Journal of the New Zealand Medical Association, 13-February-2009, Vol 122 No 1289
A survey of respiratory and sleep services in New Zealand undertaken by the Thoracic Society of Australia and New Zealand (TSANZ)
Jeffrey Garrett, Bob Chen, D Robin Taylor
Concerned by the inequality in standards of care observed by practicing respiratory physicians, the New Zealand Branch of the Thoracic Society of Australia and New Zealand (TSANZ) developed Minimum Standards for Respiratory Services in New Zealand in 1996.2
The “Standards” were distributed to members of the TSANZ to help guide them in the development of services within their respective hospitals. However, they were never formally implemented. Further development of the “Standards” was undertaken in 2002 by the TSANZ. On this occasion the review was limited to adult services but was broadened to include sleep disorders. These “Standards” were finally recognised by the MoH and subsequently published on the MoH website in 2004.
In 2004, a National Respiratory Council was established by the TSANZ with representation from the New Zealand Asthma and Respiratory Foundation (NZARF), primary care, the Paediatric Society, the MoH, District Health Boards New Zealand (DHBNZ), and the TSANZ. The structure was similar to that established for umbrella groups in cardiology, mental health, renal medicine, diabetes, and (more recently) cancer services.
The principle aims of the Council were to advocate for the further improvement of respiratory services in New Zealand, to provide advice to the MoH and to the DHBNZ Committee regarding priorities in service development, and to encourage adherence to the “Standards” by respective DHBs. However, the Council was disbanded in 2005, principally as a result of a lack of perceived engagement by the MoH and DHBNZ.
Since more comprehensive specialist respiratory services are centred within larger New Zealand hospitals, it is essential that larger DHBs work closely with smaller DHBs. The “Standards” were created to outline the various structures and workforce necessary to achieve these aims. They included an explanation of the scope of respiratory practice, an analysis of the burden of respiratory disease, the need for the main emphasis to be maintained in primary care and within the community, and the need for patient-focused education and self-management strategies.
Māori and Pacific Health issues, new technologies and treatments, disease-specific issues, outcome and impact indicators, prioritisation criteria for outpatient clinic appointments and hospital admissions, and credentialing tools for respiratory physicians and respiratory services were also included.
Minimum service requirements (Table 1) and staffing rates were also defined based on an assessment of international figures in countries with comparable health care resources. The minimum rates agreed upon were lower than for Australia, USA, Canada, and the UK but were deemed realistic given New Zealand’s economic constraints and health care infrastructure.
This audit set out to assess whether the “Standards for Adult Respiratory and Sleep Services in New Zealand”2 were being taken up by any of the 21 DHBs and to evaluate the extent to which deficiencies in care, infrastructure or staffing rates exist relative to the size of population each DHB serves. The audit also set out to evaluate whether any impact or outcome indicators were being collected and systematically measured. An assessment of oxygen and sleep services was undertaken (2 of the 12 respiratory services considered auditable by way of postal questionnaire).
Table 1. Summary of minimum respiratory services required within various sectors of health
*Need to be affiliated with Regional Hospital such that difficult cases can be discussed. +Radiologist needs to have developed sufficient expertise to be allowed to perform.
(Italics) added since publication in 2004.
Those services offered at a local level would be expected to be available at a district level and so on.
A structured questionnaire (see http://www.nzma.org.nz/journal/122-1289/3456/Appendix.pdf) was sent to the CEOs of each of the 21 DHBs in late 2006. The questionnaire sought information on:
The questionnaire also sought information on whether multidisciplinary team meetings were conducted and whether regional links had been developed between DHBs to manage more complex patients with (for example) sleep-related breathing disorders or lung cancer.
The questionnaire was eventually returned by all 21 DHBs, the last in June 2007.
Although no respiratory disorders are listed amongst 15 national health priorities, 14 of 21 DHBs reported respiratory disorders (COPD, asthma, lung cancer) in their list of health priorities. All DHBs reported strategies to address chronic care management of respiratory disorders. The most frequently mentioned were asthma and COPD with related pulmonary rehabilitation and smoking cessation programmes.
In line with recent MoH initiatives, the majority of DHBs reported a strong focus on primary care services. The relationship between primary and secondary care services appeared strongest in the smaller DHBs though their strategies were more usually broad in content rather than disease specific. Chronic care strategies fell into two categories: 1. preventive and 2. clinically focussed. The preventive initiatives included flu vaccination programmes, health promotion (e.g. healthy homes projects, exercise and healthy eating programmes), and community screening programmes. Respiratory clinics in the community were provided by some DHBs, mainly for asthma and COPD.
Fourteen of the 21 DHBs reported an asthma strategy. Those without a strategy tended to be the smaller DHBs. Only 10 of the 21 DHBs reported initiating specific strategies for COPD. Twelve of the 21 DHBs reported services that have evolved between primary and secondary care providers and included GP liaison team (formal education sessions with GPs and practice nurses by secondary specialist physicians and specialist nurses) and combined respiratory clinics (involving respiratory physicians, respiratory nurses, GPs, and practice nurses).
Six of the 21 DHBs provide a radiation oncology service and 10 of the 21 DHBs a medical oncology service. Those DHBs not providing oncology services reported a regional referral pathway which seemed to be working well but only 15 were undertaking multidisciplinary care meetings. Similar findings existed for thoracic surgery. Two DHBs had insufficient facilities or specialists to investigate or stage lung cancer patients and had no bronchoscopy service; 9 DHBs were unable to sample mediastinal nodes using bronchoscopic techniques (a standard test for staging lung cancer) and 10 DHBs could not perform cardiopulmonary exercise tests to evaluate fitness for thoracic surgery.
Seventeen of the DHBs had access to CT scanning and/or Isotopes scans. The four DHBs without these services had referral pathways to another DHB. Sixteen of the 21 DHBs offered CT assisted percutaneous needle biopsy or bronchial artery embolisation. The 5 DHBs without this service had referral pathways to another DHB.
Twelve of the 21 DHBs provided a sleep service although only 9 had sleep testing equipment. The other 9 DHBs offered a referral pathway to another DHB. Only 9 of the 21 DHBs reported a service to manage respiratory complications of obesity, and no specific funding base for bi-level ventilation existed in any of the DHBs. Fifteen of the 21 DHBs reported provision of a cystic fibrosis service. Of the 6 DHBs not providing this service, all offered a referral pathway to another DHB.
The 21 DHBs were ranked according to the size of population served into large (population >250,000), medium (population 100,000–250,000), or small (population <100,000). Four of the 6 large DHBs, 4 of the 9 medium-sized DHBs, and 2 of the 6 small DHBs complied with the standards.
Table 2. Procedures
Y=Yes; N=No; Shaded cell=doesn’t comply with standards.
Of those providing bronchoscopy services (n=19) only 12 performed transbronchial needle aspiration (Table 2). Induced sputum testing remains an alternative to bronchoscopy for the investigation of tuberculosis, requires little technical support, and is substantially more sensitive than obtaining spontaneous sputum samples from patients (particularly those without a productive cough).3
Although 17 offered induced sputum examination, the two hospitals without bronchoscopy services did not. The number of hospitals providing induced sputum examination to evaluate inflammatory airways disorders was higher (12 of 21) than anticipated. Induced sputum testing is a well validated tool for testing for both infection and inflammatory airways disorders4 and does not include the testing of routine sputum samples. The test for evaluating inflammatory airways disorders requires careful quality controls and with the need for formal training by the technician performing the test. (A follow-up enquiry revealed only 5 of 21 DHBs have access to induced sputum testing with appropriate quality control measures and not the 12 reported.)
Whilst all hospitals provided a spirometry service, two of nine medium-sized hospitals could not measure either lung volumes or DLCO (a basic measurement of diffusion), four of the nine could not test for bronchial hyper-responsiveness (a standard asthma test), and five of the nine could not perform a cardiopulmonary exercise test (CPET) (Table 3). Whilst CPET was deemed essential only for DHBs servicing populations of over 250,000 in 2002, a more realistic standard now would be for CPET to be routinely available to populations of greater than 100,000.
Table 3. Lung function testing
Y=Yes; N=No; Light shaded cell=doesn’t comply with standards; Dark shaded cell=doesn’t comply with 2006 standards.
Five of the lung function laboratories servicing medium sized DHBs did not have trained respiratory scientists/physiologists and therefore, under New Zealand standards, are ineligible for laboratory accreditation. The credentialing of respiratory scientists per se was not included in the survey. Only six of the DHBs had had their lung function laboratories accredited by the TSANZ (a more robust accreditation process than New Zealand runs). As a consequence, 13 DHBs cannot be recognised as postgraduate respiratory medicine training centres by the TSANZ and may not be able to employ respiratory registrars (advanced trainees). The net effect will be to increase the difficulty smaller DHBs have in attracting advanced trainee registrars to their hospitals and ultimately in attracting senior medical staff.
Whilst the place of exhaled Nitric Oxide (eNO) testing in patients with asthma (or possible asthma) has not been fully established the test has been adopted by some New Zealand hospitals (6 of 21) (Table 3).5 It is, however, available through two asthma societies in New Zealand and which raises the question as to the primary responsibility for service provision.
In New Zealand, lay societies have historically attempted to fill holes created by inadequately funded hospitals and this appears to remain the case. Issues surrounding quality assurance measures when such testing is undertaken outside of a professional organisation are real. However, the lack of quality control around testing would seem to extend beyond lay societies and to include a number of smaller DHBs in New Zealand.
All 21 DHBs ran an oxygen service (Table 4).
Table 4. Oxygen therapy service
Y=Yes; N=No; Shaded cell=doesn’t comply with standards.
The rate at which long-term oxygen therapy (LTOT) is provided ranged from 20 to 150 patients per 100,000 with a mean of 63/100,000 (Table 4). The projected rate of prescription of LTOT, if international guidelines are carefully followed, is around 35–55/100,000 based on the known prevalence of chronic respiratory failure. Five DHBs are therefore under-prescribing and 11 DHBs over-prescribing oxygen (6 DHBs are grossly over-prescribing).6,7 Four DHBs do not provide portable oxygen therapy (despite good scientific evidence of benefit and support of use in NZ guidelines8 and which 20 DHBs stated, guided their practice).
The rate of prescription of portable oxygen ranged from 0–50/100,000 with a mean of 14/100,000. The predicted rate, if guidelines are followed, should be 5–10/100,000 inferring that some DHBs are grossly over-prescribing. In view of the large range of prescribing rates for both LTOT and portable oxygen, a draft copy of this report was sent to all DHBs to allow a check for inaccuracies in the figures supplied.
Despite an attempt to differentiate portable oxygen (the use of a light weight delivery device to be used when patients are mobile) (Table 5),8 there was some confusion regarding this question and some DHBs had listed all oxygen equipment dispensed. Since the only oxygen therapies of proven benefit are LTOT and portable oxygen, there appear to be many instances where patients are receiving oxygen for which there is no scientific evidence of benefit (e.g. short-burst oxygen, administration of oxygen to current smokers, or oxygen therapy prescribed for long-term use at the time of discharge from hospital9 rather than when the patient is stable).
Twelve of the 21 DHBs reported a specified budget for the management of sleep-related breathing disorders based predominantly on volume contracts. The number of full sleep studies performed by each of the DHBs ranged from 0 to 750 with a mean of 161 in the previous 12 months (Table 5). The rates ranged from 0 to 98/100,000 with a mean of 25. The number of partial sleep studies (non PSG) performed ranged from 0 to 105 translating to rates of between 0 and 65/100,000 with a mean of 22/100,000. The number of home sleep studies ranged from 0 to 968 (0 to 125/100,000) with a mean of 22/100,000. Only 8 of 21 DHBs conducted home studies.
Although an overnight oxygen study can be used as a screening test (level IV) to more detailed testing (levels I-III), it was used in three DHBs as the only investigation. Thus, based on a liberal interpretation of a “sleep study,” the overall rate of testing at the time of this audit was 50/100,000/year (this may have increased in 2008 to around 75/100,000/year; personal communication, A Neil, 2008).
These rates fall well below that of Australia (282/100,000), Canada (370/100,000), and the US (427/100,000).10 It is also well below the rate required to adequately investigate and treat OSA acknowledging that at least 10% of Māori 11 and Pacific Islanders have OSA and that 2000/100,000 studies a year would be required to adequately screen the population.10 Of equal concern was the finding that there are only two fully accredited (to TSANZ specifications) sleep laboratories in New Zealand and that no formal accreditation of any of the sleep services in DHBs outside of Auckland and Wellington has ever taken place.
All 21 DHBs provided inpatient non-invasive ventilation (NIV) for patients with acute type 2 respiratory failure. The service was provided in a variety of settings: emergency department, intensive care unit, and medical ward. Fourteen of the 21 DHBs reported a lead clinician responsible for this service, but in only 13 had the service been audited (a mandatory requirement when establishing NIV).12
Only 13 of the 21 DHBs used the MoH/TSANZ prioritisation criteria for respiratory outpatient referrals and 11 reported the use of MoH/TSANZ prioritisation criteria for sleep-related breathing disorders. Only one DHB audited waiting times against any of the criteria. Seven DHBs reported the measurement of key performance indicators (KPIs) in respiratory medicine. The KPIs recorded included: readmission rates within 30 days, average length of stay for hospital admissions (both are national criteria for all hospital admissions), outpatient waiting times, and time from referral to commencement of treatment in lung cancer.
Eleven of the 21 DHBs reported their respiratory service had been credentialed. Most had employed independent respiratory physicians from other DHBs and had used the “Standards” as the reference document. Only 15 of the 21 DHBs reported that their respiratory physicians had been credentialed.
Table 5. Sleep services
*Majority overnight oximetry; **66% overnight oximetry, ***Mainly performed in private (mixture of partial and overnight oximetry); +Referred through to Regional Centre; – no numbers (calculated); Y=Yes; N=No; Shaded cell=doesn’t comply with standards.
Fourteen of 21 DHBs were below the minimum standard for employment of specialist respiratory physicians (Table 6) and the overall rate of 0.67/100,000 was 60% that of the UK 1.2/100,000,13 40% of Australia 1.9/100,000, and 25% of that predicted in UK workforce planning (2.5/100,000).
Of particular concern was the fact that more than 400,000 New Zealanders have no access to a respiratory physician. Seven of the 21 DHBs employed fewer respiratory nurse specialists than defined in the “Standards.” Although the overall rate of employment of specialist respiratory nurses was encouraging major gaps were noted with two DHBs employing no nurse specialists.
For large DHBs, the rate of allied health workers (physiotherapists, clinical health psychologists) dedicated to the practice of respiratory medicine ranged from 0.1 to 0.5/100,000 with a mean of 0.4. For medium-sized DHBs, the rate was 0.3 to 0.9 with a mean of 0.6—and for small DHBs, the rate was 2.8/100,000. The low rate of employment of allied health professionals within larger DHBs is of particular concern. Allied health workers are an essential part of a multidisciplinary approach to chronic care management and the rate estimated falls well below the minimum standard of 1 per 100,000 population.
Table 6. Staffing
* Running Lung Function Lab without Technician; Shaded cell=doesn’t comply with standards.
Summary of current status—Whilst a number of DHBs have identified respiratory disorders amongst their health priorities (mainly COPD and asthma), the implementation of effective strategies appears patchy with limited supportive infrastructure and few outcome measures to assess impact. Whilst integrated care programmes appear more advanced within smaller DHBs, the lack of detail around these and the lack of disease-specific measures makes it hard to evaluate their effectiveness. The higher uptake of integrated care programmes in smaller DHBs may reflect closer working relationships between primary and secondary care providers in smaller communities than exists in metropolitan areas.
Whilst some clinical support services appear well developed (e.g. bronchoscopy, CT scanning, and percutaneous needle biopsies), there were worrying deficiencies in physiological support services (namely sleep and lung function testing), and transbronchial needle aspiration (a standard method of investigating mediastinal adenopathy). The latter is a basic test that can be undertaken by all bronchoscopists after relatively straightforward training.
Five lung function laboratories were operating without qualified respiratory scientists and no longer comply with national guidelines for lung function testing. This ‘unsafe’ staffing of pulmonary function laboratories is possibly due to a shortage of qualified respiratory scientists in the workforce and reflects a deficiency in workforce development at both a national and regional level.
Only six lung function laboratories are registered for accreditation by the TSANZ. The 15 DHBs without TSANZ accreditation of their lung function laboratories will not be able to support postgraduate training in respiratory medicine. At least 730,000 of the population do not have access to a test of bronchial responsiveness, a basic test of airway pathophysiology which is used diagnostically and in pre-employment screening, or in evaluating patients at risk of developing occupational asthma. Bronchial challenge tests are also used as a screening test for SCUBA diving in patients with a history of asthma (a positive test indicates an increased risk of acute bronchospasm and may preclude patients from diving).
Fifteen of 21 DHBs do not have access to a nitric oxide analyser, which complements other tests in the evaluation of airways diseases. The lack of availability of this test in DHBs has led to asthma societies in New Zealand acquiring equipment. This ad hoc application of new technology in New Zealand is common and contributes to substantial variation in practice.
A seven-fold variation in the prescription of oxygen therapy and five-fold variation to both the investigation and treatment of patients with sleep-related breathing disorders exists between DHBs. Even DHBs with the highest rates of both investigation and treatment of sleep-related breathing disorders fall well behind the rates of investigation and treatment performed in Australia, Canada, and the USA.
Increasing levels of obesity are clearly linked to rising levels of OSA. OSA affects at least 120,000 New Zealand adults. Based on this analysis, only 6000 are receiving treatment. Whilst the smaller DHBs have no sleep testing equipment, they do have a referral pathway to regional sleep laboratories but are often unable to tell us how many patients are referred. Many have no record of the number receiving assisted ventilation.
The estimated total societal cost per annum in New Zealand from OSA has been estimated as $40 million or around $419 per case.11 The incremental direct medical cost per quality of life gain from use of CPAP is only $94 (nearly 100-fold lower than the costs PHARMAC pay for new drug therapies to achieve the same result). Clearly, the majority of OSA sufferers are untreated and undiagnosed under the current service structure.
Key deficiencies—As a consequence of the increasing prevalence of a range of respiratory conditions notably COPD, asthma, OSA and pneumonia, respiratory disorders have now overtaken ischaemic heart disease and cancer as the most common cause of mortality14 and remain the most common reason for primary care consultation and the second most common cause of hospital admissions.
Despite these figures, not one respiratory condition is listed as a health priority by the MoH, although (to their credit) some DHBs recognise this deficiency. Consequently, there is no monitoring of a DHB’s performance with respect to implementation of respiratory guidelines on treatment and no monitoring of performance against minimum standards of care. Further, no national or regional infrastructure exists to help establish or monitor respiratory services.
It is therefore not surprising that over 400,000 New Zealanders have no access to a respiratory physician, that 11 of 21 DHBs fall below the minimum standard of care as defined by the TSANZ, and that there are no national health targets for respiratory services upon which to base individual DHB performance.
The lack of planning for respiratory services is of major concern to those practicing respiratory medicine in New Zealand. Despite substantial efforts by the TSANZ to improve services for a range of respiratory conditions in New Zealand since 1996, progress has been limited. Despite scientific evidence of clear benefit from comprehensive management of sleep-related breathing disorders there are large geographic areas in New Zealand where access to diagnostic testing for OSA is absent and little or no treatment is prescribed. Although only two respiratory therapies were evaluated in this audit, the implication is that such variation also exists for a variety of other respiratory services.
There are many-fold differences in the complexity and quality of respiratory care offered around New Zealand. There is little external evaluation of quality and no evidence that a number of smaller DHBs have implemented practices that conform with international guidelines (e.g. sleep, NIV, lung function testing). Whilst there were large gaps in provision of services there were also examples whereby smaller hospitals were providing services (e.g. bronchial artery embolisation and rigid bronchoscopy), whereby the small number of procedures undertaken would make made maintenance of expertise difficult. Since no information is systematically collected or analysed there is no way of evaluating whether outcomes are adversely affected as a result.
Whilst the TSANZ standards of care have obviously influenced quality of care, uptake, and implementation of the standards by individual DHBs has been patchy. This reflects the lack of accountability of DHBs and the fact that no national health targets in respiratory medicine have ever been set. In fact, there is a complete lack of national monitoring of even basic respiratory health care information and this review is the only systematic evaluation of respiratory services ever undertaken in New Zealand.
The way forward: recommendations—This review therefore calls for the following changes:
Representation of all stakeholder groups involved in respiratory care on the committees would ensure improved communication between health care professionals, primary and secondary care providers, professional societies, and lay organisations as well as Māori and Pacific communities. In fact this structure was proposed in 1996 by the TSANZ.
Disclosure: Drs Garrett and Taylor are Past Presidents of the NZ Branch of the TSANZ.
Author information: Jeffrey Garrett, Respiratory Physician/Clinical Associate Professor of Medicine/Clinical Director of Medicine, Division of Medicine, Middlemore Hospital, Otahuhu, Auckland; Bob Chen, Clinical Health Psychologist, Department of Medicine, Middlemore Hospital, Otahuhu, Auckland; D Robin Taylor, Respiratory Physician and Professor of Respiratory Medicine, Otago Respiratory Research Unit, Dunedin School of Medicine, University of Otago, Dunedin
Acknowledgement: This study was funded by the TSANZ.
Correspondence: Dr Jeffrey Garrett, Division of Medicine, Middlemore Hospital. Private Bag, Otahuhu, Auckland, New Zealand. Fax: +64 (09) 6307128; email: firstname.lastname@example.org
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