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In a great environment Miguel Roman (pictured), IPCRG World Conference President, opened the IPCRG's 4th World Biennial Conference in Seville. He introduced his colleague, GRAP President and Chair of the Scientific Committee, Eduardo Calvo and Carmen Cortes Martinez, Directora General from the Consejeria de Salud de la Junta de Andalucía, thanked the sponsors and then proudly announced 932 registrations from 42 countries. 
Mark Levy (pictured right), Editor-in-Chief of the Primary Care Respiratory Journal (PCRJ), introduced the speakers for the PCRJ session on respiratory services in primary care: Nick Glasgow on Australia, Osman Yusuf on Pakistan, and Alan Kaplan on Canada. All three mentioned a shortage of GPs in their countries with subsequent gaps in needed medical care. These overviews will all be published in the PCRJ.
In Pakistan 40% of the population is under 15 years of age, asthma rates range around 16%, symptoms are increasing, but diagnosis of asthma is decreasing, so "we do something wrong", as Osman Yusuf stated. In his country there are almost no peak flow meters, no spirometers, and no allergy tests except in the bigger cities, which mean extra diagnostic difficulties. Apart from that there is a taboo about the use of inhalers in Pakistan; patients prefer oral, which often means less effective, medications.
Nick Glasgow pointed out that the degree of difficulty of respiratory diseases is aligned to their morbidity: upper respiratory tract infections are most common, but fortunately not always presented to GPs, while lung cancer is much less prevalent, but means a far greater burden for primary care. COPD and comorbidities lie in between these two extremes. Australia has slightly more than 2000 general practitioners, who conduct 90 million consultations per year, which means an average of 4-5 consultations for every inhabitant. There is a shortage of 800-1300 GPs. Recent extended educational possibilities with 60% subsidies seem one solution; eyes are now focused on the new Labour government.
Canada depends upon provincial, not federal, funding for health care, and due to the size of the country with so many rural areas, some 25% of inhabitants have no direct access to primary care. In some cases pharmacists prescribe, which is not a desired option, but is accepted as an alternative to no prescription at all.In relation to asthma care, 40% of GPs in Canada use guidelines, 11% of patients have a written action plan and 47% of patients are controlled. With 16 million smokers and ex-smokers, and 1.5 million patients diagnosed with COPD, Alan Kaplan (pictured) emphasized that a great number of them have not been identified yet.
During the next forum it became clear that besides similarities there are lots of differences too. For example, some drugs in Pakistan are as available as Pizza Hut due to pharmaceutical industry promotion according to Osman Yusuf. Prices are 90% lower than in western countries, and patients buy it without prescription. Most female COPD patients in Pakistan get the disease not from tobacco dependency, but from inside cooking. "You can smell her in the waiting room", Yusuf stated.
GPs in Australia have 100 guidelines for every disease, a fact that doesn't encourage using them on a regular basis. "Look for a guideline of your own", Nick Glasgow advised - developed by general practitioners and suited to local circumstances.
And then it was time for the official opening reception in the fairy-like surroundings of the Royal Palace, Real Alcazar. Several guides told us the incredible history of the building and its famous inhabitants, and under a heavenly sky, music, drinks and tapas were provided until the late hours. It was an unforgettable opening to a remarkable conference.Variability
The next morning, Siân Williams, Executive Officer of IPCRG, gave an overview of current conceptual models for considering variation in practice. Most of the early research on variation looked at surgery, where data is often better. The Dartmouth Atlas analyses in the USA have shown that there is little variation in the rates of hip replacement for fractured neck of femur because it is painful and there is strong consensus amongst surgeons about the correct intervention. However this is not the case for other orthopaedic surgery nor for hospitalisations for medical conditions. This suggests misuse, underuse or overuse of treatments. With medical conditions it is related to the supply of hospitals: the more beds available, the more the bed days are used. Why do middle class children in the UK still have their tonsils, while those of poorer children are removed? It is unacceptable inequitable provision. If equity of care is the goal of us all, the challenge is to reduce unwarranted variation - due to variable clinical knowledge, behaviour and beliefs, whilst enabling warranted variation related to patient difference and preference. What is the likelihood of patients receiving optimal smoking cessation in China if 57% of Chinese male physicians smoke? A combination of robust statistical analysis such as process control charts that identify special cause variation, and evidence-based behavioural interventions will be necessary for both patients and clinicians.
Asthma follow up and treatment: everything under control
Asthma follow up obviously can be better done. In the majority of cases asthma is not under control. John Haughney, President of IPCRG, stated that symptoms and lung function are bad markers of asthma control. Eosinophils in sputum and exhaled NO are better ones. Thys van der Molen, Dutch representative, explained that exacerbations are very closely related to asthma control. Uncontrolled asthma patients experience on average 17 "worsenings" in their condition per year. Let us imagine what that means for the quality of life of those patients. "Control" is the new magic word in asthma, according to Van der Molen.
Carlos Gonzalves from Portugal did a survey in his country to find out why only 5% of asthma patients achieve asthma control. He estimated that inhaled corticosteroids are widely underused. Gonzalves questioned 100 patients with asthma, 71 of them admitted that they stopped medication by themselves. Bjorn Stallberg from Sweden draw attention to the fact that one third of asthma patients experience asthma problems when having sex with their partner. According to the reactions in the audience most doctors are not aware of this, and Stallberg stated that doctors underestimate the severity of patients' complaints. Besides, patients seem to have different treatment goals compared to goals in guidelines. 20% of the questioned patients used their inhalers improperly, and 12 % never used the prescribed medication! All this was measured in Sweden; data of course may differ in different countries.
Laura Stacul, who works in the poor north of Argentina, showed us that using homemade spacer devices with correct inhalers, achieved a decrease of 80% in hospital admissions for acute respiratory illness in children.
GARD (Global Alliance Against Chronic Respiratory Diseases)
In the GARD Forum speakers described different situations in low and middle income countries. GARD was launched by WHO in 2006, and Niels Chavannes, IPCRG representative in GARD, explained its role. Worldwide 300 million people suffer from asthma and 210 million from COPD. Low and middle income countries however have to pay much more attention to and many more funds for communicable diseases. Chronic diseases are of minor importance, in the struggle for surviving infectious diseases.
Osman Yusuf (Pakistan - pictured), Pedro Ordunez (Cuba), Laura Stacul (Argentina), Prof. Y.J. Mashalla (Tanzania), Catalina Panaitescu (Romania), Sarath Paranavitane (Sri Lanka) and Afshin Parsikia (Iran) presented an insight into their national needs and demands. Education and information is what all of them want, but only 10 out of 36 primary care centres in Argentina have a personal computer, and none have access to internet. Cuba wants guidelines translated and presented at a local level. Their greatest health enemy, according to Pedro Ordunez, is tobacco, which is not surprising in a tobacco producing country. Smoking rates have decreased from 50% to 30% over the last 30 years.
Some countries have an absolute ignorance of evidence-based medicine, or there are very few research possibilities, all of which are funded by laboratories with commercial interests, and when there is only one doctor for 50.000 patients, other priorities than guidelines take priority, despite an increase in prevalence of respiratory diseases.
Tanzania has a tremendous shortage of human capital. Most health workers' work is not adequate for the needs; there is a lack of local guidelines; the international ones are not accessible; there is a lack of diagnostic facilities and inadequate funds for them, and there are competitive priorities as HIV/Aids, malaria and cholera. The audience was kindly invited to come to Tanzania, to appreciate the highlights such as Mount Kilimanjaro.
Romania has had 12 Ministers of Health in the last 10 years, all of whom were specialists. It meant that primary care had struggled for survival until the arrival of the current minister, who is an economist. Now it is primary care's time and there is ambition to have GPs with special interests, access to spirometry and CT scans and to be able to prescribe inhalers without hospital specialists' permission.
It was felt that GARD and IPCRG could provide complementary approaches: GARD can address the high level politics, while IPCRG can be more informal and support local adaptation and innovation.
During the following animated discussions lots of possible solutions and ideas were contributed and discussed.
Severe COPD - the final stage
Managing the final stage of severe COPD is a serious subject, with patient needs that may be at least as great as those approaching the end of life with lung cancer. However, patients who die from COPD often have little contact with health and social services, contrary to patients with terminal cancer. Rupert Jones stated that lung function is the main measure to assess severity in COPD, but that it does not measure lung damage very well. He introduced the DOSE-index, a simple instrument that with the help of the MRC Dyspnoea scale, airflow Obstruction, mobility Status and Exacerbations number, gives a better assessment of the severity of COPD.
Hilary Pinnock told us that recognizing the end of life in COPD is rather complicated and she led us through several trajectories in that stage. Our patients are vulnerable enough to need high quality palliative care from primary care services, which means that we have to identify patients' needs and wishes in time. "There is always something that can be done", she said.
Patrick White emphasized that we have no reliable tools to detect patients who need palliative care. Kike Cimas, who deputised for Clavel Arce, gave an overview of ways of relieving symptoms of COPD at the end of life in Spain. 65% of them receive palliative care, but only one and a half day before death. He drew attention to ways to control dyspnoea and coughing, and the need for emotional support for the patient and family. Quality of life is even more important if someone's lifetime is limited. Cimas warned us not to be too afraid of using morphine and benzodiazepines in the end stage, although these are contra-indicated in patients with COPD. He considers them in these circumstances as "good clinical practice". Respiratory infectious pandemics
Recent experiences with SARS and avian flu have made global medical and social authorities think of infectious respiratory pandemics as a real potential problem. David Price and Mike Thomas led us through the roles and responsibilities of WHO, EU, ECDC, surveillance networks, governments, international groupings, regulatory bodies, industries, health care workers, individuals, and finally the role of IPCRG. Indeed there is a need for a platform where all sectors can come together and discuss pandemic planning.
Karl G. Nicholson highlighted the role of anti-influenza drugs and emphasized that they must be administrated as soon as possible in case of a pandemic. Amantadine is inappropriate as a first line agent as there is a need to check renal function, possible CNS adverse effects and a rapid development of resistance.
John Watkins pointed out the real possibility of an infectious pandemic. When and where it will happen, what type and how virulent and who are the risk groups: we don't know. The role of vaccination will be limited as it takes 6-9 months to produce an appropriate vaccine.
Catherine Weil-Olivier stated that we have known for about ten years that children at any age are a major vector of influenza transmission. Therefore seasonal vaccination could play a role during an epidemic. Current strategy in Europe says that children at risk should be vaccinated, while in the USA all children above 6 months receive (intranasal) vaccination.
There was consensus that the IPCRG could support the development of primary care's role in public education, adminstration of vaccines and in delivery of care in the event of a pandemic.
During the Annual General Meeting of IPCRG that evening Greece was welcomed as a full member, while Edinburgh was elected as host town for the World Conference 2012.
Life style influence on respiratory diseases
Judith Garcia-Aymerich from Spain, who is an international recognised expert in this field, stated that only recently has physical activity been related to reduced lung function decline and a reduced risk of COPD development in the general population. Her studies showed additionally that for COPD patients physical activity, which is a behaviour, not a condition, is related to a lower risk of hospital admission for COPD and to lower risk of all-cause and respiratory mortality. We do not understand the specific mechanisms yet and type, duration and intensity of physical activity needed to obtain benefits in COPD are also unknown. Judith studied simple walking by COPD patients and her current ongoing research focuses on the identification of other effects of physical activity. Patients with COPD have less physical activity than healthy subjects, not only due to the disease, but also to co-morbidity. Just walking 20 minutes three times a week is enough to obtain better health outcomes. Rehabilitation programmes in primary care are much cheaper than in secondary care and are at least as effective.
Changing outcomes by earlier intervention in COPD
Rupert Jones introduced us to the silent early phase of COPD and emphasized the challenge of early detection. Early means earlier than we do now, as Anders Ostrem pointed out. It should be a priority in clinical practice, as there seems to be under diagnosis as well as misdiagnosis, with subsequent wrong treatment. All speakers in this theme discussed helpful tools such as questionnaires, target spirometry and the web (www.copdscreener.com) as instruments for busy general practitioners. Smart screening (all smokers between 35 and 70 years of age who visit the general practice and offered a short questionnaire) can be done within 4 minutes and cost 5-10 Euros, according to Anders Ostrem. Lill Moll from Denmark said we have the responsibility to change the prognosis for our patients and stop the progression of the disease. A reasonable tool is annual COPD review. She pleaded for better cooperation between general and specialist services to improve detection and treatment.
Anders Ostrem from Norway led us into the first line of the tobacco war. He stated that smoking is not just a bad habit, but a serious medical condition. After smoking cessation, 30% of people relapse after a week, 60% after a month and 90% after 4 months. Behavioural therapy with medication seems to help best (30% success). Without medication the percentage slopes down to 15%. Besides nicotine replacement therapy (NRT) two drugs were discussed: bupropion and varenicline. Both seem to have a place in smoking cessation, but be aware of contra indications and remember that patients should be carefully informed.
Tuberculosis
Tuberculosis is spread unevely around the world, which means different challenges and limitations in different countries. Ben Marais, paediatrician from Cape Town, pointed out that in his country, South Africa, TB follows the HIV-lines, with a remarkable shift to young children and women. Mycobacterium tuberculosis is the second most common pathogen in children with acute pneumonia, who fail antibiotic therapy. Incidence of TB in South Africa is 407/100.000 inhabitants. As there is no reliable skin test and X-rays are not always available to TB nurses, who are the first contact in primary care, workers must use symptom-based screening methods. Patients are only referred if the response after a nurse's therapy is not what she expected. A successful treatment means a retrospective diagnosis, Marais stated.
In low incidence countries as Spain i.e. (incidence 18/100.000) physicians focus more on case detection. Luis Olmo from Spain gave an interesting overview of active concentric case-detection in his country. Fernando Calvario, pneumonologist from Portugal reminded us of the problems of INH-resistence and recommended to treat with a 4-drugs cocktail, as is new policy in Spain too. Pere Joan Cardona from Spain explained several new treatments, from which the one that reduces the duration of treatment with INH from 9 months to 2 months, will be a welcome alternative. He assessed that it will not be until 2015 before a reliable vaccine is available.
IPCRG Awards
At the end of the congress the 6 best submitted communications were presented in three categories: original approach to respiratory medicine in primary care (PC), advanced research in primary care and patient-based research. The winners in each category were:
In between in downtown Seville everyone could have a lung function test. The last performance invited a patient-professional partnership to build a strong part in the chain. On the one hand health services need to be streamlined and efficient, budgets are limited, and ageing populations with more chronic diseases require more health care. On the other hand are our patients, who have individual health issues, unique learning styles and personal beliefs and expectations. From both sides we should better harmonize healthcare goals and listen more to each other when trying to manage diseases. Jo-Anna Gillespie gave a moving example of personalized (unpaid!) health care in remote parts from Canada when she was an asthma-allergic nurse. Rob Horne (UK) pleaded for better implementation of self-management in asthma and the last words were spoken by Marianella Salapatas on behalf of the European Federation of Allergy and Airways diseases and Laura Fernández on behalf of Foro Catalán de Pacientes.
Hetty Van Dijk
July 2008
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