NIHR Global Group on COPD in primary care in South America (Breathe Well South America)

RESEARCH QUESTION

How can we effectively implement good primary care pathways for diagnosis and management of COPD in South America, and reduce inequities? BACKGROUND

South America is the most inequitable region in the world. Three of its largest countries are Argentina (population 45m), Brazil (211m), and Peru (32m). Geographically and ethnically diverse, they experience wide health and social inequalities.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death, with high hospital healthcare and societal burden, disproportionately affecting the poor. However, more than 75% of cases remain undiagnosed, therefore untreated. Good quality, affordable and accessible primary care services for COPD patients are lacking.

Diversity of risk factors and health systems with limited human/financial resources require local adaptation of international guidance and implementation using task-sharing within multi-disciplinary teams.

Building on our previous Global Health Group in Brazil, this programme will develop primary care research capacity in South America to improve earlier identification and management of COPD. Co-led by the University of Birmingham and the Universidad Científica del Sur (UCSUR) together with CRONICAS Centre of Excellence in Chronic Diseases in Peru, the project will be delivered through an equitable partnership with the International Primary Care Respiratory Group (IPCRG), an NGO clinical primary care respiratory network; the Institute for Clinical Effectiveness and Health Policy (IECS) in Argentina; the University of São Paulo (USP) in Brazil; and University College London.

AIMS/OBJECTIVES The programme’s objectives are as follows. 1. Develop sustainable research infrastructure/research leaders to deliver high quality COPD research in primary care

2. Develop sustainable engagement with community members, clinical leaders and policy stakeholders to ensure research is rooted in local, national and regional needs with clear pathways to impact on health and healthcare 3. Assess current quality of COPD primary care 4. Develop a set of COPD quality indicators

5. Co-develop/adapt pathway of identification and management of COPD patients in primary care, with locally-appropriate team-based task-sharing implementation 6. Test feasibility of implementation; compare different settings 7. Model preliminary cost-effectiveness of this pathway and potential impact on health inequalities

8. Submit funding applications for full trials of the interventions. METHODS

Over four years, starting in July 2024, Breathe Well partners will assess the current context and quality of COPD care in each country/region, develop a set of COPD quality indicators and an identification and treatment pathway for COPD patients in primary care. They will test the feasibility of these in different settings, and model the preliminary cost-effectiveness of the pathway and its potential impact on health inequalities.

Based on the outcomes of the work, partners will then submit funding applications for full trials of the developed interventions.

The programme set-up is based on a ‘hub and spoke’ model. The lead University in each country (Argentina, Brazil and Peru) will work with 2-3 less-experienced institutions to recruit 45-50 local general practices in each country, train their staff and conduct the research within their communities. Capacity building at individual, institutional and environmental level is a fundamental part of the programme to ensure sustainability.

A range of different research methods will be used across three research work packages (WPs).

WP1 will evaluate the quality of COPD care and healthcare records. Data from interviews with relevant stakeholders will be combined with new/existing surveys and primary healthcare data records.

WP2 will co-create pathways sharing tasks between the healthcare and community teams to identify people with COPD and provide treatment, including supporting those diagnosed to manage their own condition better. This pathway will then be tested out in a few general practices. WP3 will evaluate the cost-effectiveness of the pathway and its impact on health inequalities.

Two additional work packages will run throughout:

WP4 will focus on engaging stakeholders from all relevant groups, including community members and patients, so that they can advise and input into the research from start to finish and help to ensure that the findings are taken up in healthcare policy and practice. A network of community members will be developed to work within and across countries, advising the research and advocating for future policy change.

WP5 will focus on training the different staff required to conduct the research, working with Universities, clinical organisations and funders to provide a framework for the future. Community engagement/involvement

To ensure projects are locally relevant, we have consulted groups of advisors including patients, carers, community members, healthcare professionals/managers and policy makers, and they will be involved throughout the life of the programme. We will develop community and professional networks in each country to be involved throughout the research and beyond. Two rotating chairs of our community advisory group will also sit on the management board.

Dissemination

Information about the programme will be disseminated at all stages to public, patient, clinical, academic and policy audiences, using media relevant to each group and advised upon by our community/stakeholder experts. OUTPUTS, OUTCOMES AND IMPACT The programme is expected to develop: - Map of current gaps in COPD care

- Core COPD quality indicators - Locally-relevant pathways of COPD care - Analysis of the cost-effectiveness of new pathways in different contexts - Community, academic and primary healthcare networks - Centres of Excellence for primary care research & education - Further funding applications to fully test pathways/indicators.