Illustrating How to Use the Validated Alsayed_v1 Tools to Improve Medical Care: A Particular Reference to the Global Initiative for Asthma 2022 Recommendations

Introduction

Over the years, pharmacists’ role has expanded from traditional dispensing to patient-focused pharmaceutical care practice.^1,2 Pharmacists are now working collaboratively with other healthcare practitioners as a neighborhood of the healthcare team to provide optimized patient care services in hospitals and various clinical settings.^3–7 As pharmacists are now required to possess closer contact with patients,⁸ the general public naturally expects them to handle challenges competently and in the best interests of their patients.⁹ Numerous studies have found that pharmacists’ participation in pharmaceutical care services improves patients’ health outcomes by recognizing and preventing treatment-related problems in various disorders^10–17 and saves health care expenses.^18–21

Among the primary responsibilities of clinical pharmacy and pharmaceutical care practitioners are the detection, prevention, and resolution of medical issues.⁷ Pharmacist interventions are pivotal in developing new pharmaceutical care services and increasing knowledge about the types and frequencies of medical problems.⁷ Clinical pharmacists must utilize a systematic documentation and classification system when reporting medical problems.^22–26

Pharmaceutical care and clinical problem-solving have a recognized utility as a method that lowers medication errors and patient harm.^27,28 Nevertheless, health care practitioners in general, including pharmacists, receive minimal formal education throughout their college years on how to gather patient data, assess this data, including drugs, establish and implement the patient’s care plan, educate the patient, and offer proper follow-up.^27,28 This may be attributed to the lack of awareness and vague understanding of who is responsible for providing this service.^29,30

Our recent interventional study found that the tutorial improved pharmacy students’ decision-making skills. The intervention also taught students teamwork, peer assessment, communication, and critical thinking.³¹ The novel Alsayed_v1 tools introduced in a recent paper were applied to actual patient cases and were validated.³¹ The tools received favorable feedback from users. The Alsayed_v1 tools include three main parts: the assessment of treatments, the medical problem-oriented plan (MPOP) classification system, and the care plan.³¹ The term MPOP was defined in our previous research⁹ as “an interventional plan directed to a specific medical problem or event involving patient treatment to achieve the optimum outcomes for a certain patient”.

Therefore, this study aims to illustrate a real case using the validated Alsayed_v1 tool as tutorial training to improve the knowledge and skills of healthcare practitioners and pharmacy /medical students in the clinical problem-solving process that is necessary to implement medical and pharmaceutical care. A real asthma case was selected to apply the tools with a particular reference to evidence-based medicine using the updated 2022 version of the Global Initiative for Asthma (GINA).

Materials and Methods

Data Collection and Assessment

In this study, the Alsayed_v1 tools were used.⁹ We provided the method in light of our recent two published studies using our related templates.^9,31 The template pertaining to the assessment of therapies was thought to be crucial since it aids in analyzing patient data for the presence of medical problems and aids in providing a suitable plan.³¹

Regarding the data collection, seven parts were included: demographic data, current issues, medical problems, patient history, treatments, tests, and special situations.

In addition to the updated related guidelines, the following websites were utilized throughout the tutorial: Lexicomp’s Drug Information, UpToDate, accesspharmacy.mhmedical.com, https://online.epocrates.com, and www.medscape.com. Practitioners are advised to consult a minimum of two sources to gather the relevant information. Practitioners must also possess decision-making and professional communication skills.

The practitioner identified the necessary data in the appropriate sources, documented the patient’s data, evaluated the distinct components with documentation, and evaluated the coherence between the recommended and the patient’s therapeutic indications. Effectiveness was determined by comparing the patient’s therapy to the most recent evidence-based clinical practice guideline recommendations and achieving treatment objectives (treatment goals). The medication’s safety was evaluated by examining the patient’s symptoms and medical records for any indications of probable adverse reactions, contraindications, or precautionary measures. Possible medication safety issues were also evaluated by determining whether or not the patient was at risk but not receiving prophylaxis. The adequacy of the dosage regimen was determined by comparing doses to evidence-based guidelines and recommendations or by consulting drug information resources such as Lexicomp’s Drug Information. The clinical characteristics of the patient were considered when determining the dosing regimen. Utilizing the UpToDate drug interactions tool, clinically significant drug-drug interactions were identified.

The patient’s knowledge and adherence were evaluated and recorded. Poor, average, or appropriate levels of knowledge of the disease and non-pharmacological and pharmacological treatments were documented. Assessing and documenting adherence to non-pharmacological and pharmacological therapies are also necessary. Primary and secondary non-adherence to pharmacological treatment can be distinguished. Primary non-adherence occurs when a patient has been prescribed a new medicine but fails to obtain it (or a suitable alternative) within a reasonable period of time. Secondary non-adherence occurs when a patient fills a prescription but does not take the medication as prescribed. Non-adherence can also be characterized based on the patient’s intent to take treatment (intentional versus unintentional non-adherence).⁹ Due to the various underlying causes, each type of non-adherence must be addressed separately. It is possible to document the reasons for insufficient knowledge and non-adherence.

Cost-effectiveness was also documented, including questioning the patient about cost. Furthermore, the monitoring parameters and their costs should also be considered.

After completing this analysis step for one drug, all of the patient’s medications must be assessed prior to the synthesis step (MPOP tool).

MPOP, Care Plan, Patient Education, and Follow Up

All medical problems reported in the assessment step were pooled and then classified according to their shared components: Indication, Effectiveness, Safety, Patient, and Miscellaneous, according to the MPOP tool.⁹

The care plan template was created to incorporate the detected MPOP as well as a free-text field for inserting additional intervention, monitoring, and follow-up details. Each care plan table was tailored to a specific patient’s disease/condition. Appropriate systematic patient education was provided directly to the patient, with a particular follow-up schedule to evaluate the outcome of the care plan.

Case Summary

A 20-year-old male with a history of uncontrolled persistent asthma presented to his primary care physician with complaints of shortness of breath (SOB), poor exercise tolerance, nighttime awakening, and the need for frequent use of his quick-relief asthma medication. The clinical pharmacist was asked to recognize and address the possible factors contributing to this patient’s uncontrolled asthma and to develop a plan for better long-term control of his asthma symptoms using the novel validated “Alsayed_v1” tools.^9,31 Changes in the patient’s pharmacotherapeutic regimen for long-term asthma control were needed.

Ethical approval was attained from a medical center in Amman, Jordan (2021-IRB-1-1). The patient’s informed consent was obtained to participate in and publish the study, including anonymized responses. This study complies with the Declaration of Helsinki.

Results

Data Collection and Assessment

1. Demographic Data

• Who is the patient? -
• Age: 20 years
• Gender: Male
• Education: Bachelor’s student
• Occupation: NA
• Phone no. NA
• Dr name: -

Day and Date: 9 October 2022

2. Current Issues

Day and Date: 9 October 2022

Time: 16.00

CC: “The dust is bothering me.”

HPI:

• Location: Lower respiratory tract
• Characteristic of symptoms: cough and SOB
• Timing (onset, duration, frequency):

He reports being awakened by a cough at night once a week during the last 4 weeks. His cough and SOB occur during at least 3 days per week in the last 4 weeks.

• Severity: needs further investigations
• Factors:

Aggravating factors:

The patient states he especially becomes short of breath when he exercises (although he admits that his SOB is not always brought on by exercise and sometimes occurs when he is not actively exercising).

The family has one cat, which may be a possible trigger of his asthma symptoms.

Alleviating factors:

Taking his medications

• Environment: Dust environment; both father and brother are smokers
• Other symptoms: NA
• Differential diagnosis: well-known asthma case

Review of Systems (ROS)

Denies fever, chills, headache, eye discharge or redness, rhinorrhea, sneezing, sputum production, chest pain, palpitations, dizziness, or confusion.

Physical Examination (PE)

Gen: Well-developed, well-nourished male

HEENT: Mild oral thrush is present on the tongue and buccal mucosa

Neck/Lymph Nodes: Supple; no lymphadenopathy or thyromegaly

Lungs/Thorax: No intercostal retractions or accessory muscle use with respirations; good air movement; mild expiratory wheezes bilaterally

CV: RRR; no MRG

Abd: Soft, NTND; (+) BS

Ext: Normal ROM; periphisal pulses 3+; no CCE

Neuro: A&O × 3. Cranial nerves II–XII are grossly intact. No focal weakness or loss of sensation.

Day and Date: 9 October 2022

3. Medical Problems

Table 1 shows the medical problems the patient has.

Table 1 Medical Problems Part of Data Collection

4. Patient History

• Surgeries: No previous intubations history
• Hospitalization: Once in the last year due to asthma exacerbation and treated with oral corticosteroids (OCS); one visit to the emergency department (ED) during the previous 6 months and treated with OCS.
• Vaccination: NA
• Allergies: No known drug allergies (NKDA)
• Family history (FH): Mother, 45 years old with hypertension (HTN) and allergic rhinitis; (nonsmoker); father, 51 years old (smoker) with HTN, type 2 diabetes mellitus, and some food allergy; brother, age 15, healthy (smoker); sister, age 6, healthy (suspected asthma).
• Social history (SH): No alcohol or tobacco use, single, not sexually active, lives at home with his parents (his father is a teacher) and one cat.

5. Treatments

Table 2 shows the medications and other treatments taken by the patient.

Table 2 Treatments Part of Data Collection

6. Tests

Day and Date: 9 October 2022

Vital signs:

BP 110/68, HR 78, RR 16, T 37°C; Wt 58 kg, Ht 170 cm

Lab tests:

Na 136 mEq/L, K 3.6 mEq/L (at risk for hypokalemia due to frequent Albuterol use), Cl 98 mEq/L, CO2 27 mEq/L, BUN 18 mg/dL, serum creatinine 0.6 mg/dL, Glu 95 mg/dL, Hgb 15 g/dL, Hct 42%, Plts 192 × 103/mm3, WBC 6.0 × 103/mm3, PMNs 56%. Bands 1%, Eosinophils, Basophils 2%, Lymphocytes 33%, Monocytes 5%.

Other tests:

His morning peak expiratory flows (PEF) have been running around 270 L/min (personal best = 400 L/min) over the last several weeks. PEF = 68% (yellow zone; caution).

7. Special Situations

• Pediatric, geriatric, pregnancy, breast-feeding, ethnicity: None
• Age 12+ according to GINA³²
• Limitations (NPO, bedridden, inability to swallow): None
• Renal impairment: Normal kidney function (Table 3)
• Hepatic impairment: No
• Allergies: No known drug allergy (NKDA)
• Sensitive issues/barriers to communication: No
• Abuse: No

Table 3 Basic Calculations

Day and Date: 9 October 2022

Basic Calculations and Assessment of Medications

Table 3 shows some basic calculations, and Table 4 and Table 5 detail the assessment of his medications.

Table 4 Assessment for Fluticasone

Table 5 Assessment for Albuterol

MPOP and Care Plan

Table 6 and Table 7 represent the patient’s care plans for chronic asthma and oral thrush infection, including the related MPOP.

Table 6 The Care Plan for the Chronic Asthma

Table 7 The Care Plan for the Oral Thrush Infection

Patient Education, Care Plan Implementation, and Follow Up

The care plan and patient education aim to provide the patient with a management plan at home when his peak flow readings go below the Green Zone. Following the care plan will help the patient gain control of his asthma symptoms if they worsen (Table 8). The instructions were given to the patient in Arabic, his mother language.

Table 8 Patient Education for Chronic Asthma for the Included Patient

Discussion

The current research aimed to illustrate a real case using the validated Alsayed_v1 tools as tutorial training to improve the knowledge and skills of healthcare practitioners, pharmacy, and medical students in the clinical problem-solving process necessary to implement medical and pharmaceutical care.

The created classification system (MPOP tool) was intended to be user-friendly, applicable, and valuable in many healthcare settings (general practice, medical centers, hospitals, community pharmacies, etc.), as well as for research and education. The MPOP classification system is an open hierarchical structure with five broad categories at the higher levels and increasing specificity at the lower ones. Incorporating interventions into the classification system is crucial, particularly in medical and pharmaceutical care research, where the type of advice should be documented to evaluate the service’s value and impact. It saves practitioners time in keying in the correct interventions. However, this MPOP application user can enter some information in the free text section.⁹

The section dedicated to treatment assessments is intended to synthesize patient information to facilitate the identification of the MPOPs. The absence of an evaluation component is a major limitation in some categorization systems.

The pharmacist’s position has changed substantially, and they will likely provide pharmaceutical care services. In most hospitals, pharmacists have not previously collected medication histories.³³ This may be due to poor process knowledge, lack of awareness, unclear understanding of who is responsible for pharmaceutical care services, and shifting obligations to other healthcare professionals.^34,35 Lack of expertise, skills, and awareness hindered pharmaceutical care service implementation. This study developed an innovative learning tool to help pharmacy and medical students and medical practitioners understand clinical problem-solving.

The ongoing project seeks to evaluate the implementation and user satisfaction of Alsayed_v1 tools in daily practice and analyze data obtained from hospitals, medical centers, community pharmacies, and other primary care settings. In addition, these templates are part of a larger project managed and owned by the corresponding author, including a website and a mobile application to provide medical care support (https://www.asami-draacare.com).

Effective management requires the development of a partnership between the patient with asthma (or the patient’s caregivers) and his healthcare professional(s). The goal of this partnership is to provide the patient with the ability to control his condition with guidance from the healthcare professional(s), discuss and agree on therapy goals, and develop a personalized, written, self-management asthma care plan.³²

While initial diagnosis and treatment of asthma typically begin with primary care providers, there are situations when specialists should become involved in managing the asthmatic patient. Education can be conducted by PharmD, pharmacist, respiratory therapist, or nurse to ensure an understanding of the technique and to stress the importance of adherence to new respiratory devices.

Primary care providers should consider referral of the asthmatic patient to pulmonology and/or allergy/immunology practices for any of the following: poorly controlled or severe asthma despite appropriate treatment and compliance, presence of comorbidities that may affect response to treatment (eg, nasal polyps, COPD, etc), additional diagnostic tests are needed (eg, skin allergy testing, bronchoscopy, etc.), asthma diagnosis is uncertain, or occurrence of a life-threatening asthma exacerbation. Referral to appropriate specialists should also be considered when a psychiatric or psychosocial condition impacts the patient’s ability to comply with appropriate asthma treatment.

The involvement of a social worker may also be considered when a patient is routinely and unwillingly exposed to environmental triggers which negatively impact their condition, such as cigarette smoke, cockroaches, fumes, etc. A social worker can also help ensure that the patient’s family can afford the recommended medications.

Conclusion

This paper applied the validated Alsayed v1 tools to an actual patient situation. These instruments consist of principal components: data collection, assessment of treatments, the MPOP, as well as a care plan and patient education. Incorporating interventions into the classification system is crucial, particularly in pharmaceutical and medical research, where the type of recommendations must be documented to evaluate the service’s value and impact, and it saves practitioners time from manually typing the appropriate interventions. These validated, and clinically tested tools provide a coding system for the MPOP that permits easy documentation with an open hierarchical structure where higher levels are broad and lower levels are particular, and the possibility to enter free text. By implementing Alsayed_v1 tools, the clinical practitioner can actively give the best practice for optimal patient outcomes.