Establishing a national standard to achieve better outcomes for people living with chronic obstructive pulmonary disease

‘When you can’t breathe, nothing else matters.’

These words, from a person with chronic obstructive pulmonary disease (COPD), provide a glimpse of the individual struggle often hidden behind the statistics.

COPD affects an estimated 1 in 13 Australians older than 40 years.¹ It is a leading cause of potentially preventable hospitalisations^* and the third leading cause of death for people aged 65 to 74 years.^2,3 However, COPD remains under-recognised, underdiagnosed and undertreated in Australia – around 50% of people living with COPD may not know they have it, so the prevalence is likely to be higher than current estimates.¹ There are also high rates of variation in care and patient outcomes between local areas, including an 18-fold variation in rates of hospitalisation.⁴ This highlights the need to improve the diagnosis and management of COPD in this country.

Clinical Care Standards are developed by the Australian Commission on Safety and Quality in Health Care (the Commission) for a range of clinical conditions in order to reduce variation in practice and drive the delivery of high-quality care. In October 2024, the Commission published the first Chronic Obstructive Pulmonary Disease Clinical Care Standard (the Standard).⁵ Guided by a multidisciplinary working group, the Standard was developed by identifying aspects of care where practice does not align with evidence and there are opportunities for quality improvement. It was further refined through public consultation and has been endorsed by 20 professional and consumer organisations, including the Thoracic Society of Australia and New Zealand, and Lung Foundation Australia.

The Standard comprises 10 quality statements that describe the care that people living with COPD should expect to receive, no matter where they are treated in Australia (Box 1). Each quality statement is accompanied by one or more specific quality indicators that healthcare services and health professionals can use to measure how well they are implementing the care described in the statement, and to identify opportunities for quality improvement. Examples of process indicators include the proportion of patients with COPD who have been vaccinated for influenza or pneumococcal disease, or the proportion referred for pulmonary rehabilitation.⁶ To support overall monitoring of the implementation of the Standard, healthcare services could consider monitoring data on admissions and readmissions for COPD exacerbations. Importantly, the Standard also serves as a tool for consumers to advocate for better care, and aligns with priority areas for national action identified by Lung Foundation Australia.⁷

In Australia, the COPD-X Guidelines, published by Lung Foundation Australia, provide robust evidence-based recommendations for the assessment, diagnosis and clinical management of COPD.⁸ However, implementation of guideline recommendations in everyday clinical practice remains challenging for a range of reasons.⁷

One such challenge is ensuring the appropriate use of inhaled corticosteroids in COPD. In asthma, inhaled corticosteroid use has made a tremendous difference to overall management and outcomes because of their efficacy in treating the eosinophilic inflammation that is predominantly seen with this condition. However, in COPD, inhaled corticosteroids have a limited role as the pattern of lung inflammation is predominantly neutrophilic and thus largely resistant to inhaled corticosteroids. There is evidence of inhaled corticosteroid overuse in COPD in most countries, with an inhaled corticosteroid often prescribed earlier than needed. The unnecessary use of inhaled corticosteroids exposes patients to increased risk of adverse effects, including pneumonia.^9,10

This emphasises the importance of the COPD-X Guidelines ‘stepwise’ approach for the pharmacological management of spirometry-confirmed COPD, which is addressed in quality statement 6 of the Standard (Box 1). The ‘stepwise’ approach guides prescribers on escalating treatment depending on patient symptoms and exacerbation history.⁸ Briefly, this starts with using a short-acting beta₂ agonist (SABA) or a short-acting muscarinic antagonist (SAMA), followed by adding a long-acting beta₂ agonist (LABA) or a long-acting muscarinic antagonist (LAMA), then dual therapy with a LABA plus a LAMA. The final step is considering the addition of an inhaled corticosteroid but only if there has been a severe exacerbation (requiring hospitalisation) or 2 moderate exacerbations in the preceding 12 months.

Other areas highlighted in the Standard include the need for regular checks of inhaler and spacer technique (up to 90% of patients do not use their inhalers correctly), the best-practice use of oral corticosteroids for COPD exacerbations (if response to a SABA or SAMA is inadequate, use an oral corticosteroid for 5 days), and the limited role of antibiotics (if the criteria in Therapeutic Guidelines: Antibiotic are met, use oral amoxicillin or doxycycline).¹¹

Optimal management of COPD also includes critical nondrug factors, which are addressed in the Standard. This includes comprehensive and accurate diagnosis in which spirometry is essential (yet underutilised), patient education and self-management, smoking cessation, vaccination and pulmonary rehabilitation. The Standard also supports effective transitions from acute care back to the community, where most COPD management occurs – coordinated care is vital.

Although Australia has one of the most advanced healthcare systems in the world, we face significant challenges in delivering high-quality care for people with COPD.⁷ Moreover, there are marked inequities in the provision of quality care for people with COPD in regional and rural Australia and for Aboriginal and Torres Strait Islander peoples.

The reasons for the inequities faced by Aboriginal and Torres Strait Islander peoples are complex and multifaceted, and include both the impacts of systemic racism and lack of access to culturally safe health care. The Standard aims to address these inequities by embedding specific cultural safety and equity considerations throughout the quality statements. These include taking a collaborative approach to care planning, engaging Aboriginal and Torres Strait Islander health workers and practitioners as part of care teams, encouraging flexible service delivery to optimise attendance, and encouraging healthcare services to establish culturally safe networks and referral pathways. The standard emphasises the importance of family and community involvement in care decisions and recognises the key role of Aboriginal Community Controlled Health Organisations and Aboriginal Medical Services in delivering culturally safe care, particularly in rural and remote areas.

In addition to Clinical Care Standards, the Commission sets national safety and quality standards for accreditation of acute healthcare services, and some primary and community healthcare services. These accreditation standards support the implementation of Clinical Care Standards and locally appropriate action on quality improvement.

Effective implementation of the Standard will go a long way towards aligning care with evidence-based guidelines, improving outcomes and overall quality of life – giving people with COPD the chance to take a better breath.

* Potentially preventable hospitalisations are defined as admissions to hospital where the hospitalisation could have been prevented through the provision of appropriate, individualised health interventions and early disease management usually delivered in primary-care and community-based care settings.

Conflicts of interest: the authors are employees of the Australian Commission on Safety and Quality in Health Care, which is funded by the Australian Government Department of Health and Aged Care, and were involved in the development of the COPD Clinical Care Standard. Maria B Sukkar holds shares in 4D Medical. Lee Fong, Rana Ahmed and Alice Bhasale have no other interests to declare.

This article is peer reviewed.

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