Chronic Obstructive Pulmonary Disease (COPD) management in the community: how could primary care team contribute?

Outcomes and Hospital Service Use Among Patients With COPD in a Nurse- and Allied Health-Led Clinic

Importance

Multidisciplinary disease management efforts enable the improvement in lung function among patients with chronic obstructive pulmonary disease (COPD), but there is little evidence of its association with risks of adverse health outcomes and health care service use.

Objective

To examine the association between the use of a nurse- and allied health-led primary care clinic for respiratory patients, namely the Nurse and Allied Health Clinic-Respiratory Care (NAHC-Respiratory), and their risks of mortality and morbidity and health care service use.

Design, Setting, and Participants

This territory-wide, population-based, propensity-matched, retrospective cohort study used data from the electronic health records of all patients who used public health care services in Hong Kong, China, from January 1, 2010, to December 31, 2019. All patients with COPD treated in public outpatient clinics between January 1, 2010, and December 31, 2014, were included. Patients who attended NAHC-Respiratory and usual care only were propensity score-matched at a 1:2 ratio. Data analyses were conducted between August 2023 and April 2024.

Exposure

Attendance at NAHC-Respiratory.

Main Outcomes and Measures

All-cause and cause-specific mortality, incidence of COPD complications, and use of emergency department and inpatient services until the end of 2019 were compared between the NAHC-Respiratory and usual care participants using Cox proportional hazard regression, Poisson regression, and log-link gamma regression models after matching.

Results

This study included 9048 eligible patients after matching, including 3093 in the exposure group (2814 [91.0%] men; mean [SD] age, 69.8 [9.5] years) and 5955 in the reference group (5431 [91.2%] men; mean [SD] age, 69.5 [11.7] years). Compared with patients in the usual care-only group (reference), patients in the exposure group had lower risks of all-cause mortality (hazard ratio [HR], 0.84; 95% CI, 0.78-0.90) as well as pneumonia-caused (HR, 0.85; 95% CI, 0.74-0.97), respiratory-caused (HR, 0.86; 95% CI, 0.77-0.96), and cardiovascular-caused (HR, 0.74; 95% CI, 0.59-0.93) mortality. Exposure was associated with reduced rates of emergency department visits (incidence rate ratio [IRR], 0.92; 95% CI, 0.86-0.98) and hospitalization through emergency department (IRR, 0.89; 95% CI, 0.83-0.95).

Conclusions

In this cohort study, the use of a nurse- and allied health-led clinic in primary care settings was associated with reduced risks of mortality and use of hospital services among patients with COPD. These findings emphasize the important role of health care workers other than physicians in disease management in the primary care setting. The NAHC-Respiratory model and service components can be used to help improve primary care programs to benefit more patients with COPD.

'People that suffer or have been through it know the answers': stakeholders' perspectives on improving healthcare systems for end-of-life care in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive and disabling lung condition with a high mortality. Our research has shown that health care for end-of-life COPD is poorly integrated. The aim of this study was to involve people with end-of-life COPD, their support people and health professionals in the design of healthcare services to help improve the delivery of care for advanced COPD, including informing system-level quality improvement.

DESIGN

We conducted a focus group study involving stakeholders of healthcare services: people with end-of life COPD, support people, bereaved support people, and community- and hospital-based health care professionals.

METHODS

We conducted qualitative analysis using deductive structural coding, and then inductive descriptive and pattern coding. Analyses were triangulated by investigators. The research positioned people with end-of-life COPD, their support people and health professionals as experts in healthcare services. Critical theory and Actor-Network theory informed the analysis.

RESULTS

Seven focus groups involving 74 participants reported their experiences of end-of-life care for COPD. Five themes related to healthcare systems responses to improving care quality were identified: governance, system integration, resource design and development, standardisation of processes, and communication.

CONCLUSION

Stakeholders provided multiple healthcare system-level responses to end-of-life care in COPD that could inform healthcare service design and clinical quality improvement.

Developments in smoking cessation interventions for patients with chronic obstructive pulmonary disease in the past 5 years: a scoping review

INTRODUCTION

Smoking cessation is the most effective strategy for slowing the progression of chronic obstructive pulmonary disease (COPD). However, COPD patients find it difficult to quit smoking with standard cessation interventions.

AREAS COVERED

A scoping review of smoking cessation for COPD patients was conducted by searching the MEDLINE, Embase, and Cochrane Library databases for all studies published between 1 January 2016 and 22 September 2021. Four themes were set up and 47 studies were included eventually. The majority of the included studies (61.7%, 29/47) investigated efficacy and effectiveness, including new strategies for extended treatment and mobile health (mHealth) delivery approach. Studies examining accessibility and utilization (31.9%, 15/47), safety (10.6%, 5/47), and health economics (6.4%, 3/47) were also reviewed. The quality of the included randomized controlled trials was also evaluated.

EXPERT OPINION

Pharmacotherapy combined with behavioral interventions delivered via mHealth may be a promising strategy to help COPD smokers quit. However, the overall quality of the current studies is poor, making it challenging for clinicians to make informed decisions. Future high-quality studies are needed to provide conclusive evidence on the optimal pharmacotherapies and the most cost-effective comprehensive smoking cessation interventions, particularly those integrated into disease management for smokers with COPD.

Clinical Factors Predictive of COPD Diagnosis in a Community Hospital

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an irreversible obstructive airway disease. Diagnosis can be made using a spirometry which may not be available in resource-limited setting or developing countries. AIM: This study aimed to evaluate if clinical factors can be predictive of COPD diagnosis. MATERIALS AND METHODS: This study was a retrospective cohort study conducted at community hospital. The inclusion criteria were adult patients who had clinical symptoms suggestive of COPD and had performed adequate pulmonary function tests. Patients were categorized into two groups by diagnosis of COPD. Clinical predictors of being COPD were executed by multivariate logistic regression analysis. RESULTS: There were 200 patients who met the study criteria. Of those, 136 patients (68.00%) had compatible pulmonary function test with COPD. There were eight factors in the final predictive model for being COPD (Table 1). Among these factors, three factors were independently associated with being COPD: Productive sputum, body mass index, and hyperinflation by chest X-ray. The hyperinflation by chest X-ray had highest adjusted odds ratio of 10.93 (95% CI 3.23, 36.96). CONCLUSIONS: Productive sputum, body mass index, and hyperinflation by chest X-ray were independent factors for COPD diagnosis. Physicians in resource-limited setting may use these clinical factors as diagnostic tool for COPD.

Challenges and Strategies for Improving COPD Primary Care Services in Quebec: Results of the Experience of the COMPAS+ Quality Improvement Collaborative

Introduction

Management of chronic obstructive pulmonary disease (COPD) remains a challenge in primary care and multiple barriers can limit implementation of COPD guidelines. Since 2016, a quality improvement (QI) collaborative, called COMPAS+, has been implemented across the province of Quebec (Canada) to support improvement of chronic disease management in primary care. The aim of this study was to describe the main COPD quality problems reported by participating teams and the strategies they proposed and implemented to improve COPD primary care services in Quebec.

Methods

Sixteen sites in four different regions of Quebec were engaged in the COMPAS+ intervention to improve primary care services delivered to people living with COPD. A total of 14 workshop reports, 31 QI action plans and 4 regional final reports underwent content analysis. Key COPD quality problems were first identified and, for each of them, root causes were classified according to the domains and constructs of the Consolidated Framework for Implementation Research. Proposed strategies were organized according to the intervention function types described in the Behavior Change Wheel.

Results

Four key COPD quality problems were identified: 1) lack of organization/coordination of COPD services, 2) lack of screening services coordination, 3) lack of interprofessional communication and collaboration and 4) lack of treatment adherence. Main root causes explaining these quality gaps were 1) lack of awareness of COPD, 2) lack of professional knowledge, 3) lack of definition of professional roles, 4) lack of resources and tools for COPD prevention, diagnosis, and follow-up, 5) lack of communication tools, 6) lack of integration of the patient-as-partner approach, and 7) lack of adaptation of patient education to their specific needs. Multiple strategies were proposed to improve healthcare professionals’ education and interprofessional collaboration and communication.

Conclusion

QI collaborative activities can support achieving understanding of QI challenges healthcare organizations face to improve COPD services.

Clinical Audit on Chronic Obstructive Pulmonary Disease (COPD) Management in Primary Care: A Quality Improvement Project from Hong Kong

Objective

To enhance the quality of COPD management in primary care via a two-phase clinical audit in Hong Kong.

Methods

COPD patients aged 40 or above and had attended any of the 73 public primary care clinics under the Hospital Authority of Hong Kong (HAHK) for follow up (FU) during the audit period were included. Performance of six evidence-based audit criteria on COPD care was reviewed in phase 1 from 1st April 2017 to 31st March 2018. Service gaps were identified and a series of quality improvement strategies were executed in the one-year implementation phase. The outcome of the service enhancement was assessed in phase 2 from 1st April 2019 to 31st March 2020. Student’s t-test and the chi-square test were used to examine the statistically significant differences between the two phases.

Results

Totally 10,385 COPD cases were identified in phase 1, the majority were male (87.7%) and the mean age was 75.3±9.9 years. Among the 3102 active smokers, 1788 (57.6%) were referred to receive the smoking cessation counselling and 1578 (50.9%) actually attended it. A total of 4866 cases (46.9%) received seasonal influenza vaccine (SIV) and 4227 cases (40.7%) received pneumococcal vaccine (PCV). A total of 1983 patients (19.1%) had spirometry test done before and 1327 patients (12.8%) had history of hospital admission due to acute exacerbation of COPD (AECOPD). After the proactive implementation phase, performance on all criteria was significantly improved in phase 2, with a marked increase in the SIV and PCV uptake rate and spirometry performance rate. Most importantly, a significant reduction in AECOPD rate leading to hospital admission had been achieved (9.6%, P<0.00001).

Conclusion

COPD care at all public primary care clinics of HAHK had been significantly improved for all audit criteria via the systematic team approach, which, in turn, reduced the hospital admission rate and helped relieve the burden of the health care system.