A national standard for people living with chronic obstructive pulmonary disease

[Music] Welcome to the Australian Prescriber Podcast. An independent, no-nonsense podcast for busy health professionals.

I'm Dhineli Perera, your host for this episode, and it's a pleasure to be chatting to Dr Lee Fong today about the inroads made towards achieving better outcomes for people living with chronic obstructive pulmonary disease, otherwise known as COPD. Dr Lee Fong is a medical advisor for the Australian Commission on Safety and Quality in Health Care and a general practitioner based in the Hunter region in New South Wales. Lee, together with his co-authors, Maria Sukkar, Rana Ahmed and Alice Bhasale have written about the what and why when it comes to establishing a national standard to improve the lives of those living with COPD. A big welcome to the program, Lee.

Thanks for having me on. Really appreciate it.

Lee, your paper starts off with some really interesting facts about COPD. One that caught my attention was the 18-fold variability in the rates of hospitalisation across Australia. How did we arrive at such a situation?

No, you're right. It's actually quite staggering just to think about that level of variation. And just a quick note that the Australian Commission on Safety and Quality in Health Care has a resource called the Atlas of Healthcare Variation, and that's where that information came out of.

And staggering as it is, behind it, there's, as you can imagine, a lot of complex factors there [which] includes geographical, resource challenges. And I think the Clinical Care Standard is about recognising that our healthcare system faces challenges, it faces gaps, it faces enormous challenges in delivering care across what is a huge country that we have. And so, this really underlines the importance of what we're trying to do with the COPD Clinical Care Standard (the Standard), it’s about saying, hey, we've got gaps and some of them are really big. What can we do to close those gaps by promoting best-practice care in this particular instance, for example, ensuring that people at risk of COPD get recognised early, get diagnosed accurately, and get the best-practice management no matter where they are?

And in terms of how we arrived at this situation, do we think it's because the factors of such a multifactorial situation that has progressed over time and then that gap has widened?

Yeah, I think so. So are there inequities in terms of access to care? Are there gaps in preventive measures like smoking cessation in terms of access to care, access to effective programs like pulmonary rehabilitation? Is that harder and more difficult to provide or get to in, for example, rural and regional areas? Do we know that there are high rates of smoking, for example, in certain communities? Absolutely. So yes, there's a lot of things that contribute to this variation in care.

So before we launch into the specific quality statements within the Clinical Care Standard, I thought listeners would benefit from understanding why the standards are developed, what their points of difference are from other guidelines, for example, the COPD-X Guidelines developed by the Lung Foundation Australia. Could you help us understand when you’d look up the Clinical Care Standard versus when a prescriber or a health professional needs to look up the COPD-X Guidelines?

That's actually a really important distinction to understand. So yes, COPD-X Guidelines, it's like I would say a super comprehensive medical textbook about a particular topic. So they contain everything you need to know about managing COPD, for particularly the COPD-X Guidelines.

On the other hand, I'd say the COPD Clinical Care Standard really complements the COPD-X Guidelines. So I'd look at it more as being like your COPD quality improvement handbook. It identifies those critical areas where we tend to be seeing care falling short, highlighting some of the really high-impact things we can do to try and improve how we're approaching COPD.

So an example would be thinking about spirometry. The COPD-X Guidelines give us plenty of detailed technical information about performing spirometry, interpreting results, understanding lung function parameters. The Clinical Care Standard doesn't do that. Instead, it really zeros in on the fact that a lot of people who have a diagnosis of COPD haven't had that confirmed with spirometry, even though it is essential for an accurate diagnosis. We just released a MedicineInsight GP snapshot report on COPD that showed only around 2 in 5 patients with COPD have a spirometry test recorded in their electronic health record.

So to recap on that, you might turn to COPD-X when you need detailed clinical guidance. And you'd look to the Clinical Care Standard when you are focusing more on quality improvement, looking at what are some ways you can measure whether you or your service is delivering best-practice care. So goes hand in hand, COPD-X tells you what best practice is, the Clinical Care Standard helps you make it happen.

I think that actually makes it really clear. If you think about it as a Venn diagram, there's a bit of an overlap, but they really are standalone documents that are supporting each other and informing each other as well. And that the Standard is how you measure how well you're really doing at implementing those guidelines.

So I guess now onto the structure of the Standard, we have 10 quality statements that are paired with one or more quality indicators. What does this mean to the end user exactly?

Say, typical day in your general practice and you're seeing a patient with COPD. The first quality statement for example, talks about if you have a patient over the age of 35 with risk factors like smoking and symptoms like breathlessness, then they should get high-quality spirometry to confirm their diagnosis. But then how, as GPs, do we know that this is actually happening in our practice? And that's what indicators are for.

So one practical measure could be, can we look at the proportion of patients with a recorded COPD diagnosis who have a record of spirometry results in their file? So we can usually generate this data pretty easily out of our practice software. And again, here's the plug. If you sign up to the Commission's free MedicineInsight Program, we can do it for you. Let's say you run the report and then like this snapshot COPD report found, maybe only about 40% of your COPD patients have documented spirometry. Well, that's valuable information. It tells you that there's a gap somewhere in the process. Maybe for example, you need to upskill your practice nurses or get them some training in performing spirometry. Maybe you could run a report and flag those patients in your practice who have a diagnosis of COPD but no record of spirometry.

So I think this is the beauty of the Clinical Care Standard. It's about saying, hey, let's use knowledge and data to identify and measure things we can actually influence.

That's a really great example of the practical implementation of the statements and the quality indicators. Thanks for that, Lee.

So although we don't have time to go through all of the quality statements today, I've, myself, have picked a couple that I think could be game-changers if they really were implemented properly. Two of them together as a pair were the statements 6 and 7, which focus on the pharmacological management of stable and exacerbated COPD, respectively. Could you please describe the crux of these statements and their corresponding quality indicators? And I guess secondary to that, have you seen really good examples of where these have been implemented in your travels?

So when it comes to the pharmacological management of stable COPD, I think one of the challenges here is the appropriate use of inhaled corticosteroids. And here I think we run into this frankly, sometimes quite confusing, overlap with asthma where you have primarily eosinophilic inflammation, then inhaled corticosteroids are fantastic, work really, really well.

In COPD on the other hand, where lung inflammation is predominantly neutrophilic, inhaled corticosteroids (ICS) don't work nearly so well. The statement talks about the importance of following the COPD-X Guidelines, so the stepwise approach. Start with the short-acting beta2 agonist or short-acting muscarinic antagonist, followed up by adding a LABA [long-acting beta2 agonist] or a LAMA [long-acting muscarinic antagonist]. Then make it dual therapy with a LAMA plus a LABA and then only add the ICS right at the end if there's been, say, a severe exacerbation requiring hospitalisation or a couple of moderate exacerbations in the preceding 12 months. It's easy to just say it, but it gets more complex.

For example, if we have a patient who we think has COPD but we're not 100% sure, or they've got COPD that hasn't been confirmed with spirometry, then what is the best treatment? Are we treating asthma or are we treating COPD? And so this goes back to that idea of we need to get that diagnosis nailed first before we can proceed to what the best-practice management is. Having established that this patient actually has got COPD and it's hopefully not asthma and not COPD/asthma overlap, then we can proceed down what we know to be the best-practice management – stepwise management of COPD. So that's a key takeaway for that aspect in terms of the management of stable COPD.

Another aspect to that is the need for regular checks of inhaler and spacer technique. And so this is again another staggering statistic, which is that maybe up to 90% of patients are not using their inhalers correctly.

That is staggering.

It is. I mean, it's kind of amazing. And it's like that whole process of stepwise management assumes that you are getting the medication.

Yeah, assumes you're getting the dose to the site of action, right?

That's right. And if 90% of the time you are not actually maximising that step, then it's a pity to be pushing into more and more medication use when maybe all that had to be done was to fix up that technique. And so that's another aspect of the statement which talks about getting that inhaler technique reviewed and corrected at opportunistic times.

So in terms of how can that be done well, this is a challenge, isn't it? In the healthcare system, who is not busy? And the answer is, well, that would be nobody. Everybody is super busy. And so where do we find the time to do this? Who is in the best place and position to do this? So as GPs, should we be focusing on this? I think so. For inhaler technique checking and education, can we make sure we've got that sorted out so we can check and pass it on? Yes, we can do that, particularly when there’s changes in medication and we should be on top of that and it's a great time to check.

Where else can it happen? I think it can happen with maybe our practice nurses. So is there an opportunity for them to be upskilling and making sure they're on top of those techniques and passing them onto patients? For example, if they're involved with doing some sort of chronic disease management things, then that's probably a great time for that to happen.

What about medication reviews with the pharmacist? Maybe that's another time. So referring to a pharmacist, get a home medication review and having inhaler technique checks as part of that, I think would be another great opportunity. And of course, pharmacists in the community when they're dispensing the medications and particularly if there's a change in medication again, would be another great time to be involved with that.

Secondly to that, Lee, the other statement that I was interested in was statement one, which winds back things to really utilising those high-quality spirometry services to enable proper diagnosis. What would you say are some of the barriers to accessing this diagnostic tool?

That's a good question. As far as spirometry, there's a lot of barriers, things that get in the way of access. We saw a drop-off in the use of spirometry when COVID happened. And there were lots of things around that includes you can't see patients face-to-face and a lot of recommendations in terms of infection protection, which again made it more difficult.

As it stands now, I would say there are quite a lot of resources involved in doing high-quality spirometry in general practice. You've got to train people, you've got to calibrate your machines, there's consumables so there's a cost involved. And so that can be a challenge for many practices. If it's hard to make that happen in your practice, then the next question is, well, is there somebody else you can access to get that done? Is there a respiratory lab around the corner that you can refer somebody to? And then there might be barriers for the patient in terms of cost. There might be a barrier to patients in terms of, well, you know what? There is no respiratory lab around the corner. It's a 4-hour drive away. So those are challenges as well.

Yeah, it is multifactorial, but then I guess investigating it for your specific practice would be your suggestion in this situation. Just to find out what are those barriers and then looking for ways to work around them as best as possible.

I'd say so. And there's different ways to approach this. For example, approaching your PHN [primary health network], so having a look on your health pathways to see what is available. Maybe having a discussion with your PHN about assisting with some sort of access. If you can identify a gap, that might be a good place to start.

I'll move to my next question then, Lee. If you could walk us through how the Standard really embeds the specific cultural safety and equity considerations throughout the quality statements. So how do you see these improving for the Aboriginal and Torres Strait Islander peoples with COPD?

I think the Standard explicitly integrates cultural safety across all the quality statements. We know that there is a big gap, a big variation in health outcomes with regard to Aboriginal and Torres Strait Islander peoples. So what can we do? I think there's a number of things that are really important to constantly keep in mind.

One is collaborative care planning. So ensuring that treatment really aligns with patient needs and preferences. Involving Aboriginal health workers and practitioners in care teams, including in primary care. The absolutely key role of Aboriginal Controlled Health Organisations and Aboriginal Medical Services.

I think we probably need to think about being really flexible in care delivery. So what are the other options that we can bring to pair? So things like, for example, when it comes to pulmonary rehabilitation, do you really have to travel to a particular place at a particular time? Are there some other options that either are available or help make available? Are there telehealth options? Are there community-based rehab options? And I think also making sure that the health networks that we're using, the referral pathways that we're using, making sure that they're culturally safe. So they're places that are accessible, that are places that the communities are happy to come to is essential as well.

That's excellent. I think just taking that step back and being flexible in the approach is the critical part to translating that for Aboriginal and Torres Strait Islander people in particular.

Absolutely.

So finally, Lee, I think it's fair to say that implementing the standards in big metropolitan cities is achievable. However, for health services in smaller practices and regional centres, where can they go for help and support when attempting to implement these important clinical standards for patients with COPD? What would be your list of go-tos?

Yeah, I think you're right. It can be really challenging in rural remote settings. I think one thing that we touched on before was primary health networks. So they're there to provide practical help and resources. So reaching out to your primary health network, accessing the health pathway that's maintained by your primary health network, they should be offering high-quality, locally relevant guidance.

Another way to look at it is just start where you are. So if you are in a small practice with limited access to resources, then maybe just start on a small thing. So maybe focus on accurate diagnosis, focus on COPD action plans, and then just gradually build your way up into looking at considering implementation of other things in the Standard. For example, the upcoming MedicineInsight report. Sign up to the MedicineInsight Program. Let us help you with something that is free for you to access, where we can provide you with the data to help you make the improvements. That's something that you can access no matter where you are, whether you are in an urban setting or a rural setting.

Excellent. Well, thank you so much for that. That's unfortunately all the time we've got for this episode. Many thanks for joining us today. I really appreciate it, Lee.

Thank you so much for having me on.

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Dr Fong's article, Establishing a national standard to achieve better outcomes for people living with chronic obstructive pulmonary disease, is available on the Australian Prescriber website. The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines. The authors acknowledge that they 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. They were also involved in the development of the COPD Clinical Care Standard. I'm Dhineli Perera and thanks for joining us on the Australian Prescriber Podcast.