A role for primary care practitioners
The International Primary Care Respiratory Group (IPCRG) regards smoking as tobacco dependency, and support to stop smoking as an effective treatment as well as a preventative intervention. This policy should encourage clinicians to take the problem more seriously and to see it as their core work. As primary care clinicians see very large numbers of patients, even the relatively small quit rate achieved from a brief intervention could make a huge impact in absolute numbers. Therefore, the IPCRG advises primary care clinicians to develop a 1-minute smoking cessation strategy that could be used with all patients who smoke. Smoking includes hookah (or waterpipe) smoking, which, although sometimes considered harmless, is in fact a form of tobacco dependency with associated adverse effects. Cannabis smoking also has adverse respiratory effects similar to those of smoking tobacco. A recent UK report found that a 1% increase in smoking rates in patients with asthma or chronic obstructive pulmonary disease (COPD) was associated with an increase in admission rates of a similar magnitude; stop-smoking support is an important treatment.
Maternity and newborn care
Tobacco smoking impairs lung growth and development, predisposing infants to respiratory disorders in early life.
Poorly controlled asthma is associated with poor maternal and fetal outcomes in pregnancy, and there is evidence of the under-treatment of asthma in pregnancy even in high-income countries. Experience in low-income countries suggests there is extremely low or no awareness among local communities of chronic diseases such as asthma and COPD. Primary care teams with a respiratory interest can be powerful advocates for stopping smoking and can be champions for evidence-based and locally appropriate strategies to reduce tobacco dependency and indoor smoke, especially that caused by burning biomass fuel.
Asthma and rhinitis (which often coexist) represent the most common NCDs among children. According to the ARIA (Allergic Rhinitis and its Impact on Asthma) study, early treatment of (allergic) rhinitis may positively influence asthma development. Despite advances in many countries in recent decades, children are still not optimally managed, and this compromises their schooling and examination performance. However, effective interventions are available that can be delivered safely in primary care.
Asthma mortality is high in countries where access to ‘controller’ drugs is low. The NCD Alliance has called for universal access to good-quality, affordable asthma inhalers, and eligible countries should be urged to take advantage of the Asthma Drug Facility of the International Union Against Tuberculosis and Lung Diseases (the Union). The current WHO cost-effectiveness evidence table could usefully be revised to indicate which drugs are ‘best buys’, rather than just ‘good buys’.
Deaths in children and young adults peak in the months when allergen levels are high; healthcare systems should make pollen calendars and other seasonal information available to predict and mitigate some of this risk.
Adults: asthma and cost-effective care
In countries with more advanced primary care, proactive primary care management of asthma (including available anti-inflammatory and bronchodilator treatments) can prevent most exacerbations. If exacerbations occur, most can be handled in primary care without the need for hospitalisation. The OECD therefore suggests that high hospital admission rates may be an indication of poor quality of care or a lack of access to properly funded and supported primary care. There is considerable variation in care between countries and there are substantial opportunities for improvement. Better continuity of care with a family doctor may be associated with a lower risk of admission in all age-groups for ‘ambulatory care-sensitive conditions’ – conditions without complications that can often be managed in the community rather than in hospital, such as asthma and COPD. Where hospital care is required, integrating and improving coordination with primary care can be effective in reducing (re)admissions.
An example of the benefits of improving primary care is seen in Finland where, despite increasing incidence of asthma, a systematic 10-year programme based on primary care resulted in a decrease in hospital days and disability payments, as well as associated costs.
Chronic obstructive pulmonary disease
Strong primary care is fundamental to the prevention of COPD as it provides support for a reduction in exposure to tobacco smoke, recognises and establishes an early diagnosis, engages patients in active exacerbation management, and provides ongoing care for patients with established disease through to the end of their life. Spirometry testing should be developed in primary care, along with access to exercise programmes, multidisciplinary collaboration, and effective communication between primary and secondary care for those who need admission to hospital. Importantly, primary care professionals are ideally placed to address the holistic needs (physical, psychological, social and spiritual) of COPD patients as the disease progresses towards end of life.
Improving access to care is more likely to reduce hospitalisation rates for COPD than attempting to change patients’ propensity to seek healthcare or eliminating variation in physician practices. Better public funding of primary care is likely to improve access.
Influenza vaccination plays its part in reducing exacerbations of both COPD and asthma. However, there is substantial national variation in its uptake; for example, in 2008, uptake in the Czech Republic was 21.2% in those aged more than 65 years, compared with 77% in the Netherlands, and an average coverage of only 54.2% in 18 European Union countries.
Where infrastructure allows, a registry or database of asthma and COPD patients should be maintained in order to enable long-term review. In addition, given the uncertainty about the best-value interventions for COPD, a dynamic database of international primary care COPD registries would help to answer relevant real-life research questions.