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A recent article in Lancet Respiratory Medicine brought the high burden of respiratory disease in Ireland into sharp focus. This is consistent with the recently-published first annual report of the National Healthcare Quality Reporting System (NHQRS), published by the Department of Health. Ireland has one of the highest age-standardised death rates from respiratory causes in Europe and high rates of hospital admission for lung disease. The recent report demonstrated that Irish admission rates for COPD are the second-highest in the OECD and 60 per cent higher than in the UK. This is all the more disturbing when we consider that some patients with COPD are admitted to private hospitals in this country. There is also considerable regional variability in the admission rates in Ireland with, for instance, Offaly having the highest admission rates for patients with COPD.
What is also of concern is that admission rates are rising in Ireland in contrast to the trend in most other OECD countries, where there has been a reduction in hospitalisation rates for COPD. Even among those patients admitted to hospital in Ireland with exacerbations of COPD, the length of stay varies enormously, from a high of 12.9 days to a low of 4.5 days. Factors such as age and socioeconomic status don’t appear to explain this. Such variability in indicators of care has to imply that the management of COPD is sub-optimal.
What factors are responsible for this variability in care and resultant high admission rates? As the NHQRS report states, many factors could be responsible, including the quality of the data, local prevalence of the disease and access to local hospital beds.
However, these factors are unlikely to explain the variability evident in the Irish figures and it is far more likely that as the OECD suggests, it may reflect a lack of resources, particularly in primary care. In particular, there is a lack of access to diagnostic facilities such as spirometry in primary care.
Given that spirometry is essential to the diagnosis of COPD, GPs are handicapped from the very start in managing these patients. Furthermore, significant input is needed into the management of COPD patients in terms of education in areas such as smoking cessation, inhaler technique and correct use of medication. Specialist respiratory nurses most appropriately give such support.
Patients with COPD can be managed more frequently in the community with appropriate support and indeed, large numbers are already being managed in the community by GPs who are stretched to provide optimum care. Other services such as pulmonary rehabilitation should also be available in the community. These services can improve patients’ quality of life, exercise tolerance and help keep people stable in the community.
The HSE’s National Clinical Programme for COPD has organised a number of developments to improve care for COPD patients. The most successful initiative to date has been the COPD Outreach Programme, which has been implemented in 12 hospitals. This is in addition to the service being available in an existing three hospitals. This has been associated with a reduction in the length of stay patients admitted for COPD exacerbations.
The programme is very much aware, however, that the main cohort of patients with COPD is in primary care. The economic downturn has previously limited finance to provide increased resources but this year the HSE has funded a number of COPD demonstrator projects for primary care. An integrated respiratory nurse and physiotherapist have been appointed, attached to three sites: Sligo Regional Hospital; the Mater Hospital, Dublin; and St Luke’s General Hospital, Kilkenny, and an integrated respiratory nurse has been appointed to St Michael’s Hospital, Dun Laoghaire.
These clinicians will operate 80 per cent of the time in the community and the 20 per cent of their time spent in hospital will relate to the care of their community patients.
They will provide spirometry in primary care centres and GP practices, as well as advice on self-management, inhaler technique and review of medication. These interventions should hopefully assist GPs caring for COPD patients in their practices. It will have the advantage of delivering care at the lowest level of complexity in a time and place convenient to patients. It is expected that more of these posts will be generated over the coming years.
For more on respiratory medicine, check out Medical Independent’s new journal Respiratory Update, which is now available online (premium content) at www.medicalindependent.ie. Prof Tim McDonnell is the Clinical Editor of Respiratory Update.