Community pharmacy-based asthma services: current perspectives and future directions

Figures & data

Figure 1 Study inclusion diagram.

Abbreviation: n, number.

Table 1 Community pharmacist–patient encounters for asthma (post-2008)

Author (location)	Methods	Outcomes measured
Kumar et al^Citation6 (India)	Study type: RCT Duration: 2 months Number of visits: four Pharmacist training: not described n (patients) =52 IG; 54 CG adults Population: adults with chronic, stable asthma n (pharmacies) =1	A higher percentage of correct answers on the Knowledge, Attitudes, and Practices questionnaire in the IG versus CG (no P-value provided). MDI technique scores significantly improved in the IG versus CG (P<0.01) at visits 2, 3, and 4. Rotahaler^® technique scores in the IG significantly improved over scores in the CG (P<0.0l). Medication adherence scores significantly improved in the IG versus the CG (P<0.0l). FEV1 improved 200 mL in IG versus CG (no P-value).
Ottenbros et al^Citation9 (the Netherlands)	Study type: prospective cohort Duration: 9 months Number of visits: not standardized; based on the identification of 19 medication-related problems using a Web-based algorithm Pharmacist training: not described n (patients) =3,757 IG; 105,507 CG Population: adults with asthma or COPD n (pharmacies) =107 IG; 105 CG	Prevalence of drug-related problems decreased by 24%–41%. Mean number of high-dose oral corticosteroid or antibiotic prescriptions decreased in the IG by an additional average of 0.54 per patient when compared to the CG (no P-value available). The reduction in high-dose prescriptions (0.92 per patient; 95% CI: 0.58–1.25) was mainly seen in those without concomitant maintenance ICS therapy per post hoc analysis. ICS prescriptions were started in 10% of patients with a decreasing number of high-dose corticosteroid or antibiotic prescriptions.
Mehuys et al^Citation7 (Belgium)	Study type: R, C parallel-group trial Duration: 6 months Number of visits: five Pharmacist training: yes n (patients) =80 IG; 70 CG Population: adults with asthma on a maintenance medication (ACT score: 15–24) n (pharmacies) =66	ACT score increased in the IG versus the CG (mean difference in ACT scores of 2.0) (95% CI: 0.1–3.9; P=0.038). Symptoms and pulmonary function per asthma diary: Less nighttime awakenings in the IG versus the CG (P=0.044); Less need for rescue medication in the IG versus the CG (P=0.012); Peak expiratory flow rate: NS. Number of correct inhalation technique steps was higher in the IG (P=0.004). Mean adherence rates (claims data) was higher in the IG (90.3%) versus the CG (74.6%; P=0.016), but not different by self-report. Number of severe exacerbations: NS. Knowledge of Asthma and Asthma Medicine questionnaire: NS. QOL questionnaire scores: NS.
Saini et al^Citation10 (Australia)	Study type: follow-up study to a RCT Duration: 6-month program with follow up at 6 months and 12 months by visit or questionnaire Number of visits: tailored education for three or four visits Pharmacist training: yes (2 days) n (patients) =398/570 completed a 6-month service; 129 completed a 12-month follow up Population: adults with asthma n (pharmacies) =96	Consumer Asthma Knowledge Questionnaire scores improved from baseline (P<0.00l), with no difference between groups receiving 3 or 4 visits (P=0.30). Group with 6-month follow-up visit had higher knowledge scores (P=0.02) than follow up by questionnaire. Difference was not sustained at 12-month follow up. No significant difference in knowledge scores l2 months after completion of service between those with three visits versus four visits (P=0.80).
García-Cárdenas et al^Citation8 (Spain)	Study type: cluster RCT Duration: 6 months Number of visits: 3-6 scheduled visits Pharmacist training: yes (1 day) n (patients) =186 IG; 150 CG Population: adults with a prescription for budesonide/formoterol n (pharmacists) =65 (33 IG; 32 CG)	Mean ACQ scores decreased from visit 1 to 2 in both the IG (0.32 points; SD=0.9I; P<0.00l) and CG (0.16 points; SD=0.73; P<0.017). Mean ACQ scores decreased from visit 2 to 3 in the IG only (P<0.001). The proportion of patients with controlled asthma significantly increased from baseline (28%), visit 2 (43%), and visit 3 (final visit) (58%) in the IG, but it was not significantly changed in the CG. More subjects with asthma were controlled in the IG versus CG (58.1% versus 46.0%; P=0.028). The proportion of those adherent increased in the IG from 38% to 78.5% versus 39.3% to 52% in the CG (P<0.001). The proportion of patients with correct device technique was significantly higher in the IG versus the CG (78.5% versus 52.0%; P<0.001).

Abbreviations: RCT, randomized controlled trial; n, number; IG, intervention group; CG, control group; MDI, metered-dose inhaler; FEV₁, forced expiratory volume in 1 second; COPD, chronic obstructive pulmonary disease; CI, confidence interval; ICS, inhaled corticosteroids; R, randomized; C, controlled; ACT, Asthma Control Test; NS, not significant; QOL, quality of life; ACQ, asthma control questionnaire; SD, standard deviation.

Table 2 Novel approaches to community pharmacy-based asthma programs

Author (location)	“Novel” strategy studied	Methods	Outcomes measured
Kritikos et al^Citation13 (Australia)	“Train-the-trainer”: pharmacists trained high school-aged peer leaders who mentored other students and provided a community asthma forum.	Study type: observational cohort Duration: NA Pharmacist training: yes; community pharmacists trained as Triple A educators to teach student peer leaders n (patients) =92 student peer leaders; 55 attendees at a community-wide forum n (pharmacists) =7	Increase in mean asthma knowledge scores of student peer leaders after training (P<0.001). Increase in requests for information on asthma (P<0.00l) and asthma devices (P<0.00l) during pharmacy visits at four time points after a community program.
Young et al^Citation14 (United States)	Phone consults: patients in the IG received three pharmacist phone consults related to asthma self-management and medication use.	Study type: RCT Duration: 3 months Pharmacist training: no; AE-C^Citation41 pharmacists followed a standardized communication guide n (patients) =49 IG; 34 CG n (pharmacists) =5	ACT scores increased from baseline to the third phone assessment in IG (t=2.84; P<0.0l). Patient activation increased in the IG and was maintained 3 months after the program (β=2.01; 95% CI: 0.15-3.91). Fewer patients in the IG had low adherence to LTC medications postintervention when compared to baseline (26% versus 58%; z=–2.78; P<0.0l).
Basheti et al^Citation15 (Australia)	Inhaler technique labels: patient inhaler technique assessed at each pharmacy visit. Label highlighted with missed steps to remind of the correct device technique.	Study type: randomized, parallel-group study Duration: 6 months Pharmacist training: yes; IG attended workshop regarding assessment and providing counseling if patients were using Turbuhaler^®, Diskus^®, and peak flow device techniques n (patients) =97 (43 Turbuhaler; 54 Diskus) n (pharmacists) =15 IG; 12 CG	Close to 75% of subjects reported using their inhaler correctly; only 10% were assessed as using the correct technique. Mean ITS (both inhalers combined) of patients taught by the IG improved 2.8±l .6 steps versus 0.9±1.4 steps (P<0.001). Asthma severity improved at 2 months (P=0.001), 3 months (P<0.001), and 6 months (P=0.015) for patients of the IG. Time to perform device instruction: First visit: device education took 5.0±2 minutes (mean of 3±l assessment/education cycles). Subsequent visits: 1 month: 2±2 minutes; 2 months: l±l minutes; and 3 months: l±0 minutes. Device difficulty: more Turbuhaler users required education at 6 months than did Diskus users (50% versus 21%; P=0.07). Correlation between improved ITS and improved PEF variability (r=0.31; P=0.008) and asthma QOL (r=–0.37; P=0.001) on post hoc analysis.
Ammari et al^Citation16 (United Kingdom)	Compared use of 2TT versus VC versus control to teach the optimal (slower) inspiratory flow rate for MDI technique.	Study type: parallel-grouped clinical study Duration: two visits; 6 weeks apart Pharmacist training: no n (patients) =50; 34 adults, 16 children CG=10; VC=19; 2TT=21 n (pharmacists) = not described	Inspiratory force decreased at visit 2 from baseline in the 2TT and VC groups (P<0.001). QOL overall and in activity domain improved at visit 2 in 2TT group (P=0.031), but NS change in emotion domain. MDI technique improved at visit 2 in the 2TT and VC groups from baseline (P<0.0l); NS difference between IG (2TT + VC) and CG (P>0.05).
Petkova^Citation17 (Bulgaria)	Pharmacy faculty member supervised students providing the patient educational sessions on various asthma topics including the appropriate use of medication, device technique, recognizing and treating exacerbations, adverse reactions to medications, and smoking cessation.	Study type: RCT Duration: 4 months Pharmacist training: not applicable n (patients) =22 IG; 28 CG; all over age 14 years n (pharmacies) =10	PEF increased in the IG (from 333.45± 15.73 L/minute to 338.64±l 2.55 L/minute) (no P-value given). There was no change in CG. Inhaler technique scores: trend to improve in the IG (from 40.9% to 54.5% at study end). (No P-value given.) No change in CG. Symptoms: 32% of the IG reported no symptoms versus 4% of the CG (P=0.013). QOL: IG improved from 3.55± 1.355 to 3.77± 1.020 at study end; P<0.0001). CG worsened (3.39±0.685 to 3.00±0.903; P=0.039).
Berry et al^Citation18 (United States)	Area-wide model of implementing integrating 19 brief educational and therapeutic asthma interventions into the dispensing workflow for each inhaler prescription (Asthma Friendly Pharmacy^® model). Workflow model incorporated entire pharmacy staff including pharmacists, technicians, and students.	Study type: program description Duration: 5 years Pharmacist training: t=yes n (pharmacies) =65 n (pharmacists) =86 (47 pharmacist champions) n (technicians) = 104 n (pharmacy students) >400 during experiential rotations	of 46 (64%) pharmacist champions submitted data from their pharmacy. Interventions: 2,419 patient educational messages. 1,284 therapeutic provider interventions. Increased annually as program was phased in. Most frequent educational messages: Role of medication; Medication regimen; Device technique; and Side effects. Most frequent therapeutic interventions: Overuse of SABA; Nonadherence to controller medicine; Controller medicine needed; and Reminder for follow up after exacerbation.
Armour et al^Citation19 (Australia)	Community pharmacists screened for risk of poor asthma outcomes based on the Jones Morbidity Index; use of SABA >3 times per week, or lack of an asthma visit in the last 6 months.	Study type: program description Duration: 4 months Pharmacist training: yes n (patients) =570 n (pharmacies) =96	Patients at risk identified= 570. 77% of at-risk patients had suboptimal asthma control. 55% of at-risk patients had an FEV1 <80% predicted. Patient demonstration of correct device technique: MDIs: 17%; MDI + spacer: 28%; Turbuhaler^® device: 23%; and Accuhaler^®/Diskus^®: 28%. If the device technique was incorrect, poor asthma control was 2.4 times more likely. Medication adherence: of 82% reporting a LTC, 63% received ≤2 refills.
van Boven, et al^Citation20 (the Netherlands)	Community pharmacists analyzed dispensing data to screen for asthma-related problems. Four indicators of suboptimal asthma pharmacotherapy were: 1) Frequent use of SABA; 2) Nonselective beta receptor blocking agents; 3) Oral corticosteroid bursts in patients not on an ICS; and 4) Monotherapy with a LABA (ie, without an ICS).	Study type: cross-sectional retrospective analysis Duration: 12 months of dispensing data from 500,000 patients Pharmacist training: not applicable n (pharmacies) = data from 50 pharmacies	Asthma patients identified= 8,504; prevalence of 50.4 per 1,000 pharmacy patients. Defined daily doses of SABA per year: 58% used > 100 SABA doses; 4% used 100-199 SABA doses without any ICS; 2% used 200-399 doses without any ICS; and 1 % used >400 doses without any ICS. Prescribed noncardioselective beta receptor blockers: 1 % of patients. ≥2 courses of oral steroids per year: 6% of patients; 17.4% of these were not prescribed an ICS. LABA without an ICS: 2.9% of patients. Combination of LABA and ICS using two separate inhalers: 4% of patients. Authors estimated that the average pharmacy, serving approximately 8,000 patients, could identify 403 patients using these criteria.
Bereznicki et al^Citation21 (Australia)	Software application assisted community pharmacists in analyzing dispensing records to identify patients at risk for poorly controlled asthma (based on dispensing of a SABA three or more times in the past 6 months). Patients in the IG were mailed educational materials and were encouraged to see a physician. The CG received the mailing after the 6-month study period.	Study type: RCT Duration: 6 months Pharmacist training: yes n (patients): IG=702; CG=849 n (pharmacies) =28	Ratio of dispensed ICS to reliever medication: increased from 0.1 to 0.3 and was maintained 18 months after the intervention (P<0.01). Percentage of patients using ICS increased in the IG (P<0.01).
Bereznicki et al^Citation22 (Australia)	Same as above,^Citation19 except patients were randomly assigned to pharmacist face-to-face intervention or by mail.	Study type: RCT Duration: 6 weeks Pharmacist training: yes n (patients) =1,483 mailed face-to-face control n (pharmacies) =71	Dispensing data: Controller-to-reliever ratio Mailed group: 0.15 preintervention to 0.19 postintervention (P<0.001). Face-to-face group: 0.15 preintervention to 0.21 postintervention (P<0.0001). Improvement in ratio due to a decrease in SABA use. Daily SABA use Mailed group: increased from 655.74 mcg preintervention to 563.42 mcg postintervention (P<0.0001). Face-to face: decreased from 765.03 mcg preintervention to 657.53 postintervention (P<0.0001). Pharmacist interventions: Lower percentage of possible interventions delivered face-to-face versus by mail (P<0.0001), so the overall benefit was greater in the mailed group. Pharmacists preferred face-to-face intervention, but lack of time was a barrier.

Note: Turbuhaler^®, AstraZeneca plc, London, UK; Diskus^®, GlaxoSmithKline plc, London, UK.

Abbreviations: NA, not available; n, number; IG, intervention group; RCT, randomized controlled trial; AE-C, certified asthma educators; ACT, Asthma Control Test; CI, confidence interval; LTC, long-term controller medicines; CG, control group; ITS, inhaler technique score; PEF, peak expiratory flow rate; QOL, Quality of Life Questionnaire; 2TT, 2 Tone Trainer^®; VC, verbal counseling; MDI, metered-dose inhaler; NS, not significant; SABA, short-acting beta receptor agonist; FEV₁, forced expiratory volume in 1 second; LABA, long-acting beta receptor agonist; ICS, inhaled corticosteroid; LABA, long acting beta agonist.

Table 3 Surveys of pharmacists’, physicians’, or patients’ attitudes regarding community pharmacy services for patients with asthma

Citation (location)	Group interviewed	Methods	Results
Bereznicki et al^Citation23 (Australia)	*Patients *Physicians *Community pharmacists	Study type: qualitative follow-up study of participants, GPs, and community pharmacists previously involved in an asthma intervention program^Citation19 based on dispensing data. n (participants) =10 n (physicians) =6 n (pharmacists) =10	Comments from GPs: Pharmacists were well placed to refer patients with uncontrolled asthma or who were overrelying on SABAs. Pharmacists had a potential conflict of interest. Pharmacists perceived as business people. Desire to be informed electronically when their patients were instructed by a pharmacist. Comments from community pharmacists: Felt they could and should be proactive in caring for patients with asthma. The information regarding overreliance on SABAs is easily accessible. Most interventions involved minimal time. Would also like to communicate more with GPs regarding patient care. Comments from participants: Generally satisfied with pharmacy services, but had low expectations of the pharmacists’ intervention. When directed to see their GP by pharmacist, often hesitant for fear of being a nuisance or that the visit was unnecessary.
Laufenberg- Horstmann et al^Citation24 (United States)	Prescribers (physicians and nurse practitioners)	Study type: prospective, multicenter, quasiexperimental n (providers) =60 faxes n (pharmacies) =16	The average response time for recommendation fax and the informational faxes was 8 days and 12 days, respectively. The majority (15/24 recommendation faxes and 10/16 information faxes) were assessed as “helpful” by providers in making a clinical decision.
Beauchesne et al^Citation25 (Canada)	Physicians	Study type: pilot n (physicians) =9 n (recommendations) =59 n (pharmacists) =21	Six of nine physicians agreed that pharmacists provided very useful information. All (9/9) agreed that pharmacists had the expertise to assess and monitor drug therapy and drug-related problems.
Dey et al^Citation26 (Australia)	Pharmacists, physicians	Study type: semistructured interview n (pharmacists) =18 n (physicians, (GPs) =7	Physicians and pharmacists both reported: Minimal understanding of each other’s roles. A need for more communication. GPs especially requested information regarding their patients. Pharmacists could benefit from increased knowledge, increased patient rapport, professional fulfillment, and improved professional image. Pharmacists: Desired GPs to be more approachable and available for consultation. Felt that GPs may feel threatened by pharmacist involvement. Physicians: Not all were convinced that patients would benefit from specialized and individualized education by a pharmacist. Identified a lack of time and poor communication as barriers to teamwork.
Naik Panvelkar et al^Citation27 (Australia)	Patients	Study type: semistructured interviews of those who received (experienced patients) and never received (naïve patients) specialized asthma services in community pharmacy n (naïve) = 10 n (experienced) =8	Almost all reported that they would be happy for their pharmacist to be more active in their asthma management. Naïve patients had a lower expectation of their pharmacist. Experienced patients: Were impressed by pharmacist involvement; Recognized the potential role of the pharmacist in asthma monitoring, device technique education, measuring lung function, and providing asthma and medication education; Valued good pharmacist communication skills (for example, empathy, attentiveness); Desired privacy for the intervention; and Were more loyal to their pharmacy.
Onda et al^Citation28 (Japan)	Patients with asthma	Study type: self-administered survey n (patients) =114 responses	Patients rating their communication with their pharmacist as “good” reported better improvement from an asthma attack (with the use of inhaled steroids) than those rating their communication as “poor” (P=0.011). Significant differences were found for “ability to use ICS skillfully” among patients who ranked their pharmacist as having good communication skills.
Rene-Henri et al^Citation29 (Canada)	Community pharmacists	Study type: self-administered questionnaire n (pharmacists returning questionnaire) =917 with 877 eligible for analysis	The most frequently reported limiting factors to pharmacists providing asthma care were: Lack of time; difficulty reaching providers; and limited access to the patient’s medical record. The level of patients’ interest in their asthma was reported as a relational factor in facilitating care by the pharmacist.
Nadaira et al^Citation30 (Canada)	Community pharmacists	Study type: descriptive results from focus groups n (pharmacists) =17	Organizational factors: Unable to monitor asthma control, assess the efficacy and tolerability of medications, and check device technique during every encounter. Barriers included a lack of: Time; A clear task definition (pharmacist versus technician responsibilities); Reimbursement; Patient access (for example, home delivery); Educational materials; and An accurate diagnosis (asthma versus COPD). Perceived a pressure to fill prescriptions quickly. Felt patients associated the lack of a fee with diminished importance of a pharmacist’s service. Professional factors: Some need for more knowledge of asthma and treatment recommendations. Most agreed that asthma education was an important professional function. Motivation to provide the service was variable amongst respondents. Relational factors: Some physicians were difficult to reach. Physicians were generally collaborative, especially if information was missing from a prescription. Good relationships between pharmacy personnel facilitated interventions.
Kritikos et al^Citation31 (Australia)	Community pharmacists	Study type: mailed questionnaire n (pharmacists) =75 69% metropolitan and 31 % regional 64% male Over the age of 40 years: 57%	Role: the pharmacists perceive that their role in asthma care involves: Patient self-management. Medication use. Asthma control. Regional pharmacists were more likely to see their role involving patient counseling about asthma control compared to metropolitan pharmacists. Barriers: 95% stated a lack of time. Patients perceive a lack of need (for example, already well cared for by a physician). Interprofessional contact: 67% stated good interprofessional contact with health professionals. 69% agreed they would like to have more contact with providers related to care of their patients.
Pradel et al^Citation32 (United States)	Community pharmacists	Study type: mailed survey n (pharmacists) =98 surveys	Asthma counseling: Providing to children (54%), and parents (68%) was important. Was difficult to perform with children (55%) and parents (36%). Intended to counsel children (46%) or parents (64%). Reported counseling a child (29%) or parent (47%) recently. Barriers identified include a lack of: Time; Parent interest; and Placebo devices for demonstration.
Berry et al^Citation33 (United States)	Community pharmacists	Study type: self-administered survey n (local pharmacists): 133	Pharmacists: Strongly perceived that providing asthma care was important; and Were interested in providing brief asthma interventions. Factors increasing interest in providing care: Using their training and skills; Making a difference to their patients; and Job satisfaction. Barriers included the need for: Additional educational materials to give patients; Training for pharmacists or technicians; Administrative or computer support; and More time.

Abbreviations: GP, general practitioner; n, number; SABA, short-acting beta agonist; ICS, inhaled corticosteroids; COPD, chronic obstructive pulmonary disease.

Table 4 Assessment of pharmacists’ knowledge and quality of asthma services provided

Citation (location)	Methodology utilized	Outcomes measured
Schneider et al^Citation34 (Australia)	Used SPs: yes Intervention: none Scenario: SP with moderately controlled asthma purchasing an OTC SABA inhaler n (pharmacies visited) = 160	At 84% of pharmacies, asthma control was assessed prior to the sale of SABA. Median number of patient assessment questions asked per visit=2. Device technique was not assessed at any pharmacy. Likelihood that the frequency of reliever use was assessed: Tripled as the visit time increased from under 1 minute to 1-3 minutes. Doubled for each additional assessment question asked during the visit (OR: 1.92 per one-question increase; 95% CI: 1.35-2.73). Counseling was provided at 24% of pharmacies.
Schneider et al^Citation35 (Australia)	Used SPs: yes Intervention: none Scenario: SP requesting an OTC treatment recommendation for an undiagnosed, nonproductive nocturnal cough. Cough was being self-treated for several months with a SABA twice daily n (pharmacies visited) = 155	Mean number of asthma assessment questions per visit: four questions. GP referral given 38% of the time (n=59 pharmacies). Of those referring:   - 36% (n=2l) also supplied medication; and   - 64% (n=38) provided referral advice only. Time period to seek medical advice was mentioned 47% of the time (n=28):   - immediately (n= 10): 17%;   - within 1 week (n=l6): 27%; and   - > 1 week (n=2): 3%. Frequency of GP referral approached 100% with six or more assessment questions. Medication recommended to SPs in 74% of visits (n=l 15): antitussive (n=l 12): 97%; antihistamine (n=7): 6%; and expectorant (n=3): 3%. Direct pharmacist involvement increased the likelihood of appropriate outcomes.
Rouleau et al^Citation36 (Canada)	Used SP: no Intervention: 2-hour asthma CE program. Given materials to educate patients n (pharmacists) =89 (CG: 41; IG: 48)	Results on six-question knowledge questionnaire (IG): Scores improved for all questions after the CE program. Statistical improvement in four of six questions. Self-reported asthma interventions during the 6 months after the program: 76 in the IG versus 62 in the CG (NS). Interventions for the overuse of asthma medicines were more frequently mentioned in the IG; suboptimal therapy interventions were more common in the CG.
Dolovich et al^Citation37 (Canada)	Used SP: yes Intervention: 1-day asthma workshop Scenario: three different SP cases to each pharmacist; each case with three asthma-related problems n (pharmacists =59; 29 IG; 30 CG)	Optimal or acceptable plans (IG=44.8% versus CG=29.3%; 95% Cl: 7.4%-23.8%; P=0.0004). Pharmacists in the IG facilitated more optimal or acceptable plans than those in the CG for three problems: Underuse of ICS (93% versus 67%; P=0.0l 7). Identification of pet dander as a trigger (54% versus 7%; P<0.001). Overuse of SABA (89% versus 50%; P=0.002). <50% of pharmacists in either group were able to facilitate plans for these five problems: medication cost; poor perceiver of symptoms; need for additional therapy; smoking trigger; and lack of an asthma action plan. Communication scores of the IG pharmacists were higher than of the CG pharmacists for two of the SP cases (P<0.05). Pharmacists’ self-assessments on the Behavioral Pharmaceutical Care Scale: NS.
Robinson et al^Citation39 (United States)	Used SPs: yes (simulations) Scenario: College of Pharmacy students assessed asthma as one of five simulations of medical emergencies n (students assigned to an asthma scenario) = 18	The asthma emergency was correctly identified 93% of the time. The correct treatment plan was recommended 89% of the time. The mean time to correctly identify the emergency (acute asthma) was a little over 3 minutes.
Schneider et al^Citation40 (Australia)	Used SPs: yes Intervention: pharmacy interns provided an asthma CE program at community pharmacy sites Scenario: SP with a story of worsening asthma control and poor inhaler technique n (pharmacies): IG=96; CG=97	Referrals to GP: IG=40 versus CG= 19 (P=0.001). Assessing the frequency of SABA use was the main predictor of GP referral (OR: 22.7; 95% Cl: 9.06-56.9). Correction of poor technique: NS.

Abbreviations: SP, simulated patients; OTC, over-the-counter; SABA, short-acting beta agonist; n, number; OR, odds ratio; CI, confidence interval; GP, general practitioner; CE, continuing education; CG, control group; IG, intervention group; NS, not significant; ICS, inhaled corticosteroids.

Kumar A, Adepu R, Parthasarathi G, Mahesh PA. Impact of community pharmacist provided patient education in asthma patients on treatment outcomes. Indian Journal of Pharmaceutical Education and Research. 2009;43(2):125–133.

 Web of Science ®Google Scholar

Ottenbros S, Teichert M, de Groot R, et al. Pharmacist-led intervention study to improve drug therapy in asthma and COPD patients. Int J Clin Pharm. 2014;36(2):336–344.

 Web of Science ®Google Scholar

Mehuys E, Van Bortel L, De Bolle L, et al. Effectiveness of pharmacist intervention for asthma control improvement. Eur Respir J. 2008;31(4):790–799.

 PubMed Web of Science ®Google Scholar

Saini B, LeMay K, Emmerton L, et al. Asthma disease management-Australian pharmacists’ interventions improve patients’ asthma knowledge and this is sustained. Patient Educ Couns. 2011;83(3):295–302.

 PubMed Web of Science ®Google Scholar

García-Cárdenas V, Sabater-Hernández D, Kenny P, Martínez-Martínez F, Faus MJ, Benrimoj SI. Effect of a pharmacist intervention on asthma control. A cluster randomised trial. Respir Med. 2013;107(9):1346–1355.

 PubMed Web of Science ®Google Scholar

Kritikos V, Saini B, Bosnic-Anticevich SZ, et al. Innovative asthma health promotion by rural community pharmacists: a feasibility study. Health Promot J Austr. 2005;16(1):69–73.

 Google Scholar

Young HN, Havican SN, Griesbach S, Thorpe JM, Chewning BA, Sorkness CA. Patient and pharmacist telephonic encounters (PARTE) in an underserved rural patient population with asthma: results of a pilot study. Telemed J E Health. 2012;18(6):427–433.

 Web of Science ®Google Scholar

National Asthma Educator Certification Board (NAECB) [webpage on the Internet]. National Asthma Educator Certification Board. Gilbert, AZ: National Asthma Educator Certification Board; 2013. Available from: http://naecb.com/. Accessed March 12, 2014.

 Google Scholar

Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008;72(1):26–33.

 PubMed Web of Science ®Google Scholar

Ammari WG, Chrystyn H. Optimizing the inhalation flow and technique through metered dose inhalers of asthmatic adults and children attending a community pharmacy. J Asthma. 2013;50(5):505–513.

 PubMed Web of Science ®Google Scholar

Petkova VB. Pharmaceutical care for asthma patients: a community pharmacy-based pilot project. Allergy Asthma Proc. 2008;29(1):55–61.

 PubMed Web of Science ®Google Scholar

Berry TM, Prosser TR, Wilson K, Castro M. Asthma friendly pharmacies: a model to improve communication and collaboration among pharmacists, patients, and healthcare providers. J Urban Health. 2011;88 Suppl 1:113–125.

 Google Scholar

Armour CL, Lemay K, Saini B, et al. Using the community pharmacy to identify patients at risk of poor asthma control and factors which contribute to this poor control. J Asthma. 2011;48(9):914–922.

 PubMed Web of Science ®Google Scholar

van Boven JF, Hiddink EG, Stuurman-Bieze AG, Schuiling-Veninga CC, Postma MJ, Vegter S. The pharmacists’ potential to provide targets for interventions to optimize pharmacotherapy in patients with asthma. Int J Clin Pharm. 2013;35(6):1075–1082.

 Web of Science ®Google Scholar

Bereznicki B, Peterson G, Jackson S, Walters EH, Gee P. The sustainability of a community pharmacy intervention to improve the quality use of asthma medication. J Clin Pharm Ther. 2011;36(2):144–151.

 Web of Science ®Google Scholar

Bereznicki BJ, Peterson G, Jackson S, et al. Uptake and effectiveness of a community pharmacy intervention programme to improve asthma management. J Clin Pharm Ther. 2013;38(3):212–218.

 PubMed Web of Science ®Google Scholar

Bereznicki B, Peterson G, Jackson S, et al. Perceived feasibility of a community pharmacy-based asthma intervention: a qualitative follow-up study. J Clin Pharm Ther. 2011;36(3):348–355.

 PubMed Web of Science ®Google Scholar

Laufenberg-Horstmann E, DeVore E, Bassuener K. The Coulee Region Community Pharmacy Asthma Intervention study. J Am Pharm Assoc (2003). 2006;46(6):738–746; quiz 746–747.

 Web of Science ®Google Scholar

Beauchesne MF, Bercier D, Julien-Baker F, Lalonde L, Boileau R, Blais L. Community pharmacy-based medication assessment program for asthma and chronic obstructive pulmonary disease. Can J Pharm J (Ott). 2012;145(2):70–71.

 Google Scholar

Dey RM, de Vries MJ, Bosnic-Anticevich S. Collaboration in chronic care: unpacking the relationship of pharmacists and general medical practitioners in primary care. Int J Pharm Pract. 2011;19(1):21–29.

 PubMedGoogle Scholar

Naik Panvelkar P, Armour C, Saini B. Community pharmacy-based asthma services – what do patients prefere? J Asthma. 2010;47(10):1085–1093.

 PubMed Web of Science ®Google Scholar

Onda M, Sakurai H, Hayase Y, Sakamaki H, Arakawa Y, Yasukawa F. Effects of patient-pharmacist communication in the treatment of asthma. Yakugaku Zasshi. 2009;129(4):427–433.

 Web of Science ®Google Scholar

René-Henri N, Khamla Y, Nadaira N, et al. Community pharmacists’ interventions in asthma care: a descriptive study. Ann Pharmacother. 2009;43(1):104–111.

 Web of Science ®Google Scholar

Nadaira N, Ouellet C, René-Henri N, et al. Factors influencing a community pharmacist’s interventions in asthma care. Canadian Pharmacists Journal. 2009;142(5):240–246.

 Google Scholar

Kritikos VS, Reddel HK, Bosnic-Anticevich SZ. Pharmacists’ perceptions of their role in asthma management and barriers to the provision of asthma services. Int J Pharm Pract. 2010;18(4):209–216.

 Google Scholar

Pradel FG, Obeidat NA, Tsoukleris MG. Factors affecting pharmacists’ pediatric asthma counseling. J Am Pharm Assoc (2003). 2007;47(6):737–746.

 Web of Science ®Google Scholar

Berry TM, Ellis MA, Durrett AJ, Prosser TR. Community pharmacists’ attitudes toward providing asthma counseling to ambulatory patients. International Pharmaceutical Abstracts. 2003;38: P-528-E.

 Google Scholar

Schneider CR, Everett AW, Geelhoed E, Kendall PA, Clifford RM. Measuring the assessment and counseling provided with the supply of nonprescription asthma reliever medication: a simulated patient study. Ann Pharmacother. 2009;43(9):1512–1518.

 Web of Science ®Google Scholar

Schneider CR, Everett AW, Geelhoed E, et al. Provision of primary care to patients with chronic cough in the community pharmacy setting. Ann Pharmacother. 2011;45(3):402–408.

 PubMed Web of Science ®Google Scholar

Rouleau R, Beauchesne MF, Laurier C. Impact of a continuing education program on community pharmacists’ interventions and asthma medication use: a pilot study. Ann Pharmacother. 2007;41(4):574–580.

 Web of Science ®Google Scholar

Dolovich L, Sabharwal M, Agro K, et al. The effect of pharmacist education on asthma treatment plans for simulated patients. Pharm World Sci. 2007;29(3):228–239.

 Google Scholar

Robinson JD, Bray BS, Willson MN, Weeks DL. Using human patient simulation to prepare student pharmacists to manage medical emergencies in an ambulatory setting. Am J Pharm Educ. 2011;75(1):3.

 Web of Science ®Google Scholar

Schneider CR, Everett AW, Geelhoed E, et al. Intern pharmacists as change agents to improve the practice of nonprescription medication supply: provision of salbutamol to patients with asthma. Ann Pharmacother. 2010;44(7–8):1319–1326.

 Web of Science ®Google Scholar