original article Wien Klin Wochenschr (2018) 130:371–381 https://doi.org/10.1007/s00508-018-1346-8 Multiprofessional COPD care in Austria–challenges and approaches Results of a qualitative study Firuzan Sari Kundt · Nina Enthaler · Anna Maria Dieplinger · Michael Studnicka · Anna Knoll · Jürgen Osterbrink · Tim Johansson · Maria Flamm Received: 8 September 2017 / Accepted: 5 May 2018 / Published online: 28 May 2018 © The Author(s) 2018 Summary internet platforms with useful information for COPD Background Chronic obstructive pulmonary disease patients and solving the data privacy issues of the Aus- (COPD) is a frequent disease of the lungs. Its preva- trian electronic medical record (ELGA) are also per- lence was estimated to be 26% in the Global Initiative ceived as viable steps. There is a need and request for Chronic Obstructive Lung Disease (GOLD) I and for healthcare professionals to work as a team with 11% for GOLD II–IV in Austria. Globally, it ranks third clear COPD management guidelines in the outpatient in mortality rate. The particular challenge is that care sector, the establishment of outpatient rehabilitation for these patients falls short due to the lack of struc- centers as well as creating a new professional proﬁle, tured integrated care. The aim was to assess the cur- the COPD nurse. rent status of multiprofessional COPD care in Austria Conclusion Current COPD care needs to be reorga- and identify gaps and potentials. nized, particularly in the outpatient sector, to address Methods We conducted guided focus group inter- the needs of patients and healthcare professionals. views between March and July 2016 addressing cur- rent COPD care and treatment gaps with the following Keywords Respiratory nurse · Ambulatory care · Re- professional and interest groups: general practition- habilitation · Telemedicine · Patient education ers, nurses, patients, pharmacists, physiotherapists and pulmonologists. We interviewed 23 patients and Background 27 healthcare professionals. The interviews were transcribed verbatim and coded into 12 relevant cat- Chronic obstructive pulmonary disease (COPD) is egories. a common chronic disease, with prevalence rates Results There needs to be a shift in thinking from estimated to be between 4% and 21% . Globally, treatment-based care to prevention. Patients, just like COPD has increased to become the third leading healthcare professionals, need periodic updates and cause of death . The largest risk factors for the comprehensive information on this disease. Creating development of COPD are exposure to active and passive smoking, genetic predisposition and occu- pational exposure to hazardous inhalants and small particles . For both, men and women, the COPD F. Sari Kundt, MPH MA () · A. M. Dieplinger · J. Osterbrink Institute of Nursing Science and Practice, Paracelsus prevalence rises steeply after age 40, exceeding 50% Medical University, Strubergasse 21, 5020 Salzburg, Austria for the over 70 age group. Although these numbers ﬁruzan.firstname.lastname@example.org are concerning, it is more disturbing that half of all COPD stage II+ sufferers do not receive a formal diag- N.Enthaler ·A.Knoll · T.Johansson ·M. Flamm Institute of General, Family and Preventive Medicine, nosis, and hence, no adequate treatment . Taking Paracelsus Medical University, Salzburg, Austria age, gender and urban-rural discrepancy into con- sideration, the COPD prevalence rate in Austria is M. Studnicka estimated to reach 36% in 2020 . Austrian COPD Department of Pneumology, Salzburger Landeskliniken, Paracelsus Medical University, Salzburg, Austria hospitalization rates (i. e. 310/100,000 population) are K Multiprofessional COPD care in Austria–challenges and approaches 371 original article the second highest among the 20 compared Euro- sional, e. g. general practitioners (GP), pulmonolo- pean Union member states . Studies have shown gists, pharmacists, nurses and physiotherapists, and high mortality rates during hospitalization as well as interest group (COPD support group). Among the after hospital discharge: the 90-day mortality is 10% professional groups, an expert interview approach with over half of these deaths happening shortly after was deemed as the most useful option to gather ex- hospital discharge . To date in Austria, there is ploratory information on COPD care. Patients and no comprehensive care network for the management their direct caregivers, on the other hand, are experi- of COPD and high rehospitalization rates show large ential experts who can provide valuable information gaps in outpatient care, rehabilitation and patient on their individual needs. education . Therefore, the Austrian healthcare sys- tem offers opportunities for improvement, such as Recruitment decreased care gaps between hospital and outpatient care, increased networking between care sectors and Inclusion criteria for participation were deﬁned a pri- reﬁned outcome evaluations . The Austrian health- ori. In order to participate, patients had to be over 18 care system has been rated as a low primary care years of age and have a formal COPD diagnosis. Pa- system  and has not yet implemented a structured tients with other pulmonary diseases were excluded. integrated cooperation between different healthcare For the healthcare professionals, the inclusion crite- professionals. This fact complicates the provision rion was to be directly involved in the care of COPD of a structured and continuous care warranted by patients, preferably with some years of experience in general practitioners in primary care . caring for this patient group. Participant sampling In the international picture, various programs to was done using non-random sampling techniques counteract some of these issues have shown great based on availability and the snowball method. Gen- successes in decreasing hospitalization and rehospi- eral practitioners were contacted by mail and then talization rates , the frequency of exacerbations as followed-up by telephone to recruit for participation. well as mortality all the while reducing treatment costs The pharmacists were recruited at the 49th annual [13–18]. In addition, personalized action plans were science continuing education congress of the Aus- able to reduce emergency department visits, hospital trian pharmacists’ association via information leaﬂets admissions and length of stay among participating pa- at the main entrance and an invitation on the in- tients by 60% , improve risk-adjusted patient out- formation screens during the congress. Nurses and comes, promote patient safety, increase patient satis- physiotherapists working with inpatients and outpa- faction and optimize the use of resources . tients, were recruited via email directed at all nursing and healthcare management ofﬁces of the Salzburg clinics. The email list with these addresses was ob- Aim tained from the Austrian Society of Pneumology. In The objective of this qualitative study was to assess the addition, we also recruited physiotherapists and pul- current status of COPD care in Austria. The results of monologists from the outpatient sector via email and the focus group interviews were intended to generate telephone calls. Due to unforeseen problems in the examples for the development and implementation of recruitment of pulmonologists from the Salzburg area, a structured, integrated multiprofessional COPD care recruitment of this professional group was expanded in Austria and with that increase patients’ health sta- to all of Austria and the interview mode was changed tus, quality of life and self-care competencies. The to individual interviews instead of focus groups. To research questions were: recruit the patients, we contacted the local COPD support group and upon request, we were granted 1. Are there any potential improvement opportunities permission to hold the focus group interview on-site. in integrated and multiprofessional COPD care con- cerning the care of patients and their caregivers as Group interviews and informed consent well as inpatient and outpatient care protocols? 2. Which viable improvement possibilities are avail- The focus group interviews were conducted by two able? trained project staff members from March through June 2016. The guided interview questions were Material and methods gathered from the literature and were also the re- sult of a kick-off meeting held with all professional Design, participants and setting healthcare groups and patients. The interview guide The pre-study interdisciplinary structured intersec- (Appendix A) was constructed using semi-structured toral (ISI) COPD was an exploratory qualitative re- open-ended questions. The interviews were held in search effort to identify main and common factors strict adherence to the interview guide to ensure com- of improvement in COPD care management in Aus- parability and one of the project staff wrote a ﬁeld di- tria. Therefore, we conducted focus group interviews ary. The interviews themselves were recorded by two with one group interview session for each profes- digital audio recorders and then transcribed verbatim. 372 Multiprofessional COPD care in Austria–challenges and approaches K original article Each participant gave informed consent before being Whereas some patients reported the fact that de- admitted to formally participate in the interview and spite a diagnosis, their lack of knowledge about their all participation was voluntary. Upon seeking ethics own disease has continued for a long time, other pa- approval, the research team was informed that there tients described that when they received the diagno- is no need for an ofﬁcial ethics approval for this type sis, they felt overwhelmed by the situation and were of study as outlined in § 30 of the Salzburg Hospitals unable to follow and comprehend the information. Act (SKAG) . “When you get the diagnosis and have never heard of COPD, you’re a bit confused and you Data analysis cannot follow it [the information], even though it is being explained thoroughly.” (Support group The data were analyzed using qualitative content anal- participant) ysis techniques [21, 22]. Once the data was tran- scribed, we used MAXQDA 12© (Verbi GmbH, Berlin, Responsibilities over who should conduct patient Germany) to code the transcripts into 12 different cat- education consultations ranged from the physicians, egories (Appendix B) that were anchored on the ques- specialists and nurses who suggested the professional tions from the interview guide and then paraphrased ﬁeld of COPD nurses already established abroad, ex- them. Each focus group or single interview was an- tensions to the ﬁeld of physiotherapy up to the in- alyzed separately and later combined to assess com- creased involvement of pharmacists. mon ground. Once the paraphrasing was ﬁnished, Patients need comprehensive patient education, we created and deﬁned new dimensions based on the similar to the one received by cancer patients. The clustered paraphrases to address the research ques- physiotherapists, nurses and inpatient pulmonolo- tions . To answer the research questions, we fo- gists agreed and added that patients not only need cused on two main dimensions: “current COPD care” one, but many follow-up consultations due to the pro- and “potential solutions to current care issues.” These gressively deteriorating nature of this disease. Physio- two dimensions yielded the following three subcate- therapists speciﬁcally stated that the information for gories: “educational measures,” “eHealth” and “struc- patients should contain comprehensive information tured integrated multiprofessional care” (Appendix C on pathomechanisms of the disease, pharmaceutical depicts the main themes of the potential solutions cat- treatment options as well as social, psychological, egory). The three subcategories are expanded on in physiological and nutritional support options. This the following. The quotes used in this article were would help keep patient expectations realistic and translated from German to English and back by two potentially delay exacerbations. different native speakers. Both translators’ transla- Health education, and in particular, the correct tions were congruent. handling of the devices, such as the inhalers, is also a major issue in successfully handling the disease. Results “The patient, who knows (...) the [proper] han- dling of his respiratory device, [such as] the A total of 27 healthcare professionals from the medical cleaning. (...) One really notices (...) in medical sector (6 GPs, 7 pharmacists, 4 nurses, 6 physiothera- surgery that the gaps [between hospitalizations] pists and 4 pulmonologists; 15 women, 12 men) and (...) are much, much better [longer] as com- 23 COPD patients (10 women, 13 men) were inter- pared to the ones who receive the instruction, viewed. Due to the large number of participants in but who are totally overwhelmed [with this in- the patient group, we had to split the group in two to formation] and have no appropriate support make the interview manageable. Both interviews were [system].” (Nurse) conducted concurrently in separate rooms. Each in- terview lasted between 30 and 105 min. We received General practitioners also expressed their desire to age and sex information on all participants, except for regularly receive the most current knowledge about one patient who refused to disclose his age. The par- COPD and evolving developments of its therapy. ticipants were between the ages 21 and 80 years, with “And you cannot (...) often enough (...) train a mean age of 57.2 years (Appendix D shows age and physicians in this respect. I don’t think I am sex distribution of the participants). the only one, who time and time again, falls un- der the (...) required knowledge level automati- Educational measures cally.” (General Practitioner) Both care providers and patients agreed that the is- In terms of prevention, although only one patient sue of COPD has not yet achieved key illness status group mentioned this as important, all healthcare in society. Although COPD disorders are increasingly professional interviewees thought it critical for the commoninAustria, prevention and disease educa- patients to receive preventative health education. tion are largely underrepresented and a lack of COPD awareness is being criticized. K Multiprofessional COPD care in Austria–challenges and approaches 373 original article “(...) prevention is, for sure, one of the most “That they are coping well through these ﬁrst important things, yes.” (Nurse) days (...) at home. (...) That we call them (...) “And a difﬁculty in this context is of course and they have a contact point. (...) Well, such that prevention is not satisﬁed in any way (...) technical aids we could also very well use. (...) we have a reparatory medical system. This Applications, which one can now simply down- means, ﬁrst there is the damage, then it is re- load.” (Nurse) paired, but the avoidance [of damage] can hardly Although both options, an EMR system (e. g. ELGA) be found in the roots of social insurance.” (In- and an online platform with information about recre- patient pulmonologist) ational and therapy offers for COPD patients, is per- All participants agreed on the lack of appropri- ceived as a good idea in theory but widespread sup- ate patient education and the need for clariﬁcation, port for the creation of these tools is still lacking. This preventative measures (e. g. in the form of televi- attitude is partly an ethical issue (i. e. patient data pri- sion clips, videos, apps) and regular training for both vacy), but also stems from a lack of resources, such as COPD patients and their caregivers. There is consen- time, money or internet afﬁnity. sus that COPD prevention in Austria is insufﬁcient as compared to other countries, because the focus Structured intersectoral care is placed on treatment rather than prevention of Networking disease. According to focus group participants, pre- vention should start in kindergarten, but at the latest, The healthcare providers clearly distinguished be- following the Scandinavian model, in school, in order tween the inpatient area, where an uncomplicated to be effective at all. and well-regulated multiprofessional exchange takes place, and the outpatient sector, where there is very little structured cooperation or exchange with other EHealth solutions disciplines. The interviewees who are working with A newly developed and recently adopted electronic a multiprofessional team of specialists all agreed that medical record (EMR) system, ELGA, is trying to ﬁll the good cooperation is the prerequisite for effective gap in networking between the different healthcare COPD therapy. providers and the patients. So far, this tool has been “They [hospitals] accept everyone who (...) met with scepticism for reasons of data privacy, which comes in even without a referral, (...) com- is also the reason why many providers have opted out pletely without any networking and communi- of it. However, an EMR system is an efﬁcient way to cation (...) and often I don’t ﬁnd out about it connect all providers and track the patients’ medical until a year later that the patient exacerbated history. Among the patient interviewees, there was three times already.” (General Practitioner) widespread support for this new EMR resource. Although the patients themselves have varying “I am a supporter of ELGA. And I feel if ELGA opinions on how well the different providers coop- really works and the people quit being so suspi- erate, everyone agreed on the importance of a func- cious, theproblem would beoff thetable.” (Sup- tional network of healthcare professionals. A pro- port group participant) fessional that is often referred to as a feasible link This openness for an EMR without being intimi- in multiprofessional collaboration is the pharmacist. dated by data privacy issues was prevalent among one The healthcare providers as well as the patients can patient group, the physiotherapists, nurses and one envision an increased involvement of this professional outpatient pulmonologist. All other interview groups group. The pharmacists recognize their low-threshold were rather ambivalent on the idea of an electronic access to the patients as a great potential and are will- patient database. ing to provide the patients with speciﬁc medication In addition to ELGA, there currently is no local op- and device training, tests and measurements of vital erational platform combining information on specif- functions. ically trained local respiratory physiotherapists, ap- “And I can certainly imagine that specially propriate sports groups or efﬁcient smoking cessation trained pharmacists could take on more re- offers to refer COPD patients to get additional assis- sponsibilities with the customers and check out tance. The majority of patients are still not very likely together with them (...) how to apply my med- to reach out for information and therapy options on ication, where he [the pharmacist] speciﬁcally their illness via digital media. Only one of the patient demonstrates how he [the patient] should do it. groups, the general practitioners, nurses and two of I believe that particularly the pharmacists (...) the pulmonologists were in favour of the idea of the could assume a larger role, also because they utility of technical aids and contact points (e. g. What- are closer to the customer [patient] and they are sApp), especially for patients who have recently been there, easily reachable.” (Pharmacist) discharged from hospital. 374 Multiprofessional COPD care in Austria–challenges and approaches K original article Networking is perceived to be an ultimate necessity measure to relieve the inpatient area and adequately for the medical professions, including the pharma- provide for the patient. cists, to be able to offer the patients comprehensive “It is necessary to understand that insufﬁcient care and avoid redundant therapeutic measures. treatment ultimately results in signiﬁcantly higher costs besides the individual suffering Disease management programs of the patients, which could be an incentive to Most interviewees agreed that the absence of struc- make improvements.” (Resident pulmonologist) tured COPD patient management plans, such as dis- ease management programs (DMP), ultimately hurts The patients, on the other hand, are not entirely the patients. Physiotherapists, nurses and general sold on the idea of an outpatient rehabilitation care practitioners distinguished between the inpatient and center. Their worry concerns the extra costs associ- outpatient sector, with the problem concentrating ated with this service, but they also perceive it to be in the outpatient sector. Healthcare professionals demanding and exhausting, not a place to recuperate. in the outpatient sector dealing with COPD patients “[An outpatient rehabilitation center is] not have to come up with their own particular disease a hospital, but a rehabilitation and that is stren- management. The patients stated that the absence uous.” (Support group participant) of structured and comprehensive COPD management programs subsequently leads to the patients being The establishment of an outpatient rehabilitation left without coordination and support, particularly center is an idea that was perceived well by most in- immediately after hospital discharge. terviewees; however, it would take a little persuasion work for the patients to also buy into it. “You are discharged from the hospital with wishes for recovery, with the documents and Respiratory/COPD nurse that’s it, more or less. There is no follow-up care, Healthcare providers agreed that chronically ill pa- there are no therapies, such as physiotherapy, tients need a stable accompanying factor helping respiratory physiotherapy, nothing is offered.” them go through the various health stops and increase (Support group participant) patient compliance while decreasing rehospitalization It is strongly encouraged to implement guidelines rates. A promising approach is the implementation by means of incorporating multiprofessional COPD of a respiratory or COPD nurse, a speciﬁcally trained care. The majority of the interviewees agreed with the nurse focusing on COPD. Thehealthcareprofession- establishment of a meaningful bridging solution after als emphasize the importance of speciﬁcally trained hospital discharge, which could contribute to a reduc- nurses due to complex needs and comorbidities of tion in the number of exacerbations, and thus, lower COPD patients. rehospitalizations. “If the patients were taken better care of at home, “A [low] rehospitalization can only take place if by the COPD nurse coming to your home, then we invest in the sick person outside the hospital.” perhaps some exacerbations could be easily (Support group participant) managed at home and would not need to be taken to the hospital; but the patient alone can- The establishment of outpatient COPD care guide- not cope by him-/herself, s/he needs help. For lines is a key issue mentioned by all interviewees. this we have nothing, in Austria, we have quite These guidelines should cover the patients the minute a few acute beds, but relatively few other facil- they are discharged from the hospital to ensure con- ities, where these patients could be supported. tinuous quality in care. So,I thinkhomecareisa good idea.” (Resident pulmonologist) Outpatient rehabilitation Most interviewees (i. e., pulmonologists, nurses and The patients, on the other hand, were somewhat physiotherapists) appreciated the idea of a transi- opposed to the establishment of a respiratory nurse tional area or period into the home environment or as interim care before and after a hospital stay. They a post-hospital follow-up procedure to address some doubted that this new type of professional would of the urgent care problems that surface right after possess sufﬁcient qualiﬁcations to be of any value to hospital discharge. The establishment of a combined them. COPD ambulatory care management and outpatient “I personally don’t believe that such a nurse (...) rehabilitation center where multiprofessional care is that that would achieve anything.” (Support provided could also help effectively deal with the gap group participant) in service. Outpatient rehabilitation facilities, which are already a standard in some cities, are not yet On the topic of the respiratory/COPD nurse, the widely available. They provide necessary services to opinions diverged. The healthcare professionals ensure continuity of care until the patients are able to thought it would be a useful addition to the care of cope on their own again. This would pose a sensible K Multiprofessional COPD care in Austria–challenges and approaches 375 original article COPD patients, whereas the patients took on a more patients themselves, since they are the utmost suffer- careful stance. ers of these shortcomings. It provides a list of issues the patients and healthcare providers battle on a daily Other resources basis, but also potential solutions with a unique in- An additional issue is exhibited by the lack of outpa- sight into the group perspectives on how to solve these tient respiratory physiotherapists in Salzburg. Most of issues. the available outpatient respiratory physiotherapists Current COPD care in Austria is distinctly hospi- are neither fully covered by the medical insurance nor tal-centered. It is a slowly progressing incurable dis- is it possible to get an appointment within a reason- ease with patchy care in the outpatient sector. Pa- able amount of time (a few months). tients are released from the hospital to fend on their own, which usually leads them back into the hospi- “Well, the only thing I really want is an afford- tal due to frequent exacerbations. There are no clear able respiratory physiotherapy in place.” (Sup- cut guidelines for the management after discharge for port group participant) healthcare professionals to follow. Hence, the high The medical care of COPD patients is not the only Austrian rehospitalization rates are not surprising. If factor in their well-being, but regular physical activity the providers act within a network of healthcare pro- offers speciﬁcally tailored to the COPD patient are im- fessionals, it is because they have personally built one portant measures as well. Information on these offers for themselves. The absence of such networks was should be made easily accessible to all searching for a common theme throughout all interviews, namely them. Most patients agree in taking a proactive role the lack of formal structures that facilitate interdisci- in their own therapy utilizing a progressive self-help plinary communication, and hence, build a functional and competence building attitude. network of care providers. These shortcomings place a large burden on all involved, but particularly on the “Through my physical activity every day, it has patients, resources and the medical economy. always been a bit better for me in recent years. International evidence has successfully solved And when I cannot be physically active due to some of these issues by implementing various mea- an exacerbation, then I notice it is getting worse. sures to lower hospitalization and rehospitalization And the more sports I do, the better I feel and rates, exacerbation frequencies and mortality and do.” (Support group participant) at the same time reducing treatment costs [13–18]. In addition, some interviewees agreed that families, Special and targeted training of healthcare person- relatives and even friends, play an important role in nel, e. g. nurses, was not only able to effectively the well-being of the patient. decrease COPD-related hospitalizations and associ- ated care costs in Finland , but also empowered “Involving family members. In my opinion, they the patients in their self-care competencies, improve also belong to this interdisciplinary manage- integrated care offers and successfully conduct pre- ment.” (Physiotherapist) vention, case management and discharge programs There is a general consensus among the patients . In addition, personalized action plans and care about taking charge of their own lives, be it with pathways/care bundles were able to reduce emer- physical activity, social gatherings or seeking a res- gency department visits, hospital admissions and piratory physiotherapist. In our study, patients, who length of stay among participating patients by 60% were the most physically and socially active, regard- , improve risk-adjusted patient outcomes, pro- less of GOLD stage, also perceived their own health mote patient safety, increase patient satisfaction and to be better than other patients, who were less proac- optimize the use of resources . tive. The pulmonologists and physiotherapists agreed In the case of Austria, although the patients’ with the patients and supported the notion to in- healthcare in the inpatient area is covered, there crease and ease access to therapeutic resources for was a unanimous request of all interviewees to im- the patients. Physiotherapists, nurses and the pulmo- prove integrated care and extend the current coverage nologists thought that relatives should certainly be to include effective therapeutic services and products involved in patient care, whereas some patients re- in the outpatient sector. The interviewees were well sponded more reservedly about involving their friends aware of the ﬂaws of the current healthcare system and relatives in their disease so as not to additionally and they were motivated to support potential and burden them. practical improvement efforts, however, they failed to carry it through due to ﬁnancial and time short- comings, but also in light of the question on how Discussion to realistically and effectively coordinate healthcare This study was the ﬁrst of its kind taking a qualitative professionals in the management of COPD to ensure approach to get an overall picture on the shortcom- a working integrated multiprofessional care system. ings of COPD care in Austria giving voice to everyone This culture of change is ongoing in many European involved in the care of COPD patients, including the 376 Multiprofessional COPD care in Austria–challenges and approaches K original article countries and the trend to offer better care beyond change. Improving structured COPD care could not the hospital is increasingly being asserted . only improve patients’ health status, but also promote There already are different educational initiatives autonomy, self-responsibility and self-empowerment for patients and health care professionals (print or in the patients’ daily life. electronic media). Repeated patient education efforts to update and strengthen disease-related knowledge, Limitations medication training courses and smoking cessation assistance have proven to be efﬁcient ; however, While planning the qualitative study, we intended to based on our results, these efforts seem to insufﬁ- conduct focus group interviews with all different pro- ciently reach the patients and providers. fessional and interest groups; however, due to unfore- The importance of e-Health (internet platforms, seeable difﬁculties in recruiting a sufﬁcient group of apps) solutions was acknowledged by all intervie- pulmonologists, we decided to conduct four individ- wees. Overall, research in this respect has found ual/personal interviews, two hospital pulmonologists positive effects of e-Health on disease coping mecha- and two outpatient practicing pulmonologists. Fur- nisms [27–33]. In our study, the plethora of practical thermore, it is recommended to conduct focus group and informative offers on the internet was overall interviews with a number of participants ranging be- perceived positively, but not within the reach of ev- tween ﬁve and eight . Due to the mentioned re- ery patient. The implementation of an overarching cruitment issues, the focus group for the nurses had EMR system, such as ELGA, with full participation only four participants. On a positive note, participants of all providers was strongly suggested by some of of all focus groups represented a very heterogeneous the interview groups (one patient group, one of the group (in terms of age, gender and years of experi- outpatient pulmonologists, the nurses and the phys- ence) enabling us to obtain diverse information. In iotherapists), under the condition of solving the data this section, it should also be noted that all patients privacy problem. were participants of the support group, meaning they Adaptations to the ever-changing requirements of were physically ﬁt enough to participate in a support the healthcare system and healthcare needs are im- group meeting, leaving all other patients who are not portant steps. The establishment and improvement of able to attend support group meetings, out of our cir- an interdisciplinary and multiprofessional integrated cle of interviewees. A ﬁnal limitation is that due to care system are reasonable and should be imple- limited resources, most of our participants (i. e. gen- mented in a step by step fashion. The participants’ eral practitioners, patients, nurses and physiothera- proposal for implementing outpatient rehabilitation pists) were from Salzburg, whereas the pulmonolo- facilities, where representatives of all relevant med- gists and pharmacists were from all over Austria. ical specialties work as a team, could be one such Acknowledgements We would like to thank all participants necessary step to solving current care issues. in this study, in particular, the patients from the Salzburg There were quite a few suggestions about the ne- COPD support group, the general practitioners, nurses, phar- cessity of structural changes. For one, a better net- macists, physiotherapists and pulmonologists as well as Mag. work of care, in other words, interdisciplinary and also Dr. Sonja Nebbia and Prof. Dr. med. Joachim Ficker, all of whom were instrumental in the conception and implemen- multiprofessional networks and enhanced communi- tation of the project. A special thank you also goes to Dr. cation ﬂow are thought to improve healthcare out- Margitta Beil-Hildebrand for her English expertise and criti- comes. For the other, sufﬁcient resource provision is cal view. crucial to cope with the complexity of comprehensive Funding Funded in part by the PMU FFF E-15/21/110-FLA, COPD care. Structured multiprofessional approaches a competitive research funding opportunity for original re- and physical activity have shown to improve patients’ search projects by the Paracelsus Medical University. health outcomes and well-being [15, 34]aswell as increase patients’ perception about feeling stronger, Funding Open access funding provided by Paracelsus Medi- more empowered, supported and safer [29–31]. An cal University. already intact structural entity, the patient support Conﬂict of interest F. Sari Kundt , N. Enthaler,A.Dieplinger, group, has been demonstrated to be helpful in sup- M. Studnicka, A. Knoll, J. Osterbrink, T. Johansson, and porting fellow patients and disseminate updated in- M. Flamm declare that they have no competing interests. formationonthe disease. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License Conclusion (http://creativecommons.org/licenses/by/4.0/), which per- mits unrestricted use, distribution, and reproduction in any In summary, we propose that the current care of medium, provided you give appropriate credit to the origi- COPD patients in Austria, in particular integrated nal author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. care and multiprofessional cooperation within the outpatient sector, needs to be reconsidered. Aus- tria’s high hospitalization and rehospitalization rate of COPD patients  is a clear plea for structural K Multiprofessional COPD care in Austria–challenges and approaches 377 original article Guide for patients Appendix A Patient care Interview guide for healthcare providers and patients 1. In your opinion, how do you experience the typi- Guide for healthcare providers cal COPD patient, how do you experience their rela- Patient care tives? 2. What are your difﬁculties as a COPD patient? 1. Please think of your COPD patients. How do you ex- 3. Do you have enough resources and can you fully use perience the typical COPD patient, how do you ex- them? perience their relatives? 4. What is your (personal) COPD patient management 2. What kind of struggles do your COPD patients have? plan? 3. Do you have enough resources for your COPD pa- 5. How do you deal with an acute exacerbation? tients and can you fully use them? 6. Do you have funds/opportunities for further educa- 4. What is your (personal) COPD patient management tion and training regarding respiratory diseases? plan? 5. How do you deal with an acute exacerbation? Networking 6. Do you have funds/opportunities for further educa- 7. Which interdisciplinary interfaces exist in the care tion and training regarding respiratory diseases? of COPD? Networking – Is there cross-sectoral cooperation in this care? 8. How is the liaison between the inpatient and out- 7. Which interdisciplinary interfaces exist in the care patient sector? of COPD? – How is the process of care in the inpatient vs. the – Is there cross-sectoral cooperation in this care? outpatient sector? 8. How is the liaison between the inpatient and out- – What is the biggest challenge in the care of COPD patient sector? patients after hospital discharge? – How is the process of care in the inpatient vs. the – What additional resources does the COPD pa- outpatient sector? tient need after a hospital discharge? – What is the biggest challenge in the care of COPD 9. In your opinion, how are the patients and their rel- patients after hospital discharge? atives integrated into the therapy? – What additional resources does the COPD pa- 10. What professional proﬁles should be involved tient need after a hospital discharge? more in the care of COPD patients? 9. In your opinion, how are the patients and their rel- 11. Whom would you contact as a COPD patient if you atives integrated into the therapy? need therapy beyond regular care? 10. In your opinion, which job proﬁles are missing in thecareof COPD patients? Communication – Which professional proﬁles should be involved 12. As a COPD patient, how would you rate your and more in the care of COPD patients your relative’s knowledge about your disease? Communication 11. Howisthe knowledge ofpatientsand theirrela- Potential solutions tives about their illness? 13. What measures are needed to ensure a functional Potential solutions cross-sectoral integrated care system? 14. If you think of innovative international COPD care 12. What measures are needed to ensure a functional concepts, which projects would be good to imple- cross-sectoral integrated care system? ment here in Austria? 13. If you think of innovative international COPD care 15. In your opinion, how can the re-hospitalization concepts, which projects would be good to imple- rate be reduced? ment here in Austria? 16. What could realistically be covered by the medical 14. In your opinion, how can the rehospitalization rate be reduced? insurance that is currently not covered and repre- sents a massive barrier due to cost? 15. What could realistically be covered by the medical 17. What role does prevention play in COPD care in insurance that is currently not covered and repre- Austria? sents a massive barrier due to cost? 16. What role does prevention play in COPD care in Austria? 378 Multiprofessional COPD care in Austria–challenges and approaches K original article Appendix B Overview of the main concepts and subcategories for coding with MAXQDA ● Knowledge – Professionals –Patients Quality of life – Good –Bad Resources – Professionals –Patients ● Exacerbation – Professionals –Patients Inpatient stay – Professionals –Patients Care aspects (structure/interface/networking) – Professionals –Patients Costs Training ● Potential solutions (measures/innovative concepts/ Appendix C prevention) ● Smoking Table of potential solutions for all professional Addiction ● groups and patients Signiﬁcance (of the disease) Potential Solutions GP PHA PAT 1 PAT 2 PHYSIO NUR OP 1 OP 2 IP 1 IP 2 Educational Health education and prevention X X – X X X X X X X measures measures Extensive health education talk – – X X X X – – X X Periodic trainings X X X – X X X X X X E-Health Online platform for training and X – – X – X – X X – therapy offers Introduction electronic medical – – X – – – X – X – record Electronic medical record with – – X – X X X – – – patient information Structured DMPs X – – – – X – – X – multiprofessional Guidelines X – – – X – – – – – integrated care COPD nurse X – X – – X X X X – Easy access to training and therapy – – X X X – X X X X offers Self-care competency – – X X X – – – X X Involve relatives – – X – X X X X X X Professional networking X X X X X X X X X X Pharmacy X X X – – – – – – – Specialized outpatient COPD care – – – X X X – X X – unit (rehabilitation, COPD outpatient care, interim nursing care) Outpatient rehabilitation for COPD – – – X X X X X X X patients GP general practitioners, PHA pharmacists, PAT patient group, PHYSIO physiotherapists, NUR nurses, OP outpatient pulmonologist, SP inpatient pulmonologist, DMP Disease Management Program, the “X” means “mentioned by the particular group” K Multiprofessional COPD care in Austria–challenges and approaches 379 original article Appendix D Group Age Sex Pulmonologist 39 m Table with participant age (years) and sex Pulmonologist 45 f distribution Pulmonologist 64 m Pulmonologist 65 m m male, f female Group Age Sex General practitioner 46 m General practitioner 48 f References General practitioner 52 f 1. LinK,Watkins B, JohnsonT, Rodriguez JA, BartonMB. General practitioner 59 f Screening for chronic obstructive pulmonary disease using General practitioner 64 m spirometry: summary of the evidence for the U.S. Preven- General practitioner 68 m tive Services Task Force. Rockville: Agency for Healthcare ResearchandQuality(US);2008. Nurse 25 f 2. LozanoR,NaghaviM,ForemanK,LimS,ShibuyaK,Aboyans Nurse 25 f V, et al. Global and regional mortality from 235 causes of Nurse 34 m death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Nurse 51 f Lancet. 2012;380(9859):2095–128. https://doi.org/10. Patient in group 1 62 m 1016/S0140-6736(12)61728-0. Patient in group 1 63 m 3. Eisner MD,Anthonisen N,Coultas D, KuenzliN,Perez- Patient in group 1 66 f Padilla R, Postma D, et al. An ofﬁcial American Thoracic Society public policy statement: novel risk factors and the Patient in group 1 70 f global burden of chronic obstructive pulmonary disease. Patient in group 1 70 f AmJRespirCritCareMed. 2010;182:693–718. Patient in group 1 72 m 4. Schirnhofer L, Lamprecht B, Vollmer WM, Allison MJ, StudnickaM,JensenRL,etal. COPDprevalenceinSalzburg, Patient in group 1 73 f Austria: results from the Burden of Obstructive Lung Dis- Patient in group 1 73 f ease(BOLD)Study. Chest. 2007;131:29–36. Patient in group 1 76 m 5. Firlei N, Lamprecht B, Schirnhofer L, Kaiser B, Studnicka Patient in group 1 78 m M. TheprevalenceofCOPDin Austria—the expected change over the next decade. Wien Klin Wochenschr. Patient in group 1 78 m 2007;119(17–18):513–8. Patient in group 1 – m 6. OECD. Health at a glance: Europe 2012. 2012. http://www. Patient in group 2 63 f oecd-ilibrary.org/social-issues-migration-health/health- Patient in group 2 65 m at-a-glance-europe-2012_9789264183896-en. Accessed 8 June2017. Patient in group 2 67 m 7. Hartl S, Lopez-Campos JL, Pozo-Rodriguez F, et al. Risk Patient in group 2 69 f of death and readmission of hospital-admitted COPD Patient in group 2 69 m exacerbations: European COPD audit. Eur Respir J. Patient in group 2 69 m 2016;47(1):113–21. https://doi.org/10.1183/13993003. 01391-2014. Patient in group 2 72 f 8. Nowak P, Geißler W, Holzer U, Knauer C. Themenqual- Patient in group 2 72 m itätsbericht COPD. Wissenschaftlicher Ergebnisbericht im Patient in group 2 76 f Auftrag des Bundesministeriums für Gesundheit. Bericht- sreihe Fokus Qualität, Vol. 1. Wien: Gesundheit Österreich Patient in group 2 77 f GmbH;2013. Patient in group 2 80 m 9. Bukert N. Ambulatory Care Sensitive Conditions. Poten- Pharmacist 41 f tiell vermeidbare stationäre Aufenthalte, entsprechende Pharmacist 43 m Diagnosen, Einﬂussfaktoren und Empfehlungen zur Durchführung von Untersuchungen. Graz: Institut für Pharmacist 50 f SozialmedizinundEpidemiologieMUG;2014. Pharmacist 58 m 10. Stigler FL, Starﬁeld B, Sprenger M, Salzer HJ, Campbell SM. Pharmacist 59 m Assessing primary care in Austria: room for improvement. FamPract. 2013;30:185–9. Pharmacist 62 f 11. HoffmannK,SteinKV,MaierM,RiederA,DornerTE.Access Pharmacist 70 m pointstothedifferentlevelsofhealthcareanddemographic Physiotherapist 21 f predictors in a country without a gatekeeping system. Physiotherapist 22 f Results of a cross-sectional study from Austria. Eur J Public Health. 2013;23:933–9. Physiotherapist 23 f 12. Oancea C, Fira-Mladinescu O, Timar B, Tudorache V. Im- Physiotherapist 24 f pact of medical education program on COPD patients: Physiotherapist 39 m a cohort prospective study. Wien Klin Wochenschr. Physiotherapist 44 f 2015;127(9–10):388–93. 380 Multiprofessional COPD care in Austria–challenges and approaches K original article 13. Calvert D,Lim W, Rodrigo C,Turner A, Welham S.British 24. European Lung White Book. Allied respiratory profession- Thoracic Society pilot care bundle project: a care bundles- als. 2013. http://www.erswhitebook.org/chapters/allied- based approach to improving standards of care in chronic respiratory-professionals/. Accessed8June2017. obstructive pulmonary disease and community acquired 25. Schermer T, van Weel C, Barten F, et al. Prevention and pneumonia. BrThoracSocRep. 2014;6(4):1–53. management of chronic obstructive pulmonary disease 14. Jakobschuk L. CFHI supports projects to improve care for (COPD) in primary care: position paper of the European COPD patients: teams from across Canada will imple- ForumforPrimaryCare. QualPrimCare. 2008;16(5):363–77. ment leading practices. 2014. http://www.cfhi-fcass.ca/ 26. Leung J, Bhutani M, Leigh R, Pelletier D, Good C, Sin DD. SearchResultsNews/2014/10/06/cfhi-supports-projects- Empowering family physicians to impart proper inhaler to-improve-care-for-copd-patients-teams-from-across- teaching to patients with chronic obstructive pulmonary canada-will-implement-leading-practices. Accessed 23 diseaseandasthma. CanRespirJ.2015;22(5):266–70. May2017. 27. De San Miguel K, Smith J, Lewin G. Telehealth remote 15. Kinnula VL, Vasankari T, Kontula E, Sovijarvi A, Sayna- monitoring for community-dwelling older adults with jakangas O, Pietinalho A. The 10-year COPD programme in chronicobstructivepulmonarydisease. TelemedJEHealth. Finland: effects on quality of diagnosis, smoking, preva- 2013;19(9):652–7. https://doi.org/10.1089/tmj.2012.0244. lence,hospitaladmissionsandmortality. PrimCareRespirJ. 28. GOLD.Globalstrategyforthediagnosis,managemenetand 2011;20:178–83. preventionofCOPD.2017. 16. Mann B. Assessing the impact of implementing a hospital 29. Jonsdottir H, Amundadottir OR, Gudmundsson G, et al. Ef- discharge COPD (chronic obstructive pulmonary disease) fectiveness of a partnership-based self-management pro- care bundle on the respiratory ward at West Middlesex gramme for patients with mild and moderate chronic University Hospital. 2012. https://www.nice.org.uk/ obstructive pulmonary disease: a pragmatic randomized sharedlearning/assessing-the-impact-of-implementing- controlled trial. J Adv Nurs. 2015;71(11):2634–49. https:// a-hospital-discharge-copd-chronic-obstructive-pulmo doi.org/10.1111/jan.12728. nary-disease-care-bundle-on-the-respiratory-ward-at- 30. Kenealy TW, Parsons MJ, Rouse AP, et al. Telecare for west-middlesex-university-hospital. Accessed 22 May diabetes, CHF or COPD: effect on quality of life, hospital 2017. useandcosts. Arandomisedcontrolledtrialandqualitative 17. Rizzi M, Grassi M, Pecis M, et al. A speciﬁc home care evaluation. PLoS ONE. 2015;10(3):e116188. https://doi. program improves the survival of patients with chronic org/10.1371/journal.pone. obstructive pulmonary disease receiving long term oxygen 31. LavesenM,LadelundS,FrederiksenAJ,LindhardtBO,Over- therapy. ArchPhysMedRehabil. 2009;90:395–401. gaard D. Nurse-initiated telephone follow-up on patients 18. Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant with chronic obstructive pulmonary disease improves pa- R, Elcock K. Using care bundles to reduce in-hospital tientempowerment,butcannotpreventreadmissions. Dan mortality: quantitativesurvey. BMJ.2010;340:c1234. MedJ.2016;63(10):(pii):A5276. 19. Lodewijckx C, Decramer M, Sermeus W, Panella M, De- 32. McDowell JE, McClean S, FitzGibbon F, Tate S. A ran- neckere S, Vanhaecht K. Eight-step method to build the domised clinical trial of the effectiveness of home-based clinical content of an evidence-based care pathway: the health care with telemonitoring in patients with COPD. caseforCOPDexacerbation. Trials. 2012;13:229. J Telemed Telecare. 2015;21(2):80–7. https://doi.org/10. 20. Index—SKAG. Salzburger Krankenanstaltengesetz. 2000. 1177/1357633X14566575. http://medizinrecht-pﬂegerecht.com/Organisations 33. Voncken-Brewster V, Tange H, de Vries H, Nagykaldi Z, recht/Krankenanstalten/SKAG/skag%2030.php. Accessed Winkens B, van der Weijden T. A randomized controlled 14June2017. trialevaluatingtheeffectivenessofaweb-based,computer- 21. Kuckartz U. Qualitative Inhaltsanalyse. Methoden, Praxis, tailored self-management intervention for people with Computerunterstützung. 3rded. 2016. p.240. or at risk for COPD. Int J Chron Obstruct Pulmon Dis. 22. Mayring P. Qualitative Inhaltsanalyse. Grundlagen und 2015;10:1061–73. https://doi.org/10.2147/COPD.S81295. Techniken. 12thed. Weinheim: Beltz;2015. p.152. 34. Waschki B, Kirsten A, Holz O, et al. Physical activity is the 23. Kaiser R. Qualitative Experteninterviews. Konzeptionelle strongest predictor of all-cause mortality in patients with Grundlagen und praktische Durchführung. Wiesbaden: COPD:aprospectivecohortstudy. Chest. 2011;140:331–42. Springer;2014. p.17. Abbp. 35. Krueger RA, Casey MA. Focus groups. A practical guide for appliedresearch. ThousandOaks: SAGE;2009. K Multiprofessional COPD care in Austria–challenges and approaches 381
Wiener klinische Wochenschrift – Springer Journals
Published: May 28, 2018
It’s your single place to instantly
discover and read the research
that matters to you.
Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.
All for just $49/month
Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly
Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.
Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.
Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.
All the latest content is available, no embargo periods.
“Hi guys, I cannot tell you how much I love this resource. Incredible. I really believe you've hit the nail on the head with this site in regards to solving the research-purchase issue.”Daniel C.
“Whoa! It’s like Spotify but for academic articles.”@Phil_Robichaud
“I must say, @deepdyve is a fabulous solution to the independent researcher's problem of #access to #information.”@deepthiw
“My last article couldn't be possible without the platform @deepdyve that makes journal papers cheaper.”@JoseServera