.84)
  Emergency medicine 32 (15.6) 24 (11.2) 1.21 (0.65–2.24)
Physician’s access to a paramedical on-site providing asthma education – n (%)
  Yes 126 (61.5) 101 (47.0) 1.74 (1.13–2.08)
  I don't know 14 (6.8) 14 (6.5) 0.94 (0.41–2.14)
  No 65 (31.7) 100 (46.5) Reference
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*

‘High agreement’ refers to responses of 4 or 5 and ‘no to fair agreement’ refers to rating of 0 to 3 on the 6-point Likert scale (0-strong disagreement to 5-strong agreement).

†

Odds ratio adjusted for years of practice, specialty, and access to a paramedical healthcare professional providing patient guidance.

Table 4.

Determinants of physician's level of agreement with pharmacists offering pulmonary function tests in the pharmacy

Determinants High agreement* (N = 205) No to fair agreement* (N = 215) Odd ratios† (95% CI)
Years of practice – Median (25–75%) 9.0 (4.0–20.0) 16.0 (7.0–23.0) 0.95 (0.93–0.98)
Specialty – n (%)
  Family medicine 112 (61.5) 137 (57.6) reference
  Paediatrics 42 (23.1) 73 (30.7) 0.66 (0.40–1.10)
  Emergency medicine 28 (15.4) 28 (11.8) 2.05 (0.99–4.25)
Physician’s comfort to prescribe long-term ICS when access to oscillometry (children age 3–6 years) – Median (25–75%) 4.0 (3.0–5.0) 4.0 (3.0–5.0) 1.22 (1.03–1.43)
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*

‘High agreement’ refers to responses of 4 or 5 and ‘no to fair agreement’ refers to rating of 0 to 3 on the 6-point Likert scale (0-strong disagreement to 5-strong agreement).

†

Odds ratio adjusted for years of practice, specialty, and access to a paramedical healthcare professional providing patient guidance.

Discussion

In this large survey, a large proportion of physicians were in high agreement with most expanded pharmacist professional activities. However, three practice fields, namely the suggestion of an action plan to physicians, adjustment of medication dosage to achieve therapeutic target and offering in-pharmacy lung function tests were least endorsed.

We acknowledge the following limitations. With a 56% response rate of potentially eligible physicians, we recognise the possibility that participants may not be representative of the entire population of targeted physicians since we did not reach the sample size. Despite a similar representation of specialties and practice settings, women and young physicians were overrepresented among respondents. Social desirability bias[22] may have contributed to overestimating the mean endorsement, although the survey that first asked questions regarding the management of the patient depicted in the clinical vignette before questions about knowledge, beliefs and self-efficacy should have lessened such bias. As the survey was conducted prior to implementation of the law expanding pharmacist professional activities, physicians had no or little prior experience with these new opportunities for interprofessional management. A follow-up survey might be of value to assess changes in perception after first-hand experience with enactment of new activities.

Our survey showed high physician acceptance of pharmacists’ monitoring of therapy, an approach associated with increased drug adherence.[23,24] Physicians also strongly endorsed pharmacists’ prescribing a holding chamber, medications to treat minor conditions and smoking cessation aids; this is supported by the proven benefit of pharmacists’ interventions in asthma care on inhaler technique, quality of life and asthma control,[9,25,26] renewing or extending of the ICS prescription as well as adjusting its form and posology were also highly accepted. Recognising that a key reason for suboptimal ICS use is the insufficient number of renewals authorised by physicians,[27,28] pharmacists’ renewal of asthma controller drugs has the potential to increase the use of maintenance ICS. There is thus strong agreement with most pharmacists’ professional activities already in practice in several Canadian Provinces and abroad.[29,30]

The three activities receiving the lowest endorsement were more complex in nature and traditionally restricted to physicians. Although written action plans are effective to increase adherence and asthma control,[31] barely a third of patients with asthma have one,[7] a situation associated with preventable emergency department visits and hospital admissions.[32] While most physicians were in favour of pharmacists writing an action plan according to their prescription, fewer, albeit still more than half, were in agreement with pharmacists suggesting an action plan to the physician in the context of a pharmaceutical opinion. Physician’s resistance to welcoming such suggestion should be explored.

Dose adjustment to achieve a therapeutic target hinges on the comprehensive assessment of asthma control (including history, physical examination and lung function) interpreted in light of patient adherence, inhalation technique, environmental factors and co-morbidities.[6,33] While pharmacists could certainly be trained to ascertain many of these factors,[34] clinical examination is often essential to diagnose co-morbidities and monitor certain adverse effects, and lung function testing is important to provide objective documentation of control and treatment response. Physicians’ lower endorsement of this activity may reflect these concerns. Of interest physicians who reported working with a paramedical healthcare professional were significantly more favourable to this activity, perhaps because in Quebec, it is usually a nurse or respiratory technician with recognised skills for medical examination and lung function interpretation.[35]

Despite guidelines recommending spirometry at each visit to complement the clinical assessment of asthma control,[6,36] objective lung testing remains underused by physicians even when accessible.[8] Our study suggests that a pharmacy-based asthma management programme including spirometry,[37] would be particularly welcomed by physicians recently in practice, emergency physicians and those recognising the importance of lung function for preschoolers, in whom the diagnosis and assessment are most challenging. An intervention in which pharmacists were trained to perform and interpret lung function was effective in enhancing medication adherence, quality of life and asthma control in adults with asthma.[9] Such programme may thus markedly increase access to, and monitoring with, lung function testing, an valued option to bridge the actual care gap. Perhaps, the observed resistance to pharmacy-based lung function testing relates to physicians’ low perceived usefulness of spirometry and their own discomfort in its interpretation.[8]

Of interest, physicians recently in practice and emergency physicians showed the strongest endorsement to the three least endorsed professional activities. Other factors, such as academic or community practice setting were not significantly associated with endorsement. Paediatrician’s resistance might be associated with the greater challenges to accurately assess control and manage asthma in the growing child including physical examination, third-party reporting of symptoms, variety of phenotype classifications and worry about ICS adverse effects requiring regular growth monitoring. In contrast, as emergency physicians recognise the importance of prescribing long-term asthma controllers[38] and the benefit of a follow-up visit on patient adherence,[39] as their practice setting is not conducive to offering follow-up, a situation that may explain their strong interest in an interdisciplinary approach.[40] Finally, an enhanced focus on interprofessional collaboration adopted in several medical schools may explain the improved collaborative attitude among younger physicians.[41]

Our findings reflect the views of Quebec physicians practicing in a publicly funded health setting where patients are insured for their medications, either publically or privately, and have access to medical care. While they may be applicable across Canada, replication in other countries is recommended due to expected variations in pharmacy and medical practices, drug insurance, and access to, and training of, allied health care professionals.

Conclusion and implications

In light of the recently legislated expansion of pharmacist professional activities, most Quebec physicians were highly favourable to interprofessional asthma management, for all but three activities. Least endorsed tasks include pharmacists suggesting an action plan to physicians, making treatment adjustment to achieve therapeutic targets and offering lung function tests in pharmacy. As a formal evaluation of the impact of the new legislation is needed, the implementation process and impact of these latter expanded activities would require careful attention in view of lower medical endorsement.

Declarations

Conflict of interest

The Authors declares that they have no conflicts of interest to disclose.

Funding

This work was funded through a research grant (no 233813) of the Canadian Institutes of Health Research (CIHR). Audrey Tilly-Gratton received a summer research bursary from the COPSE program of the University of Montreal.

Acknowledgements

We acknowledge the support of the Fonds de la Recherche du Québec en Santé for the infrastructure support provided to the Research Institutes of the Centre Hospitalier Universitaire Sainte-Justine (CHUSJ). We are indebted to the Lucie Bergeron and Johanne St-Pierre for providing the list of the College des médecins du Québec, Thierry Ducruet for preparing the randomisation list and Katia Lessard, Bhupendrasinh Chauhan and Annie Théorêt for assisting with the mailing of questionnaires and phoning of participants and for assistance in manuscript preparation.

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