To examine the value of using an electronic monitoring device in optimising the role of community pharmacists in adherence and inhaler technique education in patients with chronic respiratory conditions

Over half of a billion people suffer from chronic respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD). The two conditions are considered as major public health challenges with substantial clinical, social and economic burdens worldwide. The preferred route of treatment of these conditions is the inhalation route using inhaler devices. However, problems related to poor adherence and inhaler technique (IT) among respiratory patients are widely and historically reported in the literature and still represent a challenge for healthcare professionals (HCPs) and healthcare systems to date. In current practice, the most common used method to assess IT is the checklist method which is subjective and inaccurate. Similarly, the current most commonly used methods for assessing adherence to inhaled medications mainly involve self-reporting, medication refill and inhaler dose counters which are also known to suffer from lack of accuracy in assessing patient's actual medication taking behaviour. Thus, there has been a need for more accurate methods for assessing patients' adherence and IT. The use of electronic monitoring devices (EMDs) has been reported to be a more accurate solution for assessing patients' adherence and IT as opposed to the currently established methods. This thesis reports on the empirical research conducted in independent community pharmacies in England using a new EMD called the inhaler compliance assessment (INCA™) device that provides an objective monitoring of both adherence level and IT of respiratory patients while using their inhalers at home. The central aim of this thesis was to examine the potential of using the INCA™ device in optimising the role of community pharmacists (CPs) in adherence and IT education. The research first explored CPs' perceptions about their role in supporting asthma and COPD patients regarding adherence and IT and their need for novel technologies such as the INCA™ device to support patients. The research then examined the level of adherence and IT among a cohort of asthma and COPD patients using the INCA™ device in comparison to other established measures of adherence (dose counter, prescription refill and self reporting), in addition to the level of disease and self-management knowledge. Afterwards, the research determined the effect of a medicine use review (MUR) type consultation provided by CPs while incorporating objective tools mainly the INCA™ device and previous disease knowledge reults on patients' disease knowledge, adherence level and IT. Lastly, the research assessed the perceptions and acceptability of the INCA™ device among participating CPs and patients. Mixed research methods were employed for data collection, this involved face-to-face semi-structured interviews, questionnaires and objective monitoring of adherence and IT using the INCA™ device. At the first stage, 23 CPs were interviewed. The thesis findings suggested that CPs role in supporting respiratory patients was patchy and opportunistic, with the MUR service being the main form of support to this category of patients. Furthermore, the use of technology in supporting respiratory patients was very limited. Nevertheless, CPs were receptive and open to the idea of having the INCA™ device as a new technology to support patients, subject to funding and remunertation. Forty-eight COPD and asthma patients were monitered using the INCA™ device. The level of adherence and IT of patients as identified by the INCA™ device was significantly different and lower than that measured by the currently established methods of adherence assessment mainly the dose counter, medication refill and self-reporting, with an INCA™ actual adherence of 42.7% when incorporating IT errors and intervals between doses. Only 8 out of 48 patients used their inhaler correctly at the correct time, i.e. had an INCA™ actual adherence ≥80%. The median technique error rate (TER) per patient as determined by INCA™ device was 30.1%. The level of disease and self-management knowledge among COPD patients was assessed using the Bristol COPD knowledge questionnaire (BCKQ). For asthma patients, the level of disease knowledge was assessed using a synthesised asthma knowledge questionnaire based on the existing literature, whereas the level of self-management knowledge was assessed using the asthma self-management questionnaire (ASMQ). The results showed poor level of disease and self-management knowledge among COPD patients with a mean percentage score of 48.3% for the BCKQ, an adequate level of disease knowledge amng asthma patients with a mean percentage score of 67.5% for the synthesised asthma knowledge questionnaire and a poor level of self-management knowledge with a mean percentage score of 46.3% for the ASMQ. Next, 18 out of the 48 patients were followed-up and had a MUR type consultation with their CP through which discussion about adherence and IT was done using the feedback provided by the INCA™ device and disease knowledge using patients' disease knowledge results as acquired by the BCKQ, the synthesised asthma knowledge questionnaire and the ASMQ during the observational phase. The results indicated significant improvement in the INCA™ actual adherence from 30% to 68% (p=0.001) and significant reduction in TER from 51% to 12% (p=0.002), after conducting the MUR consultations. There was a significant improvement in level of disease and self-management knowledge among COPD patients from poor (median BCKQ percentage score 49.9%) to adequate (median BCKQ percentage score 62.3%) (p=0.003). There was also a significant improvement in level of disease knowledge among asthma patients from adequate (median sythesised asthma knowledge percentage score 65%) to good (median percentage score 85%) (p=0.031) and level of self-management knowledge from poor (median ASMQ percentage score 37.5%) to adequate (median ASMQ percentage score 75%) (p=0.027). Patients were receptive to the idea of monitoring their adherence and IT using the INCA™ device and to recommend the device to other patients. CPs advocated the introduction of the INCA™ devices into the care pathway of respiratory patients and its implementation in community pharmacies. In addition, the usability score for INCA™ device indicated a good passable score. However, CPs articulated several barriers, facilitators, and suggestions that need to be taken into consideration. Barriers include time, workload, funding, patients' attitudes and recruitment. Facilitators comprised funding and remuneration, commissioning, training, extra resources and involvement of other HCPs. In summary, the original contribution to knowledge in this research lies in the use of a new objective measure, the INCA™ device for the first time in England among patients recruited from independent community pharmacies. The use of this objective measure reflectd the magnitude of the problem of adherence and IT from a realistic point of view as opposed to clinical settings. Furthermore, embedding this objective measure as part of an MUR type consultation in England for the first time showed a significant positive impact in relation to patients' adherence level and IT