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Research

Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation

Muhammad Amir Khan, Muhammad Ahmar Khan, John D Walley, Nida Khan, Faisal Imtiaz Sheikh, Saima Ali, Ehsan Salahuddin, Rebecca King, Shaheer Ellahi Khan, Farooq Manzoor and Haroon Jehangir Khan
BJGP Open 2019; 3 (1): bjgpopen18X101632. DOI: https://doi.org/10.3399/bjgpopen18X101632
Muhammad Amir Khan
1Chief Coordinating Professional, Association for Social Development, , Pakistan
DHA, MPH, PhD, FFPH
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Muhammad Ahmar Khan
2Research Coordinator, Association for Social Development, , Pakistan
MBBS
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  • For correspondence: ahmarkhan@asd.com.pk
John D Walley
3Professor of International Public Health, Nuffield Centre for International Health and Development, University of Leeds, , UK
MComH, FFPH, MRCGP
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Nida Khan
4Project Coordinator, Association for Social Development, , Pakistan
MSc, MS
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Faisal Imtiaz Sheikh
5Research Coordinator, Association for Social Development, , Pakistan
MS, PharmD
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Saima Ali
6Research Coordinator, Association for Social Development, , Pakistan
MBBS, MSc
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Ehsan Salahuddin
7Research Coordinator, Association for Social Development, , Pakistan
MS, PharmD
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Rebecca King
8Lecturer, Nuffield Centre for International Health and Development, University of Leeds, , UK
BA (Hons), PhD
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Shaheer Ellahi Khan
10Assistant Professor, Humanities and Social Sciences Department, Bahria University, , Pakistan
MSc, MPhil
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Farooq Manzoor
9Provincial Manager, Non-Communicable Disease Control Program, , Pakistan
MBBS, MBA, MPhil (Public Health)
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Haroon Jehangir Khan
11Director, NCD & Mental Health, Directorate General of Health Services, , Pakistan
BSc, MA HMPP, MPH, FRIPH
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Article Figures & Data

Figures

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  • Figure 1.
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    Figure 1. Sampling for interviews COPD = chronic obstructive pulmonary disease. RHC = rural health centre. THQ = Tehsil headquarters.
  • Figure 2.
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    Figure 2. Asthma and COPD patient attrition in intervention and control arms COPD = chronic obstructive pulmonary disease.

Tables

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    Box 1. Logic model of an integrated intervention
    Intervention inputsIntervention process and actionsIntended
    Process changeOutputsHealth outcomes
    • Case management desk-guide & counselling tool

    • Training of doctors and allied staff (on full care package)

    • Supplement drugs and supplies (for example, peak flow meter)

    • Recording formsa

    • Screen and diagnosea

    • Prescribe and/or dispense asthma and/or COPD drugs

    • Counsel on lung condition; also smoking cessation (if applicable)

    • Follow up care, including retrieval

    Providers practise programme protocols to:
    • screen, diagnose, treat, counsel, follow up, and report as per programme protocol


    Patients:
    • attend follow-up visits

    • adhere to treatment

    • cease smoking (if applicable)

    Patient are:
    • screened and diagnosed as per programme protocol

    • prescribed and/or dispensed correct drug and dose

    • counselled for smoking cessation

    • followed-up and treated for continued care

    Asthma control and BODE index change in COPD patients
    • aThese inputs and practices for screening, diagnosis, and recording were the same in intervention and control arms to ensure comparing ‘like with like’ asthma and COPD patients.

    • BODE index = Body-mass index, airflow Obstruction, Dyspnea, and Exercise index. COPD = chronic obstructive pulmonary disease.

    • View popup
    Box 2. Selected care tasks and key indicators
    Care taskKey indicators
    QuantitativeQualitative
    Identification and diagnosis of cases1. Number of asthma and COPD patients registered (of overall outpatient attendance)
    2. Number and percentage of asthma and COPD patients receiving PEFR and/or spirometry; and findings thereof (at baseline)
    Patient’s and provider’s experiences of (also practice deviations and reasons for):
    • identifying symptoms

    • conducting clinical examination and diagnosis

    Treatment and prevention3. Number and percentage of asthma and COPD patients prescribed inhalers (as per guidelines) and/or other treatment to relieve and/or prevent airway obstruction
    4. Smoking cessation rate (comparing baseline and endline status)
    Patient’s and provider’s experiences of (also practice deviations and reasons for):
    • prescribing, as per guide

    • dispensing inhalers (drugs)

    • counselling patient (tool-assisted) for smoking cessation

    • coping with input gaps

    Patient follow-up and adherence5. Number and percentage of patient attrition on each follow-up visit (in first 6 months)
    6. Number and percentage of patients referred for expert check-up and/or complication and/or severe drug reaction
    Patient’s and provider’s experiences of (also practice deviations and reasons for):
    • patient adherence to follow-up visits (include retrieval)

    • staff adherence to care during follow-up visit

    • COPD = chronic obstructive pulmonary disease. PEFR = peak expiratory flow rate.

    • View popup
    Box 3. Intervention outline
    Tasks
    1. Diagnose on the basis of history and clinical examination

    2. Register patient (complete chronic disease card)

    1. Prescribe drugs, according to the disease condition (as per desk-guide)

    Asthma
    • Use short acting inhaled beta-2 agonist salbutamol (SABA) for quick relief (as required)

    • Administer beclomethasone inhaler twice a day

    • Change to beclomethasone + formeterol combination if symptoms remain uncontrolled

    • Add montelukast or theophylline if symptoms remain uncontrolled

    • Add oral steroid if symptoms remain uncontrolled



    COPD
    • Start with SABA or short acting muscarine antagonist (SAMA) inhaler

    • Change to SABA and SAMA combination if symptoms remain uncontrolled

    • Change to long acting beta-2 agonist (LABA) + steroid combination if symptoms remain uncontrolled

    • Add long-acting muscarine antagonist LAMA or oral theophylline to LABA + steroid combination if symptoms remain uncontrolled


    2. Counsel the patient, using a pictorial tool, for prevention and treatment adherence
    3. Examine (clinical), prescribe (and dispense), and record, as per desk-guide, on each monthly follow-up visit
    4. Identify and retrieve those found with a delay in their monthly follow-up visit (three-tray system to identify; and a mobile phone to communicate with such patients)
    • The two tasks (a and b) were common for all asthma and COPD patients. The four tasks (1–4) differed in the intervention and control arms (as per desk-guide in the intervention, and as per doctor routine in the control). LABA = long acting beta-2 agonist. LAMA = long-acting muscarine antagonist. SABA =short-acting inhaled beta-2 agonist. SAMA = short-acting muscarine antagonist.

    • View popup
    Box 4. An outline of screening and diagnosis protocols for asthma and COPD (extracted from case management desk-guide)
    AsthmaCOPD
    ScreeningAsthma is indicated, if:
    • younger patient (though can be an older adult)

    • patient and/or family has history of asthma, allergic rhinitis (hay fever), or eczema

    • patient complains of:

      • recurrent episodes of dry cough and/or difficulty breathing, more so at night or in the morning

      • worsening with exercise, cold, dust, seasonal allergens, or drugs

    COPD is indicated, if:
    • middle-aged or older adult who smokes or used to smoke

    • patient has a history of recurrent chest infection

    • patient complains of:

      • progressive persistent shortness of breath (rather than episodic)

      • cough (productive and persistent)

      • exercise worsening the symptoms.

    Assess for asthma or COPD diagnosis, if one or more of the above indications.
    DiagnosisDiagnose asthma, if patient has history of ≥1 asthma indications, and during an exacerbation has:
    • wheeze (widespread and more on expiration)

    • on investigation (may be normal):

    • PEFR during an exacerbation <80% which improves with bronchodilator

    • other supporting/ indicative investigations:

    • blood CP (eosinophil >5%, though also in bronchitis and COPD)

    • chest X-rays (not usually indicated; may be normal, may be hyperinflation)

    Diagnose COPD, if patient has history of ≥1 COPD indications, and has:
    • wheeze – widespread and more on expiration

    • on investigation:

    • PEFR during an exacerbation <80%, with minor or no change with bronchodilator

    • other supporting/ indicative investigations:

    • blood CP (to check for anemia and polycythemia, if required)

    • chest X-rays (vertical heart, hyperinflated lungs, low-set diaphragm)

    • COPD = chronic obstructive pulmonary disease. Blood CP = blood complete picture. PEFR = peak expiratory flow rate.

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Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation
Muhammad Amir Khan, Muhammad Ahmar Khan, John D Walley, Nida Khan, Faisal Imtiaz Sheikh, Saima Ali, Ehsan Salahuddin, Rebecca King, Shaheer Ellahi Khan, Farooq Manzoor, Haroon Jehangir Khan
BJGP Open 2019; 3 (1): bjgpopen18X101632. DOI: 10.3399/bjgpopen18X101632

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Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation
Muhammad Amir Khan, Muhammad Ahmar Khan, John D Walley, Nida Khan, Faisal Imtiaz Sheikh, Saima Ali, Ehsan Salahuddin, Rebecca King, Shaheer Ellahi Khan, Farooq Manzoor, Haroon Jehangir Khan
BJGP Open 2019; 3 (1): bjgpopen18X101632. DOI: 10.3399/bjgpopen18X101632
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Keywords

  • integrated care
  • public health facilities
  • mixed method research
  • asthma
  • COPD

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