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| Journal of the New Zealand Medical Association,
13-February-2009, Vol 122 No 1289
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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.
MethodsA 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.
ResultsThe 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.
DiscussionSummary 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: jegarrett@middlemore.co.nz
References:
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