Can we deliver better health care to people with sev ere Chronic Obstructive Pulmonary Disease (COPD) in the Southern Region of New Zealand?

Problem

Chronic obstructive pulmonary disease (COPD) is a common chronic disease with significant morbidity and mortality which places a large burden on the New Zealand (NZ) health system. Costs attributable to COPD include medications, hospital care and primary care visits: NZ has the second highest rate of hospitalisations due to COPD in the OECD. People with severe COPD account for most COPD morbidity and mortality. They have significant symptoms, including breathlessness and fatigue, and impaired quality of life. They also receive suboptimal care, notably in relation to uptake of a key effective intervention - pulmonary rehabilitation (PR). One important reason why people with COPD receive suboptimal care is that the NZ health system struggles to provide integration of health services across primary and secondary care. Care remains ‘provider centric’ as opposed to ‘patient centric’, with patients having to navigate an increasingly complex and fragmented health system. We aimed to determine: a) health care utilisation and health care and social support needs of people with severe COPD and b) the barriers and enablers to the provision of high quality integrated COPD care in both primary and secondary care.

Approach

Design: a mixed-methods implementation research study utilizing quantitative (retrospective case note review of patients hospitalized with severe COPD) and qualitative approaches (interviews with patients with severe COPD with health care providers). Setting: Primary and secondary care in a health region in the lower South Island of NZ (Southern District Health Board (DHB)) serving a population of 309,000 dispersed over the largest geographic region of NZ (62,360 km2).Participants: 340 patients hospitalised with severe COPD over a 12 month period had their case notes reviewed; 23 patients/carers with severe COPD and 11 health care providers participated in qualitative semi-structured interviews.

Findings

Preliminary findings are that people with severe COPD are multimorbid and have high health care utilization, notably repeat hospitalisations for infective exacerbations, and that there is low uptake of PR. Patients report variable awareness of, and access to, PR particularly those living in rural areas. They also reported variable advice regarding prompt management of infective exacerbations in primary care. Health care providers emphasised the need for more provision and access to PR and the need for better awareness of PR and more PR referrals from primary care. They also highlighted need for better early management of infective exacerbations by primary care.

Consequences

The study findings are being used to develop a short set of key implementable recommendations which focus on improving uptake of PR and better primary care management of COPD exacerbations. These recommendations are currently being implemented by regional health care providers across secondary and primary care.