Management of Chronic Obstructive Pulmonary Disease by Pharmacists in an Internal Medicine Department

Rebecca P. Mann, Pharm.D., BCPS; Kathy Zaiken, Pharm.D.


Am J Health Syst Pharm. 2009;66(10):890, 892-893. 



Pharmacist involvement in the management of chronic diseases has been shown to produce beneficial outcomes, such as cost savings, and it has also been shown to improve therapy and patient outcomes.[1] The Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the American Thoracic Society (ATS) published guidelines that provide health care providers with best practices for the diagnosis, management, and treatment of patients with chronic obstructive pulmonary disease (COPD).[2,3] Both the GOLD COPD guidelines and the ATS/European Respiratory Society standards for diagnosis and management identify that COPD is largely treated based on symptoms; however, spirometry is required for diagnosis.[2,3] The GOLD guidelines recognize spirometry as the best measure of pulmonary airflow limitation; therefore, it is considered the standard for diagnosis of COPD and is considered the best way to monitor ongoing changes in the disease.[2] ATS recommends spirometry testing in all patients suspected of COPD because it is necessary for diagnosing, assessing, and providing appropriate treatment.[4] Dales et al.[5] examined physicians' diagnosis and management of respiratory disease before and after spirometry results were provided. The results showed the physicians changed treatment in 15% of the patients (n = 154) after the spirometry results had been provided to them. These numbers climbed to nearly 60% for newly diagnosed patients.

In spite of national recognition of the importance of spirometry and the availability of a handheld device in the internal medicine department, the use of such a device was low at our center. This was possibly because of the availability of only one device, as well as a lack of widespread training on how to use and interpret the results. In order to increase the proper use of, knowledge of, and familiarity with spirometry, a pharmacist- driven spirometry and medication program was created. This program took place at a multispecialty medical group practice center with 19 locations in and around the greater Boston area. Within this practice group, clinical pharmacists are part of the team and available to the internal medicine departments. The program was conducted from January to April 2007 at 1 location and was approved by the institutional review board of the Massachusetts College of Pharmacy and Health Sciences.

The internal medicine staff at the center recognized the need to improve the chronic management of their patients with respiratory diseases, and this project was part of a larger respiratory program. The purpose of this project was to implement a pharmacist-driven spirometry program to track the effect that an ambulatory care pharmacist had on the staff's spirometry use and, more importantly, to increase the overall department awareness and use of spirometry in patients with COPD. During the program, the number and percent of accepted pharmacist recommendations for medications and spirometry were tracked, thus indirectly examining the role of a pharmacist in spirometry use and medication management for COPD. The pharmacist reviewed medical records and made recommendations to primary care physicians (PCPs) regarding spirometry and medication regimens.

The first step of the project was determining inclusion and exclusion criteria for patients. Patients with a diagnosis of COPD, chronic bronchitis, or emphysema from December 1, 2005, through November 30, 2006, and who had a PCP at the study location were included in the study. Chart reviews were performed, and patients were excluded from this project if they were younger than 18 years, were pregnant, had an active history of lung cancer, were regularly followed by a pulmonologist, or had a spirometry test done within the previous 2 years.

The electronic medical record (EMR) system at the study site is comprehensive and includes all chart notes, laboratory and test information, and pharmacy information. In addition, the EMR has staff messaging capabilities. All pharmacist recommendations to the physician occurred through the EMR system. The results of the spirometry tests, as well as the interpretation, were entered directly into this system. This was beneficial for documentation, follow-up, and ease of communication.

The pharmacist looked for past spirometry tests and results for each patient. If none were available, then the pharmacist made two sets of recommendations—spirometry test and medication management. If the recommendation for a spirometry test was accepted by the physician, then the order was placed, and the patient received a spirometry test at an upcoming appointment or at a newly scheduled one. For our program, the spirometry test could be scheduled and administered by a pharmacist, specially trained medical assistants, or physician assistants who were part of the project. Our goal was to increase the number of patient appointments by increasing the number of providers who could administer the spirometry test. Also, by training more members of the internal medicine team, it was anticipated that the use and awareness of the spirometer would continue beyond the duration of this project. During the appointment, the patient completed the spirometry test and answered questions regarding symptoms and medication use. After spirometry results were available, the pharmacist reviewed the medication list, documented patient symptoms, and made medication recommendations if needed.

In preparation for this project, an on-site training program was provided by the National Respiratory Training Center. The training covered proper care of patients with COPD, use of spirometry, and how to interpret the results. All physician assistants, as well as involved pharmacists and physicians, attended the training. The physician assistants who attended the training interpreted all spirometry results and reviewed the results with a pharmacist. After spirometry results were discussed, the pharmacist was able to make medication recommendations to the PCP when necessary. The pharmacist made guideline-driven recommendations for a medication addition, discontinuation, or change based on the results of the spirometry and reported respiratory symptoms and medication use. Throughout the process, the number and percent of accepted pharmacist recommendations for spirometry and medications were tracked by the pharmacist.

From January to April 2007, 244 charts were reviewed. Of the 244 charts reviewed, 157 patients were excluded; the primary reason for exclusion was care by a pulmonologist. The 87 patients who were included consisted of 44 women and 43 men.

A total of 80 spirometry recommendations were made to PCPs by the pharmacist, all through the EMR messaging system. Of the 80 spirometry recommendations, 60 (75%) were accepted by the PCPs. Five recommendations for spirometry were denied and 15 were unanswered, despite follow-up messages from the pharmacist. Seven recommendations were not made even though patients were deemed eligible. These recommendations were not made for various reasons including change in PCP, case of pneumonia at the time of chart review, no symptoms reported at a recent appointment, no prescriptions for inhalers (diagnosis was deemed an error), and upcoming surgery.

During the four-month project duration, 60 recommendations for spirometry were accepted, resulting in 29 spirometry tests. The results of the 29 spirometry tests led to various outcomes. In 14 patients, medication recommendations were made to add or change inhalers. The most common medication recommendation was to add a long-acting anticholinergic agent. In 9 patients, the spirometry results were normal or not diagnostic for COPD and, at the time of the test, these patients did not report respiratory symptoms; therefore, no medication recommendations were made. Five spirometry tests resulted in invalid results and repeated testing was not possible, so no medication recommendations were made. The test is difficult for some patients because of the required breathing technique, the coordination required to perform the test, and the status of their disease; therefore, it was not alarming to the team that some patients were unable to perform the test. For these patients, medical history and symptoms guided medication use. In 1 patient, a spirometry test was performed and an appointment with a pulmonary specialist was scheduled for the following day. The remaining 31 spirometry tests remained to be scheduled for various reasons, mainly upcoming appointments with a PCP, travel plans, illness, and concerns for the weather since the project took place during winter months.

Because of the short duration of this project, the results of medication recommendations were not available before the project end date. Responses from several of the PCPs indicated that the medication changes would be discussed with the patients at their next visit with the physician. Symptoms could be assessed and, if necessary, the patient could also be trained to use any new inhaler at this visit.

Similar to other new programs, this one was not without challenges. Spirometry recommendations were denied by a small number of PCPs and no reasons were provided. Other recommendations went without responses despite follow-up. Although outreach to PCPs was completed before the start of the program, more education or outreach was needed. If the PCP had an office and saw patients on the same floor as the pharmacist, recommendations were accepted at a higher rate than when the PCP and the pharmacist were located on different floors. This trend identifies a potential barrier for pharmacists but also identifies an opportunity. Future programs in which a pharmacist is involved with patients, particularly those with a chronic disease, may be more successful if the pharmacist is more familiar with the providers who are involved. From our experience, the relationship does not have to be extensive; even meeting once or twice during this program with the PCP was enough to establish a relationship. This created a mutual understanding of collaboration and working in the best interest of the patient. A pharmacist may increase the use of spirometry, which is essential for patients with COPD, and may affect their medication management. It is essential to recognize unique opportunities for pharmacists' participation in managing chronic diseases.


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