Practical Approach to Lung Health - Experience from the Republic of Macedonia

Among the adults and children aged 5 yrs who attend PHC settings, 20-30% seeks to care for respiratory symptoms. Over 80-90% of the respiratory patients suffer from acute respiratory infections (ARI), followed by chronic obstructive pulmonary diseases (COPD), asthma, and less frequently with pneumonia and tuberculosis (TB). To improve the quality of care in patients who seek assistance for respiratory symptoms in PHC settings and the efficiency of respiratory service delivery within healthcare systems, WHO has designated several initiatives among which one is PAL (Practical Approach to Lung Health). PAL is an integrated and symptom-based approach focused on all priority respiratory illnesses encountered in PHC, including TB. Its patient-centred syndromic approach aims to improve the quality of diagnosis and treatment of respiratory illnesses in a PHC setting.

To evaluate the short-term impact of PAL approach in improving the management of patients with the most frequent respiratory diseases by the GPs from PHC settings in the Republic of Macedonia.

A total of 588 GPs were educated for the most frequent respiratory diseases during the PAL training from 2013-2016. To evaluate the efficiency of GPs education from PHC settings, GPs fill in a form out of 69 questions for the patients enrolled before (baseline survey) and after PAL training (impact survey), and the results of the two surveys were compared. This analysis aimed to assess if the theoretical and practical skills obtained during the PAL training have been used in the routine practice of the GPs who attended the training and to what degree.

Our results showed that in the impact study more patients with ARI (P < 0.000001) and more patients with COPD exacerbations were treated in the PHC settings (P < 0.000008). More patients suspected of asthma were referred to upper health level for diagnosis (P < 0.037). The comparison of the findings between the baseline and impact surveys suggest that training on PAL had an impact in decreasing drug prescription through a reduction in a prescription for antibiotics for ARI, COPD and asthma. Our study indicates that training on PAL is likely to increase the prescription of inhaled corticosteroids and tends to decrease the prescription of other formulation of these drugs (P < 0.0000001). The impact surveys showed that the patients with COPD and pneumonia in the PHC settings were better managed due to the more frequent use of CAT questionnaires and CURB test. And regarding TB cases, our study indicates that the GPs were more aware of this disease and were more willing to take part in the patient treatment follow-up (P < 0.000001).

The results from this study showed that implementation of PAL approach for GPs from the PHC setting in our country have positive results (effect) in the management of patients with respiratory symptoms: it is likely to reduce prescribing for antibiotics, to increase the use of inhalation medication which is highly recommended in the management of asthma and COPD, and to decrease the referral of patients with chronic diseases to the upper health level. However, more experience is needed for long-term influence on the effects over the cost-effectiveness of respiratory care services and on strengthening the health care system.