Situational Assessment: Pulmonary Rehabilitation in New Brunswick

​

1. What is the situation?

2. •  

     ​

     The current situation with respect to Chronic Obstructive Pulmonary Disease (COPD) is that it is the fourth-leading cause of death among Canadians (World Health Organization, 2022). This chronic disease affects the lives of over 2 million Canadians (Government of Canada, 2018). When narrowing this down to the specific target population of New Brunswick residents, COPD is diagnosed in 1 in 9 residents over the age of 35 and 1 in 5 seniors within the province (New Brunswick Department of Health, 2016).

   • ​

   • When looking at which population of COPD patients is at a higher risk, those with more severe COPD are at an increased risk of exacerbations of COPD which may result in hospitalization and/or death (Bahadori et al., 2007). Those who do not have their COPD under control with medication or lifestyle changes are also at increased risk of exacerbation (Bahadori et al., 2007).

   • ​

   • Pulmonary rehabilitation among the COPD population has been proven to improve health outcomes, including hospital readmissions, patient symptoms, exercise tolerance and overall quality of life (Ryrso et al., 2018). These programs should be implemented after discharge following an acute exacerbation of COPD to produce the best outcomes for the patient and to reduce the risk of readmission (Ryrso et al., 2018). Implementation of these programs consistently to this population could improve health outcomes and reduce healthcare spending by reducing hospital admissions.

   • ​

   • The Government of New Brunswick has recognized that COPD is one of the most prevalent diseases in the province and that exacerbations of COPD are the leading cause of hospital admissions (New Brunswick Health Department, 2016). There have been many programs and initiatives launched in an attempt to improve outcomes for these patients, including vaccine campaigns, smoking cessation programs and hospital-based pulmonary rehabilitation clinics (New Brunswick Health Department, 2016). The issue is that COPD admissions are resulting in an excessive amount of healthcare spending, which impacts their ability to dedicate more funds to other services and programs. There is a need for an overhaul in where these funds are allocated to better serve this population.

   • Respirologists in the province recognize the need for more pulmonary rehabilitation clinics in the province and the impact that could have on the COPD population. These programs are currently only accessible via a referral from a Respirologist so they are involved every step of the way. In order to meet the needs of their patients, there needs to be more access to services.

   • ​

3. What influences are making the situation better or worse?

4. •  

     ​

     The most common cause of COPD in Canada is tobacco smoking (WHO, 2022). Due to the continued use of tobacco products and the aging population, the rate of COPD continues to rise globally. Other risk factors for COPD include occupational exposures and air pollution (WHO, 2022). Those who do not take the appropriate precautions are putting themselves at an increased risk of COPD. Increased prevalence of COPD is causing increased strain on the minimal existence of pulmonary rehabilitation clinics in the province as they already cannot keep up with the demand.

   • ​

   • According to the American Cancer Society (2022), most people who smoke started smoking at a young age due to exposure to smoking by family or friends. They also noted that often people indicated that they thought it was the cool thing to do so they tried it and got addicted to nicotine (ACS, 2022). It is also noted that tobacco smoking and the use of e-cigarettes is marketed to be safe and the general public think it is a harmless habit (ACS, 2022). Providing education to youth about the risks associated with smoking and vaping may help mitigate some of the issue. If they do not see vaping and smoking as harmless habits and realize the health risks associated, the rate of smoking and vaping may improve among the population which will in turn reduce the risk of COPD later in life.

   • In order to address the current situation of COPD in New Brunswick and the best way to improve the health of the COPD population, it is important to note that current pulmonary rehabilitation programs in the province are working. There are patient testimonials to how much these programs have changed their lives for the better. So despite knowing how to make these programs successful, the weaknesses lie in the access to services. Firstly, the requirement of being referred by a specialist when patients take months if not years to get in to see one is a major weakness to the current procedure. Also, having only a select few clinics running that can only take a few patients at a time is slowing down the process. When looking at outside factors, there are opportunities to improve on the current situation. One major opportunity would be to have an automatic referral go in to a clinic upon discharge for COPD patients who meet the criteria for services. This eliminates the wait time for getting in to see a specialist and reduces the wait time for starting a program. Another opportunity would be to privatize the clinics to become community-based rather than hospital-based which would reduce resource burden on the already overwhelmed healthcare system. These clinics would then be able to open in any community and not be limited to major hospitals in the province. This would increase access to more residents who could not travel to the major cities. A threat to these changes is of course funding. Not having enough funding to make changes necessary to improve the system.

   • ​

5. What possible actions can you take to address the situation?

6. •  

     ​

     Recently, New Brunswick Community College (NBCC) launched a pilot project of a student-led pulmonary rehabilitation clinic which showed that a community-based clinic with multi-disciplinary involvement can have a positive impact among the COPD population (Doucet et al., 2021). This clinic has resulted in patients on the waitlist for hospital-based clinics being brought in for rehab sooner. This clinic has since published an article in the Canadian Journal of Respiratory Therapy to indicate the positive impact this community-based clinic has had on the COPD population.

   • ​

   •  Our New Brunswick Lung Association is constantly working to improve lung health. They provide access to counselling services for patients to improve their lung health, including smoking cessation (NB Lung, 2023). With respect to air quality, they have a number of projects that range from wood smoke education and air quality monitoring to electric vehicle education to improve the air quality in New Brunswick to reduce the risk of lung disease among New Brunswick residents (NB Lung, 2023). This group provides New Brunswick residents access to resources to improve their lung health and are constantly working on new projects to continue this work.

   • The Government of New Brunswick (2018) as discussed have implemented hospital-based pulmonary rehabilitation programs, smoking cessation programs and smoking cessation initiatives. These programs have had a positive impact on our COPD population but this disease is still the most common cause for hospital admissions in the province so there is still more to be done.

   • There is a wide variety of research available that all demonstrate that prevention is key for COPD as there is no cure. Since the major causes of COPD are smoking and exposure to environmental and occupational pollutions, it is evident that not smoking and being aware and cautious of surroundings puts the public at a decreased risk of COPD. The research also indicates that COPD can be managed with medications and lifestyle changes (ie. Quitting smoking, increased exercise, better diet, etc). However, the intervention with the most positive impact on overall health and quality of life is pulmonary rehabilitation, specifically early access to pulmonary rehabilitation. This evidence is presented in the form of meta-analyses and systemic reviews of research on the topic of pulmonary rehabilitation for COPD.

   • ​

American Cancer Society (2022). Why People Start Smoking and Why It’s Hard to Stop. https://www.cancer.org/cancer/risk-prevention/tobacco/why-people-start-using-tobacco.html

​

Bahadori, K., & FitzGerald, J. M. (2007). Risk factors of hospitalization and readmission of patients with COPD exacerbation--systematic review. International journal of chronic obstructive pulmonary disease, 2(3), 241–251.

​

Doucet, J. R., Fournier, T. A., Bishop, C. M., Gaudet, D. J., & Nagel, D. A. (2021). Pilot of a community-based interprofessional "student-infused" pulmonary rehabilitation program in Saint John, New Brunswick. Canadian journal of respiratory therapy : CJRT = Revue canadienne de la therapie respiratoire : RCTR, 57, 26–31. https://doi.org/10.29390/cjrt-2020-053

​

Government of Canada. (2018). Chronic Obstructive Pulmonary Disease in Canada. https://health-infobase.canada.ca/datalab/copd-blog.html

​

New Brunswick Department of Health. (2016). Chronic obstructive pulmonary disease (COPD) in New Brunswick. https://www2.gnb.ca/content/dam/gnb/Departments/h-s/pdf/en/Publications/Profiles/ProfilesHealthCOPD.pdf

New Brunswick Lung (2023). Our Programs. https://nblung.ca/

​

Ryrso, C. K., Godtfredsen, N. S., Kofod, L. M., Lavesen, M., Mogensen, L., Tobberup, R., Farver-Vestergaard, I., Callesen, H. E., Tendal, B., Lange, P., & Iepsen, U. W. (2018). Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC Pulmonary Medicine, 18(154). 10.1186/s12890-018-0718-1

​

World Health Organization. (2022, May 20). Chronic obstructive pulmonary disease (COPD). https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)