Introduction by Croakey: New recommendations for improving the management of chronic obstructive pulmonary disease (COPD) highlight the importance of ensuring services are culturally safe for Aboriginal and Torres Strait Islander people, who are at increased risk from COPD but have lesser access to appropriate services.
The first national COPD Clinical Care Standard stresses the importance of Aboriginal Community Controlled Health Organisations (ACCHOs) and Aboriginal and Torres Strait Islander Health Workers and Health Practitioners in improving access to care, as well as the safety and quality of care for Aboriginal and Torres Strait Islander peoples with COPD.
Implementation of the new standard has the potential to improve many peoples’ quality of life and also to reduce demand on hospitals, according to the University of Sydney authors below, Professor Jennifer Alison and Dr David Meharg.
Jennifer Alison and David Meharg write:
Chronic obstructive pulmonary disease (COPD) – an umbrella term for chronic bronchitis and emphysema – is a debilitating, irreversible lung condition which reduces airflow, causing breathing difficulties that can severely limit everyday activities and have a significant impact on quality of life.
It is estimated that one in 13 Australians over the age of 40 years have COPD and in 2020-21 the condition cost the healthcare system an estimated $832 million. Each year in Australia, more than 7,600 people die from COPD, and it is associated with the deaths of another 9,600 people.
COPD is a leading cause of potentially preventable hospitalisations, which means that if COPD is well managed in primary care, hospitalisations could be prevented.
Best practice management of COPD in primary care includes confirming a COPD diagnosis through spirometry, prescribing medications and exercise to reduce symptoms, alongside education on correct inhaler medication use and strategies to conserve energy and manage breathlessness.
Routine reviews of medication and other management strategies are essential to ensure ongoing effectiveness of care. Getting an early and accurate diagnosis, and taking steps to manage symptoms, can enable people to have a better quality of life and improve their health outcomes.
This is why the Australian Commission on Safety and Quality in Health Care (the Commission) launched the first national COPD Clinical Care Standard last month. While there is no cure for COPD, there is evidence to support a range of interventions to reduce the risk of hospitalisation and improve overall outcomes.
Disparities
What the above statistics don’t show are the unacceptable disparities that exist for COPD across Australia, with higher rates among Aboriginal and Torres Strait Islander peoples and people living in rural and remote areas.
For example, Aboriginal and Torres Strait Islander peoples have approximately double the prevalence of COPD, three times the mortality rate and five times the hospitalisation rate compared to other Australians, as highlighted in the Fourth Australian Atlas of Healthcare Variation.
These disparities are due to complex intergenerational issues, such as the ongoing impacts of colonisation, racism and discrimination when engaging with healthcare systems, socio-cultural determinants of health, and lack of access to culturally safe healthcare services aligned to Aboriginal and Torres Strait Islander peoples’ needs, which together drive the unequal burden of disease.
Despite the high prevalence of COPD in Indigenous communities, our research has demonstrated that many Aboriginal and Torres Strait Islander peoples have limited knowledge about COPD and often hold the belief that nothing can be done to help people live better with the condition.
When interviewed, some Aboriginal community members viewed a COPD diagnosis as a death sentence, having witnessed relatives die from the condition. As an Aboriginal person in one of our studies explains: “If I said, I have emphysema, they think you’re nearly on your death bed straight away.”
Key intervention
Pulmonary rehabilitation is one of the key management strategies recommended in clinical practice guidelines for COPD.
This is a health professional-led program of individualised exercise training and self-management education. Pulmonary rehabilitation has strong evidence of improving exercise capacity, reducing symptoms of breathlessness and fatigue and improving quality of life.
If commenced after a hospitalisation for a COPD exacerbation, pulmonary rehabilitation can reduce readmission rates by 52 percent.
For Aboriginal and Torres Strait Islander peoples, there is very limited access to culturally safe pulmonary rehabilitation programs in Australia.
Most pulmonary rehabilitation programs are delivered through hospital outpatient clinics, funded under the Independent Hospital Pricing Authority Tier 2 Classification.
Many Aboriginal people are unwilling to access these hospital-based programs due to experiences of racism. In addition, the travel distance to such programs may be prohibitive.
Culturally safe environments
Aboriginal Community Controlled Health Organisations (ACCHOs) are primary care services that were established to address the inadequacies of mainstream health services in delivering culturally safe care for Aboriginal people.
The provision of pulmonary rehabilitation programs in the culturally safe environments of ACCHOs may improve access for Aboriginal and Torres Strait Islander people to this evidence-based intervention.
Upskilling Aboriginal and Torres Strait Islander health workers and practitioners in providing self-management education through co-designed ‘yarning’ sessions within pulmonary rehabilitation programs will help to ensure that this education is culturally appropriate.
The COPD Clinical Care Standard highlights the importance of recognising historical, social and cultural factors when providing care for Aboriginal and Torres Strait Islander peoples living with COPD. This includes considerations for clinicians and healthcare services to support the delivery of culturally safe and equitable care.
The Commission collaborated with expert advisors from across the health sector, including Aboriginal and Torres Strait Islander practitioners, in developing guidance and recommendations about culturally safe care in the Standard.
Improving access
In light of the disparities in COPD outcomes across Australia and recognising the importance of access to culturally safe pulmonary rehabilitation programs, we offer the following recommendations for clinicians and healthcare services to improve access for Aboriginal and Torres Strait Islander peoples with COPD.
1. Fund models of care that enable ACCHOs to deliver pulmonary rehabilitation programs.
2. Create pathways for referrals to pulmonary rehabilitation programs including:
- Establish referral pathways to culturally safe programs for Aboriginal and Torres Strait Islander peoples in line with their needs and preferences, where available.
- Improve pulmonary rehabilitation referral rates by general practitioners, for Aboriginal and Torres Strait Islander peoples following a COPD diagnosis.
- Improve pulmonary rehabilitation referral rates by hospital staff, for Aboriginal and Torres Strait Islander peoples after an exacerbation of COPD.
3. Upskill the Aboriginal and Torres Strait Islander health workforce – including Aboriginal and Torres Strait Islander health practitioners, physiotherapists, exercise physiologists, and nurses within ACCHOs – to provide the self-management education components of pulmonary rehabilitation programs, prescribe individually-tailored exercise programs and monitor clients during exercise sessions.
4. Strengthen long-term, meaningful relationships between clinicians delivering pulmonary rehabilitation programs in hospital outpatient clinics and ACCHOs, and people living with COPD from local Aboriginal and Torres Strait Islander communities. This includes collaborating to co-design programs aligned with cultural needs in the local context.
For guidance on providing culturally safe care in the management of COPD, access the Commission’s COPD Clinical Care Standard.
Author details
Professor Jennifer Alison is Professor of Respiratory Physiotherapy, University of Sydney and Professor of Allied Health, Sydney Local Health District.
Dr David Meharg is Post-Doctoral Fellow, School of Business, University of Sydney.
Also see the National Aboriginal Community Controlled Health Organisation (NACCHO) COPD Action Plan.
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