Role of Pharmacists in Chronic Obstructive Pulmonary Disease Management

Background: Patient-centered medical homes (PCMHs) are foundational for integrated primary healthcare delivery and population health management. A key PCMH principle is chronic disease management, which requires collaboration among healthcare professionals to meet patients' medical and psychosocial needs. Chronic obstructive pulmonary disease (COPD) is well suited to benefit from collaborative care. The expanding role of pharmacists positions them as suitable for close collaboration in managing chronic diseases, including COPD. Pharmacists may contribute to COPD management through detecting adverse drug reactions, medication reconciliation, smoking cessation counseling, addressing treatment adherence, and inhaler technique assessment. Besides participating in case-finding activities including referral patients to spirometry, diagnosis, and treatment initiation. Objectives: Aim one is to map pharmacists' activities and collaboration between pharmacists and physicians, describe outcomes of pharmacist-physician collaborative care in COPD according to the Economic, Clinical, Humanistic Outcomes (ECHO) model. Aim two is to understand current COPD management practices by physicians and examine their perceptions of COPD clinical services provided by community pharmacists within Alberta. Method: The first project was a scoping review that followed the methodological framework developed by Arksey and O’Malley. A comprehensive search from January 2003 to August 2024 was conducted using Scopus, MEDLINE, Web of Science, Embase, and the first 100 results of Google Scholar. The search strategy employed a combination of "pharmacist”, "COPD”, "collaboration", and "physician" concepts, incorporating MeSH terms and expanded free-text terms. The second project was an online cross-sectional survey conducted with a convenience sample of respirologists, emergency medicine, and family medicine physicians within Alberta between November 1st, 2023, to November 1st, 2024. The survey tool was developed by the authors based on previous literature. Results: In project 1, Most studies originated from the USA (n=11; 61%) and used observational research designs (n=15; 83%) to evaluate outcomes. Multi-component interventions were common and the main pharmacists’ activities were: 1) Medication optimization (n=16; 89%), 2) COPD monitoring (n=18; 100%), 3) Screening and diagnosis (n=4; 22%), and 4) Other activities (n=12; 67%). Integrated services were delivered by pharmacists co-located with physicians in 12 studies (67%); 8 (44.4%) studies scored high on collaboration scale (≥6 out of 10). The most commonly reported outcomes were clinical (n=11; 61%) particularly hospital-related outcomes, followed by humanistic (n=8; 45%) most commonly quality of life, and economic (n=7; 39%) primarily cost savings. In project 2, Of the 96 individual surveys returned, 52 were complete. The majority (n=38, 73.1%) had experience collaborating with pharmacists providing clinical services and 68% (n=26) of these rated pharmacist’s services as good or very good. Two-thirds of respondents (n=34; 66%) encounter 6 or more COPD patients/month. Patients had access to smoking cessation programs and required medications. Access to timely pulmonary rehabilitation; specialist referral and post-hospitalization assessment were viewed as inadequate. Eighty-one percent of physicians agreed that pharmacists have an important role in COPD care. Regarding assessment, most participants (n=36, 69%) agreed that pharmacists can inform physicians about the need for spirometry in those with suspected COPD, but only half (n=25, 48%) supported pharmacists performing spirometry in patients at risk. The majority agreed to items relating to pharmacist roles in patient and caregiver education. Regarding management, half of the respondents (n=25, 49%) agreed that pharmacists could assist with managing COPD exacerbations, while almost all (n=51, 98%) agreed that pharmacists can ensure COPD patients have up-to-date immunizations. Conclusion: Using a scoping review and cross-sectional survey, this thesis explored the pharmacists’ activities in COPD care and the outcomes of these collaborative practices in addition to the perceptions of physicians about the care provided and the role of community pharmacists in COPD management. The findings highlighted considerable variability in pharmacist interventions, tailored to address diverse patient needs. Collaborative approaches involving physicians and pharmacists in COPD management may have a positive impact on both health-related and economic outcomes, although the impact on humanistic aspects remains inconsistent. Also, the results of the survey showed most respondents recognized that community pharmacists play an important role in patient education and ensure that treatment aligns with current evidence-based practices. However, physicians' perspectives varied and there was less support for pharmacists' capacity to contribute to the process of diagnosing patients with COPD. Most of the participating physicians believed that the majority of their patients had adequate access to the recommended care. Additional research is necessary to investigate physicians' views on pharmacists' roles in COPD management to support high-quality COPD care.

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