Qualitative Validation of COPD Evidenced Care Pathways in Japan, Canada, England, and Germany: Common Barriers to Optimal COPD Care

Figures & data

Table 1 Report on the Accordance with the COREQ Checklist for Domain 1: Research Team and Reflexivity

Research Team and Reflexivity	Description
Interviewer/facilitator	RGA, GW, AM, AR, KPS, YM and TdL conducted the interviews
Credentials	AM has a Master of Science (MSc) in Control of Infectious Diseases, RGA has a BA Hons in Humanities, GW and AR have an MSc in Public Health, TdL has an MSc in Health Economics, YM has an MSc in Health Data Science, KPS has an MSc in Health Economics
Occupation	All researchers were employees of Aquarius Population Health at the time. RGA is working as a Director, AM is working as a Consultant, YM and KPS are working as Analysts, AR and TdL were working as Analysts, and GW was working as a Senior Consultant.
Gender	AM, GW, YM and AR are female. RGA, KPS and TdL are male.
Experience and training	RGA had 31 years of qualitative market research experience, AM and GW had one 1-year qualitative experience, AR, KPS, YM and TdL had 6-months of qualitative experience.
Relationship with participants
Relationship established	There was no established relationship between the researchers and participants before the interview. Apart from one HCP, all interview participants had a prior relationship with AstraZeneca.
Participant knowledge of the interviewer	The participants received the information that the interviewer was from Aquarius Population Health. Participants were informed that the aim was to develop representative pathways depicting the steps involved in COPD care and identifying the barriers to optimal care from the perspective of clinical experts in each country.
Interviewer characteristics	The participants received the information that Aquarius is an independent consultancy firm employed by AstraZeneca to conduct the research.

Abbreviations: BA (Hons), Bachelor of Arts with Honors; COPD, chronic obstructive pulmonary disease; HCP, healthcare professional; MSc, Master of Science.

Table 2 Details on the Time Period and the Interviewer/Facilitator Involved in Each Phase

	When	Interviewer/Facilitator
Phase 1	August-September 2020	RGA, AM, YM, TdL, GW
Phase 2	February-May 2021	AM, RGA, AR, KPS

Figure 1 Overview of the Evidenced Care Pathway for patients with COPD from four countries.

Notes: *COPD is a progressive disease that deteriorates over time. Stable COPD has been used here to describe patients whose symptoms are currently well managed and controlled.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 3 The Themes and Sub-Themes That Describe the Barriers to Optimal COPD Care Across Japan, Canada, England, and Germany

Key Themes	Sub-Themes
Journey to diagnosis	Low consideration of COPD by patients (HCP reported)
	Low consideration of COPD by HCPs
	Misdiagnosis due to poor quality diagnosis
	Poor utilization of spirometry
Treatment and management	Poor utilization of non-pharmacological treatments
	Inadequate or inappropriate use of pharmacological treatment
	Unreported and unrecognized exacerbations
Impact of COVID-19	Increased use of telehealth
	Impacts on patient health
	Impacts on diagnosis, treatment and management

Notes: These themes were derived from the pre-determined themes. For example, “Pre-diagnosis” and “Diagnosis” and “Awareness” were found to be closely interlinked and therefore were combined into the new theme of “Journey to diagnosis” which better conveys the long temporal journey people with COPD experience before receiving a correct diagnosis. “Management of exacerbations” was treated as a subtheme of “Treatment and management” rather than a separate theme as there was not enough data to stand alone.

Abbreviations: COPD, chronic obstructive pulmonary disease; HCP, healthcare professional.

Table 4 Qualitative Evidence to Support Common Structural Differences

Structural Differences	Supporting Quotes
Insurance is a barrier to the provision of quality COPD care in Japan, Canada, and Germany	“The way that the insurance works in Japan is that they [doctors] cannot prescribe therapies that are not covered by the insurance. So even if the patient says, I will pay on my own […] they cannot prescribe it and so because the government will only pay a certain amount set at a low amount, they can only prescribe so much of the therapy, so it is in an insufficient amount” (ID 18, Respiratory specialist, Japan) “The cost side is a bit of an issue here because the coverage is not complete […] But inhalers are quite expensive here, they are hovering around about $100 plus and minus […] and if you are on two inhalers […] that can be quite inhibitory than if you are on one inhaler.” (ID 11, Respiratory specialist, Canada)
Rural settings affect patients’ ability to be properly diagnosed, urgently treated for acute exacerbations, and have regular monitoring by HCPs	“Canada, because it is such a vast country, has a few particular groups of care they provide. So, there will be the urban-type model within the city, it’s very similar to the primary care we all recognize in all of our countries, where you have your family doctor, and they are accessible fairly easily. And then we have got the rural model in Canada […] really you could be 150/200 miles from your family doctor. So, for them to come and see their family doctor is a big journey. Some of them will have taken a plane if they are in a remote location.” (ID 9, GP, Canada)
Lack of time in primary care affects the diagnosis and management of COPD	“GPs have a finite amount of time; they get 5–10 minutes with a patient and a proper holistic assessment requires at least 20–30 minutes for a patient. Most GP practices unfortunately just cannot provide [that amount of time].” (ID 2, Respiratory specialist, England) “In a primary care setting we see so many patients that have so many normal lifestyle diseases, hypertension and diabetes, metabolic syndrome […]. We only have a few minutes to see each patient and we are working with very limited staff in a primary care setting.” (ID 16, Respiratory specialist, Japan)
A disease management program (DMP) is available in Germany only but there is a lack of consensus among HCPs on its cost-effectiveness	“I see DMP as something very useful. Yes, you could say that I can charge four times to see the patient every quarter, but for me, it’s good to see the patients every three months so that four times in a year I can ask, how are you, and I can adjust the medication, if necessary, I can see how the patient is doing. […] So, this is a way of reviewing the situation and it makes the situation safer.” (ID 21, Respiratory specialist, Germany) “Cost of healthcare for DMP patient is higher than in non-DMP patients. Yes, due to the effect that the insurance companies are getting […] money from the Government, but they are not receiving […] more frequent visits or better monitoring, that’s not true.” (ID 22, Respiratory specialist, Germany)

Note: Some clinicians were not speaking their native language and/or only English interpretations were transcribed.

Abbreviations: COPD, chronic obstructive pulmonary disease; DMP, disease management program; GP, general practitioner; HCP, healthcare professional.

Table 5 Qualitative Evidence for the Subthemes Within the Theme: Journey to Diagnosis

Subtheme: Low consideration of COPD by patients (HCP reported)
Quotes	“They think it’s due to ageing, they don’t complain to GP […] and the symptoms are very, huge symptoms, very, in other words very later stage of the disease. They came to the chest physicians.” (ID 16, Respiratory specialist, Japan)
Any national nuances?	Yes, there is no term for “COPD” in Japanese “It’s not a very well-known illness in Japan, because for Japanese people it’s actually written out in English and it’s not very familiar to Japanese people. We are trying to enlighten ourselves, but it’s been a slow process. You can say this for the doctors as well.” (ID 13, Respiratory specialist, Japan)
Subtheme: Low consideration of COPD by HCPs
Quotes	“We still have not found a way to bring the physician to understand the importance of this disease, that the treatment and management has changed. You can really make a difference with the treatment pharmacology and non-pharmacology in terms of the patient’s life, in terms of preventing exacerbation.” (ID 8, Respiratory specialist, Canada)
Any national nuances?	No differences: issues common to all countries. HCPs across the countries reported that low consideration of COPD by HCPs, particularly in primary care, was common due to a lack of interest in respiratory diseases, COPD being seen as a lower priority compared to other chronic diseases such as cardiovascular diseases or diabetes and lack of knowledge that there are treatments available that make a difference to patients’ HRQoL.
Subtheme: Misdiagnosis due to poor quality diagnosis
Quotes	“I think if you go to presentation to healthcare, there’s often a loop there. […] presentation, missed diagnostic appointment, re-presentation. So that pathway is far more likely, I would say, 10 times more likely to result in the patient returning home with the same symptoms than it is for them to have a confirmed diagnosis” (ID 6, Respiratory specialist, England)
Any national nuances?	In Japan, the one non-respiratory HCP mentioned that relationships between primary and secondary care, especially when diagnosing outside of their specialty, are important. “But when a patient is very severe, it is easy to send the patient to the hospital. But some confusing cases […] it is very hasty to send the patient to the doctor because they think my diagnosis is wrong. […] (ID 17, Non-respiratory specialist, Japan)
Subtheme: Poor utilization of spirometry
Quotes	“You can have specialist nurses being recruited who could just do spirometry in one of the practices within the network […]. They could do spirometry for all the six practices within the network. Instead of training one nurse in six surgeries, you have one nurse looking after, say all the patients that present. She becomes very skilled in doing that again and again.” (ID 4, GP, England)
Any national nuances?	In Japan and Germany “loud voices” were stated as one reason why spirometry is not performed.

Note: Some clinicians were not speaking their native language and/or only English interpretations were transcribed.

Abbreviations: COPD, chronic obstructive pulmonary disease; GP, general practitioner; HCP, healthcare professional; HRQoL, health-related quality of life.

Table 6 Qualitative Evidence for the Subthemes Within the Theme: Treatment and Management

Subtheme: Poor utilization of non-pharmacological treatments
Quotes	“Non-pharma treatment’s very important, often neglected. It’s easier to change a prescription than to change someone’s lifestyle. […] In medicine, it’s much easier to forget about the difficult jobs of losing weight, taking more exercise, and stopping smoking and just say, ‘Why don’t we try a different inhaler?’ Different inhaler takes me three minutes. Changing a lifestyle can take 15 to 20 [minutes] and might not succeed.” (ID 1, GP, England) “Well, there are several issues or problems. One problem is […] don’t offer structured smoking cessation programs, pulmonary rehab, all these non-pharmacological treatments aspects, which are really important clinically, absolutely meaningful.” (ID 19, Respiratory specialist, Germany)
Any national nuances?	Countries report variations in the available alternatives to pulmonary rehabilitation. As pulmonary rehabilitation is a limited resource in all four countries patients were instead encouraged to attend community exercise programs in England, Canada, and Germany. In Japan, HCPs prescribed a certain number of steps per week measured by a pedometer. “We have a weaker kind of pulmonary rehab which is called lung sports. This is usually easier for the GP or the pulmonologist to prescribe exercise or sport for the patients [.] they get the prescription for one year and they can meet recruits with a trainer in the gym once a week. But this is not pulmonary rehab.” (ID 19, Respiratory specialist, Germany)
Subtheme: Pharmacological treatment is often inadequate or inappropriate
Quotes		“There are a lot of therapies now available which is also a very luxury position. But my impression is that with all the new inhalers that became available, with all the new combination therapies, that the GPs are a bit lost at the moment. And we have some issues with over-prescriptions […] the same medication from different inhalers, just because it’s a different brand name, different inhaler, or whatever, but the medication itself is the same.” (ID 19, Respiratory specialist, Germany)
Any national nuances?		Japanese HCPs are less likely to use inhaled corticosteroids due to the perception of increased risk of pneumonia in their population.
Subtheme: Poor treatment and recognition of exacerbations
Quotes		“My patients that have action plans, I will tell you right now they do not even report to me to get the action plan. The next three months go by, I see them again, and still, “Have you activated your action plan?” They go, “Oh, yes. No, I used my antibiotic and prednisone a couple of weeks ago”, “Where’s the phone call?” (ID 8, Respiratory specialist, Canada)
Any national nuances?		Japanese patients have a longer hospital stay for exacerbations than in other countries.^Citation47 “In Japan, they wait until the patient is able to take care of themselves at home before they release them. Whereas in England, if they still have some trouble breathing, they still have some trouble walking, they send them home but there’s a healthcare team that will take care of them at home, and that’s not available in Japan.” (ID 13, Respiratory specialist, Japan)

Note: Some clinicians were not speaking their native language and/or only English interpretations were transcribed.

Abbreviations: GP, general practitioner; HCP, healthcare professional.

Table 7 Qualitative Evidence for the Subthemes Within the Theme: Impact of COVID-19

Subtheme: Increased use of telehealth
Quotes	“I think new models of care have to evolve pretty quickly […] home spirometry, […] digitally supported pulmonary rehab […] are already happening by default, people are being innovative and changing what they do. So, this […] approach to disease management is happening despite […] the guidelines not catching up yet, but people are finding their own routes forward” (ID 6, Respiratory specialist, England) “I found that patients, especially the sicker patients, they somehow like to be remote because it saves them travelling.” (ID 11, Respiratory specialist, Canada) “Especially during this COVID incident […] people are using telemedicine and some of the subtleties of making that diagnosis get missed. […] everybody is so focused on this current disease at the moment, which is COVID, that other chronic diseases are getting missed and put to one side even though they are clearly risk factors for developing that.” (ID 9, GP, Canada)
Subtheme: Impact on patient health
Quotes	“In the year of COVID, I would say we had none [exacerbations] at all, through these regular visits and through the patients doing the DMP, but it’s generally known that during COVID we did not have these viruses we normally have because many patients are at home and they were mask covering and so on, so we did not have as many infections, or hardly any really.” (ID 21, Respiratory specialist, Germany) “A lot of patients stay at home and suffer at home, especially again with COVID, they would be offered an admission, but refuse to come in, because they are terrified they may catch COVID.” (ID 5, GP, England)
Subtheme: Impact on diagnosis and treatment and management
Quote	“So, in terms of pharmaceuticals there is not such a big influence, but what I am worried about […] is being able to diagnose in the future as fewer patients are coming to see. So, I am afraid the COPD patient change their active lifestyle […] physical inactivity is in COPD patients.” (ID 18, Respiratory specialist, Japan)

Notes: No national nuances were found for this theme; some clinicians were not speaking their native language and/or only English interpretations were transcribed.

Abbreviations: COPD, chronic obstructive pulmonary disease; GP, general practitioner; DMP, disease management program.

Igarashi A, Fukuchi Y, Hirata K, et al. COPD uncovered: a cross-sectional study to assess the socioeconomic burden of COPD in Japan. Int J Chron Obstruct Pulmon Dis. 2018;13:2629–2641. doi:10.2147/COPD.S167476

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