Pharmacist Management of Adult Asthma at an Indian Health Service Facility

Probably the most important mechanism for the success of the clinic is education. Each visit is set at 30-minute appointments (1 hour for new patients), allowing for a significant amount of time that can be spent on education topics, including pathophysiology, trigger avoidances, and medication use. Patients are asked to bring their medications to the clinic and demonstrate inhaler technique at every visit. Patients who do not bring their inhalers to the clinic will have them filled at the clinic and given to them for demonstration. This type of show-and-tell education allows clinic providers to correct improper inhaler technique immediately. Having patients actually use their medication seems to influence the patient’s inhaler mechanics to a greater extent than does demonstration with a placebo.

In the eyes of the clinic provider, it is important for patients to understand the basic pathophysiology of the disease. The better understanding patients have of a disease, the better they can take part in the treatment. Since the clinic actively engages patients in education topics, it brings patients into an active role in the treatment. As mentioned, the inhaler technique seems to be the most effective first step. However, as patients gain trust in clinic providers due to significant improvement in symptoms secondary to inhaler technique, this trust leads to a dialogue about pathophysiology and triggers.

Another key component in the clinic success is the nature of the clinic itself. Providers in the clinic focus on only 1 disease and the guidelines to treat that disease. Therefore, providers in the clinic are trained to be extremely familiar with the treatment of asthma. This is not to imply that a patient’s PCP or usual care provider is unfamiliar with the guidelines. It simply means that specialty care involves an extra time commitment to a specific disease. Each clinic provider must attain a high level of asthma knowledge before consideration as a full-time provider. Pharmacists are encouraged to sit for the Certified Asthma Educators examination, Board Certified Pharmacotherapy Specialist examination, and/or obtain the Indian Health Service National Clinical Pharmacy Specialist certification.

Although the clinic has moved in the right direction, there are still several patients who have not had any improvement since being referred to the clinic. These patients have refractory asthma (ie, step 6) and are not able to be treated at this facility, continued poor medication adherence, or do not have asthma at all. These patients will be flagged and will be evaluated on a case-by-case basis.

In conclusion, the clinic has begun to achieve what it was intended to do: improve asthma control, reduce patient burden on ED staff, and decrease financial burden to the facility. Additionally, there is improvement in the satisfaction of the asthma care and a trend toward the patients’ perception of asthma control agreeing with medical guidelines. These findings further support the use of pharmacists in the role as provider for the management of chronic diseases.

Acknowledgements
Shail Mehta, MD, is an internal medicine provider at the NNMC. He attended the University of Pittsburgh School of Medicine in Pennsylvania and completed a residency in internal medicine at the University of Michigan in Ann Arbor. Dr. Mehta is certified with the American Board of Internal Medicine.

Erica Markovitz, MD, is an internal medicine provider at the NNMC. She attended the University of Miami School of Medicine in Florida and completed a residency at the University of Michigan. Dr. Markovitz is certified with the American Board of Internal Medicine and the American Board of Pediatrics.

Thad Koppenhafer, PharmD, is the director of pharmacy at the NNMC and the area pharmacy consultant for the Navajo Area of the IHS. He is a member of the American Society of Health-Systems Pharmacists.

CAPT Mark Strong, PharmD, MT (ASCP) is a senior supervisory pharmacist with the U.S. Public Health Commissioned Corps and is assigned to the IHS. He is currently the chief of outpatient pharmacy services at the NNMC.

CDR Clint Krestel, PharmD, is the assistant chief of pharmacy responsible for Inpatient Pharmacy Services. His professional memberships currently include the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, and the Commissioned Officers Association.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.