Provision of Primary Care to Patients with Chronic ...

INTERNATIONAL REPORTS Provision of Primary Care to Patients with Chronic Cough in the Community Pharmacy Setting Carl R Schneider, Alan W Everett, Elizabeth Geelhoed, Peter A Kendall, Kevin Murray, Peter Garnett, Mariam Salama, and Rhonda M Clifford

hronic cough is a symptom experienced by between 9% and 33% of BACKGROUND: Community pharmacies are at the forefront of primary care people within the last year.1 While acute providers and have an important role in the referral of patients to a medical cough (defined as 8 weeks’ duration) medically refer patients with a chronic nonproductive cough. may be caused by an underlying condiMETHODS: Following ethics approval, a simulated patient study of 156 community tion such as asthma, gastroesophageal repharmacies in Perth, Western Australia, was conducted over a 3-month period. flux disease, rhinosinus diseases (also reSimulated patients presented to the pharmacy requesting treatment for a cough. ferred to as postnasal drip syndrome); adThe simulated patient required a referral based on a designated scenario. verse effects of angiotensin-converting Demographic details, assessment questions, and advice provided were recorded by the simulated patient immediately postvisit. A logistic regression analysis was enzyme inhibitors; and smoking.2,3 British performed, with referral for medical assessment as the dependent variable. and American guidelines currently exist RESULTS: Of the 155 community pharmacies included in the analysis, 38% for the treatment of chronic cough that inprovided appropriate medical referral. Cough suppressants were provided as corporate both the primary and secondary therapy in 72% of all visits. Predictors of medical referral were assessment of care setting.4-6 symptom duration, medical history, current medications being taken, frequency of The 1978 Declaration of Alma-Ata reliever use, and the position of the pharmacy staff member conducting the states that primary health care is “the consultation. A third of community pharmacies provided appropriate primary care by recommending medical referral advice to patients with chronic cough. The first level of contact of individuals, the majority of pharmacy staff members acquired information from the patient that family and community with the national suggested a need for medical referral, yet did not provide referral advice. 7 health system.” Australian community CONCLUSIONS: Appropriate medical referral is more likely when adequate assesspharmacies are well positioned to proment is undertaken and when a pharmacist is directly involved in the consultation. vide primary health care. Pharmacy proThis highlights the need for pharmacies to ensure that processes are in place for fesses to be the most accessible healthpatients to access the pharmacist. care provider in Australia, with approxiKEY WORDS: asthma, cough, counseling, pharmacy, simulated patient. mately 5000 community pharmacies Ann Pharmacother 2011;45:402-8. nationwide having no appointment rePublished Online, 15 Feb 2011, theannals.com, DOI 10.1345/aph.1P514 quired for a consultation.8 The 1978 Declaration of Alma-Ata also states that primary health care “should be refer patients to other appropriate health professionals sustained by integrated, functional and mutually supportive 7 when their medical condition so warrants.9 referral systems.” The Pharmaceutical Society of Australia Pharmacy literature recommends that community pharendorses this view by advising community pharmacists to macy perform a primary health-care function for all cough presentations by symptomatic treatment of acute cough and provision of referral advice to patients with a chronic Author information provided at end of text.

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cough for medical review.10-13 However, published evidence that community pharmacy provides consistent and effective referral to other health-care providers is lacking. The aim of this research was to assess the ability of community pharmacy staff to recognize and refer patients with a chronic nonproductive cough for treatment. The specific objectives were to assess the ability of community pharmacy staff to identify a (chronic) cough requiring referral, measure the rate of referral to a medical practitioner for review, and determine factors that correlate with medical referral. Methods Ethics approval for the research was obtained from the University of Western Australia Human Research Ethics Committee. Consent was also obtained from the Pharmaceutical Council of Western Australia (PCWA) in its dual role as regulatory authority for pharmacy practice in Western Australia and as the professional body representing pharmacists and pharmacy practice in Western Australia. SETTING

The study was conducted in conjunction with our previously published study and used the same simulated patient methodology.14 Briefly, simulated patient methodology uses individuals who are trained to mimic patients through presentation of a scenario. The methodology is an established technique for examining pharmacy practice behavior.15 Pharmacies were visited between March and May 2007. Exclusion criteria were pharmacies that were included in a pilot study, potentially had prior knowledge of the study, did not supply nonprescription medication to the public, and were unable to be located according to contact details supplied by the PCWA. Every other pharmacy was allocated to the study from the resulting list of pharmacies (n = 316), organized by postal code. The sample selected

(n = 156) represented greater than 40% of the pharmacy population in Perth, Western Australia. SIMULATED PATIENTS

Researchers (N = 4) posing as simulated patients presented to a pharmacy asking, “Could I please have something for a cough?” (Table 1). The simulated patients did not provide further information unless requested by the pharmacy staff member. Subsequent information provided (on request) was that the individual was suffering from a chronic, nonproductive, nocturnal cough that had been present for “a couple of times a week” for “a couple of months.” The patient was using an asthma reliever (salbutamol) inhaler twice a day, with benefit. The appropriate outcome was determined to be referral for treatment, as the cough had been present for over 3 weeks.10,11 An additional reason for referral was that the symptoms were consistent with uncontrolled asthma (reliever use twice a day) according to the Global Initiative of Asthma guidelines.16 The simulated patients were trained via roleplay to perform the scenario in a consistent manner and practice the collection of data by filling out the data collection form immediately after the visit. The form (available from corresponding author) was the same as that used in our previously published work and was based on a data collection form developed by Berger and colleagues.17 The simulated patients conducted a pilot study (N = 8 pharmacies) to test the content and delivery of scenario. The results of the pilot study were reviewed by the primary author to ensure consistency in the collection of data by the simulated patients. DATA ANALYSIS

The data from the collection form were entered into a Microsoft Access database. Descriptive statistics were used to report data for demographics, assessment, and advice provided. A logistic regression analysis was conduct-

Table 1. Scenario Description Simulated patient enters the pharmacy and asks: “Could I please buy something for my cough?” The pharmacy staff member is provided the following information, only upon questioning: Pharmaceutical Society of Australia assessment information9: Who is the patient? The request is for himself/herself. What are the symptoms? Dry cough; wake up at night with it every now and then. How long have they had them? Maybe a couple of months or so. What treatment/s have they tried for these symptoms/How effective were they? Haven’t tried anything. Do they have any other medical conditions? Asthma. Additional information: Asthma has been getting worse. They are currently using their reliever medication twice a day to relieve asthma symptoms. The last time they have seen a physician was “ages ago” and they have not been admitted to a hospital with asthma before. Do not have a written Asthma Action Plan. Outcome: Determine the patient’s cough as being due to worsening asthma control. Advise patient to visit medical practitioner for assessment of asthma.

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ed using an information theoretic model selection approach, which enabled assessment of all potential models for best fit. Patient referral to a medical practitioner was used as the dependent variable. Independent demographic variables considered in the analysis were pharmacy type and location, sex of the pharmacy staff member, pharmacy employment position, approximate age of the pharmacy staff member, visit time, pharmacy busyness (measured as waiting time from presentation at pharmacy counter until being served by pharmacy staff and pharmacy staff/pharmacy customer ratio), and the identity of the simulated patient who undertook the visit. Individual assessment questions were also included as independent variables. Odds ratios for the final model are presented along with 95% confidence intervals.

outcome. Visits in which a pharmacist was directly involved (either initially or via assistant referral) resulted in an increased likelihood of an appropriate outcome as compared with visits without a pharmacist directly involved. Discussion The simulated patient was provided some form of medical referral advice in less than half of the pharmacies visited; where it was provided, the quality of this advice was variable. A quarter of all pharmacies appropriately provided medical referral advice without sale of an antitussive

Table 2. Pharmacy and Staff Member Characteristics

Results

Characteristics

One of the 156 pharmacies visited was removed from analysis, as the simulated patient recognized the pharmacy staff member. Demographic data of the 155 community pharmacies included in the analysis are presented in Table 2. The appropriate outcome for the scenario was determined as referral to a medical practitioner for assessment of the patient’s chronic cough. The simulated patient was provided some type of referral advice in 38% (n = 59) of community pharmacies. All referrals were by verbal communication to the simulated patient. Of the pharmacies that provided referral advice, 36% (n = 21) also supplied medication, while 64% (n = 38) provided referral advice only. The pharmacy staff member mentioned a time period for referral in 47% (n = 28) of cases; the simulated patient was advised to seek medical advice immediately in 17% (n = 10) of visits, within a week in 27% (n = 16) of visits, and within a period of greater than a week in 3% (n = 2) of visits. Medication provided to simulated patients in visits resulting in a sale (n = 115, 74% of visits) contained an antitussive in 97% (n = 112) of all sales. Other recommended medication classes included an antihistamine in 6% (n = 7) of visits resulting in medication supply and/or an expectorant (3% of visits resulting in medication supply, n = 3). A mean of 4 questions (3.99 ± 2.03) were asked during the visit, with 1 pharmacy not eliciting any assessment. The most common question types are listed in Table 3. Figure 1 shows that the percentage of pharmacies that referred the simulated patient to a medical practitioner increased to nearly 100% when the number of questions asked was 6 or more. Logistic regression analysis determined that the model of best fit included the following predictors of referral: medical history, frequency of reliever use, medications being taken, and assessment of symptom duration (Table 4). The type of pharmacy staff member interacting with the simulated patient also had an impact on the appropriate 404

n


n

%a (N = 155)

Pharmacies type independent

55

chain

43

other

2

location shopping center

47

street

34

medical center

17

other

3

busyness staff >customers

79

staff ≤customers

21

waiting time until addressed no

64

yes

36

Staff sex female

83

male

17

type pharmacist assistant

31

pharmacist

24

pharmacist referral (by assistant)

15

pharmacist consulted (by assistant)

16

other/unable to identify

14

estimated age (y) 50

13

visit time (minutes) 3

22

a

Rounding to nearest whole percentage means that some of the percentages add to 101%.


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Provision of Primary Care to Patients with Chronic Cough in the Community Pharmacy Setting

and half of these pharmacies provided a time period for referral. All medical referral advice was provided verbally to the simulated patient; no pharmacy provided a written referral or contacted a physician on the patient’s behalf. The primary outcome demonstrates that community pharmacy currently provides suboptimal (and variable) advice to patients with a chronic cough. The practice exhibited by the pharmacy staff in this study suggests that the pharmacy profession is not fulfilling the requirements set out by the 1978 Declaration of Alma-Ata that primary care have “integrated, functional and mutually supportive referral systems.”7 Current guidance to community pharmacists by the Pharmaceutical Society of Australia (PSA) recommends that referral advice for nonprescription medication requests consist of the reason for the referral, documentation when appropriate, and patient follow-up when appropriate.9 Guidance that is more systematic and is designed in collaboration with secondary health-care providers and consumers may have the potential to improve practice. Three quarters of visits resulted in the sale of an antitussive, despite this recommendation being an inappropriate outcome for the scenario used in the study. Antitussives are to be used for suppression of a dry cough that is acute (