Respiratory diseases are characterised by their heterogeneity, prevalence, symptomatology, and morbidity and mortality (Fig. 1). In fact, they are the third leading cause of death worldwide and in Spain.1,2 The relevance of these diseases will increase in the future as a result of increasing prevalence, pollution, and new infections.3

Fig. 1.

Prevalence and impact of respiratory diseases.

Colour code: red (very high); orange (high); yellow (moderate); green (low).

Abbreviations: COPD, chronic obstructive pulmonary disease; ILD, interstitial lung disease.

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Pharmaceutical care (PC) is key to the management of respiratory diseases due to complex treatments such as inhalers and nasal devices. They are used correctly only in one-third of cases due to their complexity, variability, need for coordination, lung capacity, and use of chambers, among other factors.4,5 Adherence is estimated at 50%6 and records show that only 63% of prescriptions are filled.7 Other treatments should also be taken into account, such as biologics for asthma or polyposis, and oxygen therapy for chronic obstructive respiratory disease (COPD) or interstitial lung disease (ILD).

The high prevalence of both respiratory and non-respiratory comorbidities, which lead to poorer outcomes in terms of quality of life and morbidity and mortality8–12 makes it essential to understand the complexity of these diseases, not only in terms of medications, but also in terms of the specific tests and techniques used in diagnosis and follow-up. In 2019, the Spanish Society of Hospital Pharmacy (SEFH) created the Respiratory Diseases Working Group (NEUMO) to address these issues.

The aim of this article was to investigate the current situation of hospital pharmacists (HPs) in the field of respiratory disease, by delineating their healthcare activities and seeking their opinions, thereby assisting in the development of activities tailored to the identified needs.

This study is the first to investigate PC levels and activity, as well as the perceptions and opinions of HPs regarding the management of respiratory diseases in Spain.

The participating hospitals showed a high level of activity with some heterogeneity, particularly in terms of respiratory admissions and the use of hospital outpatient medications. Most hospitals treated a wide range of diseases, including asthma, COPD, pneumonia, bronchiectasis, and ILD. Treatment for some diseases was restricted to referral hospitals. HP activity could be influenced by the number of pharmacists working in these hospitals, the uneven implementation of new treatments, and the presence of day hospitals.

The presence of referral pharmacists and specific PC in most hospitals was notable. However, referral activities only took up an average of 40% of the HPs' working day, indicating a shortage of specialist pharmacists, unlike in other areas.13 HPs have been recognised for their importance in the management of respiratory disease, especially within the area of community pharmacy.14–16 However, differences appear at the hospital level. Inpatient care involves ongoing and acute care, leading to interventions for health-related problems in 50% of patients.17 Outpatient consultations tend to focus on severe diseases with complex treatments. The SEFH's approach to PC for these patients is based on the MAPEX project, which aims to provide individualised pharmacotherapeutic targets according to the patient's situation.18 Although there was PC activity in outpatient and inpatient settings in most hospitals, patient stratification was very selective. The SEFH's MAPEX initiative developed a stratification model for respiratory diseases using the Capacity, Motivation, and Opportunity model.19

The field of respiratory diseases requires subspecialisation, but our results suggest that HP activity is limited to certain diseases within this field. This finding is underscored by their unequal participation in committees as well as the weight placed on their assessments. The participation of HPs was higher in diseases such as asthma, pneumonia, or those requiring biologics. Involvement in pharmacotherapy management and participation in committees are opportunities to be further developed in the future. Pharmacists already play a clinical role in the setting of COPD or asthma, but they also a role in emerging areas: SARS-CoV-2, critical care, antimicrobials, or the prevention of respiratory viruses.20–25

The marked interest of resident and consultant HPs in relation to PC in respiratory disease was evidenced by their level of participation in expressing their opinions on the topic. They expressed the need to prioritise prevalent diseases (asthma, COPD), but also others such as cystic fibrosis, pulmonary hypertension, IDPD, and certain infections. Half of the respondents considered that the inclusion of HPs was “good,” albeit with room for improvement and, in most cases, a need for prioritisation criteria. These results highlight the limited use of prioritisation criteria and suggest that those used in other diseases are acceptable.26 One of the problems identified by the HPs are time constraints due to the need for multitasking. However, there are promising signs of HP specialisation in the area of respiratory disease and its positive impact on clinical outcomes.27,28

Training and the development of competencies are a fundamental aspect of subspecialisation. Our study showed improvements in the 4 areas of HP competencies described in the framework provided by the European Association of Hospital Pharmacists: patient, medicines, system, and practice.29 External or hospital sessions were positively rated by respondents, although provision was limited, there was room for improvement, and certain diseases were identified as priorities. In any case, training should be tailored to meet the specific needs of each hospital in order to optimise PC. Some competencies need improvement, such as the inclusion of HPs in multidisciplinary teams, the use of motivational interviewing, the use of electronic monitoring devices, and telepharmacy.30

This study has limitations. The number of hospitals sampled and pharmacists interviewed was reasonable, but limited. Thus, the results may have been biased by the presence of pharmacists with a greater interest in respiratory diseases. Therefore, although the study provides valuable information, the results may not be representative of all hospitals in Spain. The degree of HP participation in committees or inclusion in sub-areas could also vary for this reason. This limitation is assumed to be minor due to the sufficient number of hospitals analysed. Some Spanish regions are over-represented, but this is aspect is likely to be offset by the participation of hospitals from other regions. Finally, the self-assessment of professional competencies is challenging and should be interpreted within the context of the study.

The study reveals the emerging role of HPs in the PC of respiratory diseases in Spain. This role requires specialisation, inclusion within multidisciplinary teams, and participation in committees. Further work is needed on these issues, given the observed variability between hospitals as well as the margins for improvement. However, specific barriers to this were identified, such as the need for prioritisation criteria, more time for referral activities, and improved training to better address specific healthcare needs and approaches to PC that are best suited to patients.

This is the first study to explore the level of PC activity, HP inclusion, prioritisation, training, and education in the field of respiratory disease.

The results of this study will help develop pioneering actions tailored to the needs within this field to improve care for patients with respiratory disease.

None declared.

Noé Garin: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Borja Zarate-Tamames: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Investigation, Formal analysis, Data curation, Conceptualization. Sonia Jornet: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Eva María García: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. María del Mar López-Gil: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Gregorio Romero: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Investigation, Formal analysis, Conceptualization. Elena Villamañan: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Marta Calvin-Lamas: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization.