Assessment of the effectiveness of a pharmacist approach for improving disease-specific knowledge and treatment in patients with chronic obstructive pulmonary disease

Abstract

Objective

Adequate knowledge is essential for the appropriate management of chronic conditions such as chronic obstructive pulmonary disease (COPD). However, some patients may not be able either to comprehend or obtain adequate information. This study aims to assess the effectiveness of the clinical pharmacist approach to refining disease-specific knowledge in patients with COPD treated in a tertiary care hospital.

Methods

A prospective observational longitudinal study was carried out in adult COPD patients for 9 months in the tertiary care hospital of Pune. At the time of enrolment, disease-specific knowledge of patients with COPD was assessed using the Bristol COPD Knowledge Questionnaire (BCKQ). After the assessment, patients were educated, counselled verbally and provided with a validated COPD information leaflet. The patients’ knowledge was reassessed 1 month and 3 months after enrolment. Pre and post scores of BCKQ were compared by ANOVA followed by Tukey’s post hoc test. The difference in the proportions was calculated using the χ² test.

Results

Of 75 patients, the majority were men (53.33%), aged >60 years (72%), employed (62.67%) and had obtained secondary education (37.33%). The mean baseline BCKQ overall score of the patients was 25.87, which increased after education to 42.43 on the first visit (1 month) and to 45.62 on the second visit (3 months) (p<0.0001). At baseline, the topics 'vaccination', 'inhaled steroids' and 'antibiotics' returned the lowest mean scores of 0.37, 0.38 and 0.60, which were increased to 2.30, 2.70 and 2.72, respectively, after follow-up.

Conclusion

The knowledge of patients with COPD about the disease and its treatment was poor at the time of enrolment. Proper counselling and education provided by the clinical pharmacist helped to improve the patients' knowledge about COPD and its treatment.

Introduction

Chronic obstructive pulmonary disease (COPD) is an important long-term condition characterised by a persistent decline in airflow and increasing breathlessness. It is the fourth leading cause of mortality, and constitutes a major public health challenge.¹ According to different population-based studies, the prevalence of COPD in India varies from 2% to 22% in men and from 1.9% to 19% in women.² COPD is a costly disease, with acute exacerbations being the second leading cause of emergency respiratory hospital admissions with a similar burden worldwide.³ It is also associated with a high burden on morbidity, mortality as well as healthcare and societal costs.⁴

The ideal management of COPD includes appropriate prescribed medication therapies, patient adherence to complex treatment regimens and proper inhaler technique.⁵ WHO studies show that adherence is observed in only 50% of patients with COPD. Factors that predispose to poor adherence include the chronic nature of the disease, complex medication regimen, significant comorbidity and difficulties in handling inhalers. A post-hoc analysis of the Towards a Revolution in COPD (TORCH) trial estimated that patients with >80% adherence had a mortality rate of 11.83% compared with a mortality rate of 26.4% in patients with ≤80% adherence. In addition, a 20% reduction in hospital admissions has also been reported with adherence.⁶ Non-adherence intensifies the acute exacerbation of COPD symptoms, which include impaired quality of life, increased mortality, limitations of daily activities, disease progression, poor lung function, previous admissions, increased risk of readmission and low physical capacity.⁷

Adequate knowledge and understanding about one’s health contributes to better adherence. For efficient management of COPD, the patients themselves should be equipped with a sound knowledge of the disease and its treatment.⁸ Appropriate and systematic education about the disease, its treatment and lifestyle changes aids in the reduction of COPD-related emergency department visits and hospital admissions that can have long-term effects in improving health outcomes in patients with COPD. Patient education is thus an integral element of the COPD management plan.⁹

It has been observed that physicians are not always able to provide patients with detailed counselling about COPD and its treatment, either due to their compact schedules or lack of time to educate each patient individually. Clinical pharmacists are the first point of contact between the patient and healthcare provider. They are well equipped to look at the key areas when dealing with the management of COPD patients—namely, inhalation technique and medication adherence. Pharmacists can provide information on disease awareness and risk prevention, advise on how to recognise an acute exacerbation, and educate on dosage, treatment expectations and vaccination. They can guide patients by instructing them on the appropriate use of inhalers, checking their ongoing technique and intervening when necessary, and can play a vital role in monitoring adherence via routine regular follow-up of patients with COPD. Studies have shown benefits with respect to reduction in hospitalisation rates, increased compliance and improved quality of life.¹⁰

The aim of the study is to assess and improve the disease-specific knowledge and treatment in patients with COPD treated in a tertiary care teaching hospital.

Methods

Study design and setting

A prospective observational longitudinal study was carried out from June 2019 to January 2020 in a tertiary care teaching hospital, Pune. All adult patients with COPD who were attendng for regular follow-up in the pulmonary outpatient department were included in the study. Patients who did not provide consent, who were not ready for follow-up at the centre and those with dementia or terminal illnesses were excluded from the study. Ethical approval was obtained for the study from the ethics committee of Bharati Medical College (BVDUMC/IEC/78). The patients were recruited according to the inclusion criteria. Informed consent of patients was obtained before initiating the study. Patient enrolment is shown in the flow chart in figure 1.

Figure 1.

Enrolment of participants in the study.

Data collection

During enrolment the patients' demographic details including past medication and medical history, COPD maintenance medication, history of hospitalisation and reason for hospitalisation were collected and noted in the self-predesigned COPD patient proforma.

Assessment of COPD knowledge

At the time of enrolment the patient’s baseline COPD knowledge was assessed by the Bristol COPD Knowledge Questionnaire (BCKQ).¹¹ After collecting complete baseline data and questionnaires, the patient was educated (20–30 min) and provided information about disease and the importance of their treatment to improve their knowledge which was then evaluated during consecutive follow-ups or at each clinic visit. A validated COPD patient information leaflet was distributed to the patients. After an initial period of 1 month and then after 3 months, patients' knowledge was reassessed. The difference in the score attained from the questionnaires was recorded at each visit.

Study instrument

The assessment of COPD knowledge was measured using the BCKQ, after obtaining permission to use it. The BCKQ is a 65-item instrument used to check the level of knowledge and understanding of COPD and treatment. The questionnaire encompasses 13 knowledge topics, with five statements for each topic giving a total of 65 questions. The topics covered are (1) epidemiology, (2) aetiology, (3) symptoms, (4) breathlessness, (5) phlegm, (6) infections, (7) exercise, (8) smoking, (9) vaccination, (10) inhaled bronchodilators, (11) antibiotics, (12) oral steroids and (13) inhaled steroids. For each statement there are three response options: 'true', 'false' and 'don’t know'. A correct answer scores one point while an incorrect answer or 'don’t know' scores zero points. Therefore, each topic has a score ranging from 0 to 5, and the total score which sums up the scores of all 13 topics ranges from 0 to 65.¹¹

Statistical analysis

Frequency and descriptive statistics were used to analyse the general characteristics of the patients. Data were represented in tables and figures. The difference in the mean BCKQ scores between the groups (baseline, 1 month and 3 months) was compared by ANOVA followed by Tukey’s post hoc test. The difference in the proportions was calculated using the χ² test. A p value <0.05 was considered significant.

Results

The majority of the 75 patients recruited were men (53.33%), aged >60 years (72%), employed (66.66%) and had received secondary education (37.33%). Most of the patients lived in urban areas (74.67%). The onset of COPD in these patients was mainly due to exposure to Chula smoke (34.67%). Around 83.33% of patients were ex-smokers (table 1).

Table 1.

Sociodemographic characteristics of study patients

Characteristics	Number of patients (N=75)	percentage
Gender
Men	40	53.33
Women	35	46.67
Age in years
<40	4	5.33
40–49	8	10.67
50–59	9	12.0
60–69	29	38.67
≥70	25	33.33
Literacy status
Uneducated	25	33.33
Primary education	11	14.67
Secondary education	28	37.33
Graduate	11	14.67
Occupation
Employed	50	66.66
Unemployed	25	33.33
Area of residence
Urban	56	74.67
Rural	19	25.33
Exposure to COPD risk factors
Current smoker	3	16.67
Ex-smoker	15
Never	57
Exposure to indoor biomass smoke	26

The most frequently used route of administration in patients was inhalation (100%). Among the different types of inhalation devices, metered dose inhalers were most commonly used (68%).

The percentage of patients giving correct responses for all 65 items and 13 topics is shown in table 2. Among the 13 topics, at baseline the topics 'symptoms' and 'phlegm' had the highest correct responses (78.4% and 71.6%, respectively), which increased to 94.4% and 85.6%, respectively, at the first follow-up and to 99.6% and 93%, respectively, at the second follow-up. The topics 'vaccination', 'inhaled steroids' and 'antibiotics' had the lowest correct responses at baseline (7.4%, 7.6% and 12%, respectively), which increased to 30.8%, 21.8% and 30.6%, respectively, at the first follow-up visit and to 46%, 54% and 54.4%, respectively, at the second follow-up (table 3).

Table 2.

Percentage of patients giving correct responses for all 65 items and 13 topics

Question no	Topics	Baseline	First follow-up 1 month	Second follow-up 3 months
1	Epidemiology	39.2	82	90
2	Aetiology	59.2	80	99.2
3	Symptoms	78.4	94.4	99.6
4	Breathlessness	44	92	95.8
5	Phlegm	71.6	85.6	93
6	Infections	52.2	72.2	84.6
7	Exercise	60	84	89
8	Smoking	37.6	56.4	75.2
9	Vaccination	7.4	30.8	46
10	Inhaled bronchodilators	32	65	88
11	Antibiotics	12	30.6	54.4
12	Oral steroids	23.4	45.8	78.6
13	Inhaled steroids	7.6	21.8	54

Table 3.

Average score of Bristol COPD Knowledge Questionnaires (BCKQ)

Question no	Topics	Baseline (mean±SD)	First follow-up (mean±SD)	Second follow-up (mean±SD)
1	Epidemiology	1.96±1.23	4.10±0.84	4.5±0.55
2	Aetiology	2.96±0.89	4.00±0.46	4.96±0.19
3	Symptoms	3.92±1.23	4.72±0.56	4.98±0.11
4	Breathlessness	2.20±1.23	4.60±0.88	4.79±0.55
5	Phlegm	3.58±1.45	4.28±0.74	4.65±0.50
6	Infections	2.61±1.10	3.61±0.69	4.23±0.66
7	Exercise	3.00±1.46	4.20±0.18	4.45±0.55
8	Smoking	1.88±1.10	2.82±0.96	3.76±0.81
9	Vaccination	0.37±0.88	1.54±0.82	2.30±0.56
10	Inhaled bronchodilators	1.60±1.24	3.25±0.88	4.40±0.78
11	Antibiotics	0.60±1.03	1.53±1.12	2.72±0.87
12	Oral steroids	1.17±1.03	2.29±0.83	3.93±0.47
13	Inhaled steroids	0.38±0.54	1.09±0.66	2.70±0.45

The mean BCKQ overall score of all the patients at baseline was 25.87. At baseline, the topics 'vaccination', 'inhaled steroids' and 'antibiotics' had the lowest mean scores of 0.37, 0.38 and 0.60, respectively, which increased after education to 2.30, 2.70 and 2.72, respectively (figure 2 and table 4).

Figure 2.

Bristol COPD Knowledge Questionnaire scores.

Table 4.

Comparison of Bristol COPD Knowledge Questionnaire (BCKQ) score on each visit

BCKQ	Average BCKQ score (mean±SD)	P value
Baseline	2.01±0.24	<0.0001*
First visit (1 month)	3.23±0.23
Second visit (3 months)	4.02±0.21
Tukey’s post hoc test Baseline vs first visit (1 month): p<0.0001* Baseline vs second visit (3 months): p<0.0001* First visit (1 month) vs second visit (3 months): p<0.0001*

*Statistically significant.

The BCKQ score differed significantly (p<0.0001) between baseline, first visit (1 month) and second visit (3 months). Tukey’s post hoc test showed the exact difference in mean values between any two groups; a significant increase (p<0.0001) was seen at the first visit (1 month) and at the second visit (3 months) compared with the baseline value. Also, the score at the second visit (3 months) was significantly higher (p<0.0001) than the score at the first visit (1 month).

Discussion

COPD is a chronic condition posing a heavy burden and expenditure on the healthcare system worldwide.¹² In our study, in the 75 patients enrolled there was a predominance of men (53.33%) compared with women, which is consistent with the observations in the study conducted by Ansari et al and in other studies.^13–19 Plausible explanations for this can be attributed to men being more vulnerable to risk factors such as tobacco smoking, occupational exposures and outdoor air pollution. However, contrary to this, Turner et al and various other studies have reported that there is a higher prevalence of COPD in women, and that the most commonly affected population is housewives (30.67%) where onset could be accredited to prolonged exposure to indoor air pollution and burning of biomass fuels on unimproved stoves (34.67%).^20–23

The majority of the patients enrolled were in the age group 60–69 years (38.67%), which is similar to the population in the study conducted by Wong and Yu.⁹ Ageing brings a number of physiological changes; forced expiratory volume in one second and forced vital capacity decrease with age. In addition, ageing is also associated with immunosenescence and inflammation. These two factors underlie most age-associated diseases and are important when considering the development of COPD in older individuals.²⁴

Although it is a known fact that smoking is a primary risk factor for COPD, the majority of patients enrolled in our study were non-smokers (76%). Most non-smokers have exposure to environmental factors like dust or fumes in the home or workplace or asthma comorbidity.7 17 25–27 Terzikhan et al confirm that the detection of COPD cases in non-smokers is due to risk factors such as genetic susceptibility, impaired lung growth and respiratory infections.²⁸

The education status of the majority of patients was low and was confined to secondary education (37.33%), which may in turn hamper their existing health condition due to improper understanding of the disease. Roberts et al also agree with this finding by stating that low literacy status leads to a poorer understanding of the disease and worse health status.²⁹ Education enhances an individual's effectiveness, reasoning, rational understanding, knowledge, skills and other abilities that enable a person to contemplate their health.^{30 31}

Self-management in patients with COPD is recommended by national guidelines to improve their health-related quality of life and reduce avoidable inpatient admissions.⁴ For a successful self-management plan, the patients themselves should be equipped with a sound knowledge of the disease and its treatment.⁹

The BCKQ tests the knowledge and understanding that is appropriate for patients with COPD and can be used as an assessment tool for individual patients or as a broad cross-sectional survey instrument.¹¹ According to our findings, maximum knowledge on the BCKQ was seen in the topics ‘symptoms’ and ‘phlegm’, which agrees with the findings of Wong and Yu.⁹ On recruitment of patients for baseline data, a lower level of knowledge was observed in the topics 'vaccination', 'inhaled steroids', 'antibiotics', 'oral steroids' and 'inhaled bronchodilators' with mean scores of 0.37, 0.38, 0.60, 1.17 and 1.60, respectively. This was in agreement with the studies conducted by Zhang et al and White et al where infections, vaccinations and inhaled steroids were found to have the lowest knowledge and awareness.^{11 32} Several studies have speculated that gaps in knowledge about vaccination are crucial and adequate counselling and informative sessions have dramatic positive outcomes.^33–35 Inadequate knowledge about chronic illnesses such as COPD is indicative of inadequate health literacy and also depicts strong correlations of the knowledge level with health literacy among patients with COPD.⁹ Sparse and less knowledge in such patients can be attributed either to the lack of time or proper attention given by physicians due to a large number of patients. Patients obtain most of their knowledge of their disease and treatment from their physician. Most health professionals are not aware of their patients' low health literacy levels or that most patients are too embarrassed to indicate to their healthcare providers that they have not understood their instructions. Furthermore, there are various obstacles to conveying health information such as literacy, culture, language and physiological barriers.³⁶ Cultural background impacts on how one comprehends the knowledge provided to patients based on their belief system, communication styles and understanding the response to health information. People with low education status have a lower likelihood of understanding the basic health information provided, medical labels and instructions. The utilisation of information may also vary among urban and rural residents due to poor educational background, the social stigma of addressing the issue, the digital divide and reduced accessibility to healthcare services. Intervention by a pharmacist is reported to be highly cost-effective with both savings on total costs and gains in effects.⁴ The urgent need in the area of education by other healthcare providers such as pharmacists was found to be mostly in the uneducated population in rural areas where a low knowledge level is prevalent.

Intervention by a pharmacist is reported to be highly cost-effective with both savings on total costs and gains in effects. A clinical pharmacist can aid in establishing an integrated approach that facilitates increased contact time with COPD patients, which is beneficial for effective execution of COPD management strategies. Brief education and counselling sessions that are individually tailored and focused on COPD, medications, effective use of inhalers, steroids, vaccinations, lifestyle changes and the impact of COPD on the overall functioning and health-related quality of life have been shown to have beneficial outcomes.³³ Previous studies on pharmacist-led interventions in COPD and other patient outcomes have been explored and the findings are summarised by Hudd et al. These studies show various patient-related outcomes such as reduction in hospital visits, hospital stay, length of hospital stay and drug-related readmissions along with reduction in patients aged >80 years. These studies also suggest that a considerable number of patients have achieved total smoking cessation and a significant improvement in inhaler techniques.³⁷Also, several studies have shown the pharmacist’s assistance to be non-negotiable in persuading better clinical and patient care outcomes.1 6 10 38

After education, evaluation done on consecutive visits showed a subsequent increase in knowledge. Khan et al and White et al report similar findings and found that a high proportion of patients reported satisfaction with the level of information provided about their medication.^{4 11} It was also found that there was a statistically significant increase in the first and second visits compared with baseline, and a significant increase at the second visit compared with the first. Wong and Yu contradict this by reporting a marked overall deficiency of knowledge about the disease among patients with COPD which did not appear to improve after administering the BCKQ to the patients. Limited studies on the use of the BCKQ scale have been conducted in India, and more research is needed owing to its significance.⁹

Conclusion

This study emphasises the effectiveness of a pharmacist-based approach in enabling patients with COPD to understand their disease conditions and treatment. During enrolment to the study, the knowledge of their disease and treatment by patients with COPD was poor. Patients were unaware of vaccination, inhaled steroids and antibiotics. There was a substantial increase in their knowledge at their follow-up visits compared with baseline. Appropriate counselling of the disease is an essential prerequisite to prevent further complications.

What this paper adds.

What is already known on this subject

• Poor understanding of disease usually results in non-compliance with treatment which results in poor treatment outcomes.

What this study adds

• This study investigates the pharmacist approach to counselling patients with COPD about the disease and treatment, which further increases their knowledge and understanding about their condition.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Obtained.

Ethics approval

Ethical approval was granted by the ethics committee of Bharati Medical College (BVDUMC/IEC/78).