Article Figures & Data
Figures
- Figure 1. Sampling for interviews COPD = chronic obstructive pulmonary disease. RHC = rural health centre. THQ = Tehsil headquarters.
- Figure 2. Asthma and COPD patient attrition in intervention and control arms COPD = chronic obstructive pulmonary disease.
Tables
Intervention inputs Intervention process and actions Intended Process change Outputs Health 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.
Care task Key indicators Quantitative Qualitative Identification and diagnosis of cases 1. 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 prevention 3. 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 adherence 5. 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 reactionPatient’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.
Tasks Diagnose on the basis of history and clinical examination
Register patient (complete chronic disease card)
AsthmaUse 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
COPDStart 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.
- Box 4. An outline of screening and diagnosis protocols for asthma and COPD (extracted from case management desk-guide)
Asthma COPD Screening Asthma 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. Diagnosis Diagnose 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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