by Tamar Chitashvili, URC Chief of Party, Georgia Health Care Improvement Project (HCI), and Ekaterine Cherkezishvili, URC Knowledge Management and Communication expert with the Georgia HCI Project
January 10, 2013
Every year the Global Initiative for Chronic Obstructive Lung Disease (GOLD) calls attention to chronic obstructive pulmonary disease (COPD) in late November. GOLD’s efforts to raise awareness of this life-limiting disease is joined by health care professionals and COPD patient groups worldwide. GOLD is a global effort to expand understanding of prevention and care of COPD and to advocate for higher quality care for patients living with COPD.
Georgia joined more than 50 countries around the globe on World COPD Day to raise
awareness about COPD and to highlight Georgia's efforts to improve the prevention
and care of COPD. The Georgia USAID-funded Health Care Improvement Project
(HCI) organized the day’s events there in collaboration with the key
stakeholders in Georgia: Ministry of Labor, Health and Social Affairs
(MoLHSA), the National Center for Disease Control and Public Health (NCDC), the
National Respiratory Association, and others. Activities included free testing
for smokers at the Nasarishvili Family Medicine Center at Kutaisi and Samtredia Ambulatory branch of Geo-hospitals in
the Imereti region, free examinations and testing for patients diagnosed with
COPD, and the distribution of over 1000 flyers and posters on smoking-cessation
support. Georgia’s events were featured by two regional
TV news channels throughout the day.
COPD is a progressive chronic disease characterized by persistent blockage of airflow from the lungs that causes significant suffering for affected patients and difficulties for their families. Its most common cause is tobacco use; other causes include chronic conditions (e.g., asthma), air pollution, and occupational exposure. COPD patients suffer from shortness of breath, chronic cough, and periodic exacerbations often requiring hospitalization. COPD has no cure, but access to evidence-based care dramatically reduces symptoms, reduces hospitalizations, and improves patients’ quality of life. Undiagnosed and untreated COPD exerts a large personal and economic toll for patients and their families and a large socio-economic burden due to an impaired workforce and high health care costs.
Because COPD symptoms are gradual at the onset, mimic other conditions, and require evaluation with a lung test called a “spirometer.” COPD diagnosis is challenging. Even in high-resource settings, COPD remains very under-diagnosed. According to the World Health Organization (WHO), an estimated 64 million people worldwide are affected by COPD and more than 3 million die every year: 5% of global deaths. Due in part to increased tobacco exposure among women, COPD now affects men and women almost equally. In the absence of effective prevention measures, mainly tobacco exposure, the WHO projects that premature death due to COPD will increase by more than 30% in the next 10 years.
Almost 90% of COPD Deaths Occur in Low- and Middle-income Countries
Low- and middle-income countries (LMICs) suffer a disproportionate COPD burden relative to higher resource countries. LMICs’ higher rates of smoking due to weak national tobacco regulation and limited tobacco prevention and cessation services mean that more individuals are affected by COPD. Furthermore, proven, high-impact prevention and treatment measures face many challenges in LMICs, including lack of supportive national policy and financing mechanisms, low provider knowledge and competence, lack of essential medications and equipment, lack of basic monitoring systems to track COPD rates and the quality of COPD services (ambulatory and hospital), lack of community awareness, and financial barriers that prevent people from using care and/or long-term medications. An HCI assessment of ambulatory clinics in four countries in Eastern Europe found many deficiencies in COPD prevention and treatment services, including essential health system functions that enable quality COPD care.
COPD Burden in Georgia
The prevalence of COPD in Georgia remains unclear but may be high in light of the high smoking rate. A 2010 survey conducted by
the NCDC and WHO found that over half of men and 4% of women are daily smokers.
Air pollution also plays a role. COPD prevalence as reported by the NCDC is considered to be
a significant under-estimate of actual COPD prevalence. Despite high population
use of tobacco, awareness of COPD remains low among most Georgians, and
knowledge of COPD diagnostic criteria and testing remains low among Georgian
doctors. A 2006 study of COPD primary care found a COPD diagnosis in only 67% of patients with more
than three years of chronic cough and that a third of patients diagnosed with
COPD had a relatively advanced stage of disease. A 2008 population-based pilot study by the Global Alliance for Non-Communicable Diseases measured
a five-times higher COPD prevalence in Georgia than official national
Georgia USAID HCI Project Tackles COPD
The primary objective of the Georgia HCI project is to improve quality, consistency, and continuity of medical care in the country. In collaboration with the MoLHSA, HCI supports front-line managers and providers to apply state-of-the-art improvement methods to rapidly improve the quality of ambulatory and hospital care for high-burden diseases in Georgia’s Imereti region, with the ultimate goal of countrywide scale-up. COPD is a project priority disease, along with asthma, cardiovascular disease, and pediatric respiratory infections. In its early phases, the project witnessed low rates of diagnosis of asthma and COPD (despite high prevalence of population risk factors); regular use of outdated, non-evidence-based disease diagnosis, classification, and treatment practices; and an absence of available guidelines and essential equipment and medications. As described below, the project supports continuous improvement methods and health system-strengthening activities essential for achieving and sustaining high-quality health care services for COPD and other high-burden diseases.
Supporting Clinics and Hospitals to Improve COPD Services
The project supports clinic- and hospital-based teams made up of facility managers, nurses, and doctors in Imereti to identify and overcome critical gaps in COPD prevention, diagnosis, and treatment best practices. After initial training in COPD best clinical practices and the use of improvement methods, teams are supported to plan, test, and refine changes in their health care processes to improve delivery of COPD best practices so that they are provided reliably for every patient needing them. Teams track simple, common quality measures to monitor their progress and guide their on-going improvement work. At regular intervals, teams come together to share the changes they have introduced and their measured indicator results in their respective facilities. These “learning sessions” offer an opportunity for clinic and hospital staff to learn from each other, continuously update their skills, and engage in a fun and beneficial initiative.
National Policy: National COPD Protocols
In collaboration with the MoLHSA, the HCI team supports on-going development and dissemination of synthesized, up-to-date medical information (documents are in Georgian) to health care providers. To date, three national COPD-related protocols have been developed in collaboration with the MoLHSA, professional medical associations, and US-based Georgian medical diaspora physicians. These protocols cover:
In addition to national protocol development and dissemination, the project regularly supports the development and dissemination (hard copy and electronic) of job aids and informational materials for providers. These materials can be accessed (in Georgian) at the Health Care Improvement webpage and the project Facebook page.
To support COPD risk-factor modification and patient self-management, the project has also developed and distributed more than 1000 smoking cessation and 500 COPD patient self-management diaries. The diaries are intended to improve the patient information that is available to care providers, support patients to give up smoking, and foster the development of individual plans for COPD patients and the day-do-day management of the disease, with the active involvement of patients and providers.
Infrastructure: Essential Supplies and Medications
Of four polyclinics and three hospitals in Imereti, only one had a spirometer, which is necessary for initial COPD diagnosis and monitoring, at the project outset. The project has advocated successfully with several clinics and with the private owner (Geo-Hospitals) of several clinics and hospitals for purchase of spirometers and other essential equipment. The provision of spirometers in three clinics has helped improve the quality of COPD diagnosis and treatment in clinics and hospitals.
Building and Sustaining Provider and Institutional Capacity for High-quality COPD Services
Provider skills to appropriately diagnose and manage COPD are low in most LMICs, including in Georgia. To build provider capacity for improved diagnosis and management of COPD, HCI contracted with the president of the Georgian Respiratory Association, Professor Tamaz Maglakelidze, to design and lead training sessions for providers: The sessions cover COPD screening, diagnosis, assessment and management, including use of spirometry.
To promote the sustainability of provider capacity-building activities, the project collaborated with the Georgian professional medical associations to support the development of several provider COPD continuous professional development (CPD) modules, including one on screening and another on smoking cessation. The modules have been formally registered as official provider CPD modules with the Tbilisi State Medical University; training will be conducted by the Georgian Respiratory Association.