Process evaluation of a pragmatic, multicentre pilot randomised controlled trial (RCT) in primary care: Tailored Intervention for COPD and Co-morbidities by Pharmacists and Consultant Physicians (TICC PCP)

Problem

The prevalence of Chronic Obstructive Pulmonary Disease (COPD) and associated hospitalisations are increasing. Evidence suggests care for people with moderate-to-severe COPD is sub-optimal, particularly in relation to prescribing and management of comorbidities. Making greater use of the increasing number of pharmacists working in primary care, an Independent Prescriber Pharmacist role may help improve the quality of care of people with moderate-to-severe COPD and comorbidities.

Approach

Pilot randomised controlled trial (RCT) in NHS Greater Glasgow and Clyde and NHS Lothian of an intervention aimed at improving health and care of people with moderate-severe COPD and comorbidities. Participants were recruited from hospital-based respiratory clinics. 55 participants randomly allocated to Pharmacist intervention in addition to Usual Care, 55 randomised to Usual Care. Intervention participants received an NHS pharmacist home-based intervention for up to one year. Pharmacists holistically assessed participants’ health and social care needs. Working closely with respiratory consultants and GPs, they prescribed, referred to other health and social care services as appropriate, individualising support to the participant’s needs and priorities. Our process evaluation involved qualitative telephone interviews with 10 Health Care Professionals (HCPs)/study staff, and 20 intervention participants. Semi-structured interviews explored perception/acceptability of trial procedures. Interviews were audio-recorded and transcribed verbatim. Data analysed thematically; framework matrices used to compare perspectives of participants from areas of high and low socio-economic status (SES). Data conceptualised through a Normalisation Process Theory lens.

Findings

The intervention was viewed positively by participants and HCPs/study staff. Changes made to care perceived as beneficial to most participants - included medication changes, increased understanding of COPD and medications, improved breathing/exacerbation management, provision of home aids/adaptations, regular check-ups, additional scans and tests. However, a small number of participants perceived the intervention to have had a limited impact on them. While trial procedures were seen as broadly acceptable, HCPs and study staff encountered some challenges in recruitment (staff and patients), training, workload, workspace, IT access, and data collection/input. Several barriers (e.g. IT infrastructure challenges) and facilitators (e.g. potential benefits of integration into multi-disciplinary teams) to future implementation of the intervention were identified. Analysis of SES suggests pharmacists were able to make changes for all participants but made more improvements for participants from areas of lower SES.

Consequences

This pharmacist intervention was well received and thought to be beneficial by participants and their HCPs. Some refinement of intervention and trial procedures would allow for smoother implementation and may overcome challenges encountered. Attention to those barriers and facilitators to future implementation identified should promote implementation on a larger scale. In resource constrained contexts, consideration could be given to targeting the intervention to those living in areas of lower SES.