Identifying barriers to care for complex airway disease and multidisciplinary solutions to optimize therapy in Canada

Complex Airway MDCs have been well established in the USA, which have demonstrated significant improvement in quality of life indicators and symptom recurrence [8]. However, a lack of similar clinics in Canada has limited the treatment potential of complex airway disease patients in this country. Our study evaluated the current diagnostic and treatment algorithms of Rhinology, Respirology and Allergy in Canada, as well as interest in and barriers to establishing a Complex Airway MDC in Canada.

The need for a MDC is based on the shared pathophysiology between the sinonasal cavity and the lungs. For example, CRS with polyps has a Type II inflammatory pattern characterized by eosinophilia and elevated IL-4, 5 and 13 cytokines [9]. Lower respiratory tract manifestations are characterized by a similar systemic inflammatory response [10]. Approximately 60% of patients with CRS with polyps have lower airway disease including co-existing asthma [9]. Treatment of the upper airway can modify the severity of lower airway disease and vice versa, and early treatment may also help prevent further progression of the patient’s airway disease [10]. However, to achieve this, sub-specialists are required to collaborate in the diagnosis and management of these complex airway diseases to provide appropriate specialized treatments. Establishing a MDC will facilitate this interaction, allow patients to receive proper diagnostic workup and tailored treatments from the relevant sub-specialists on the team. While it is true that multidisciplinary meetings such as case conferences provide avenues for similar collaborative care, we believe that gathering providers in a physical MDC space provides value both for patients, who can attend one appointment instead of many, and for providers, who can share diagnostic findings such as endoscopic examinations in real time.

Although there was expressed interest in establishing a MDC (69%), we identified 4 fundamental barriers through our interviews: Current Dogma, Control, Location and Funding. In our current system, sub-specialists operate independently and practice through a blend of personal experience and evidence-based medicine. Challenging this status quo and asking practitioners to forego some degree of independence to optimize patient care through evidence-based medicine may initially be difficult. There is a similar barrier with regards to the preferred location of the MDC. Finally, to maintain both research and clinical pillars, the MDC would require a steady stream of funding. Any loss in income flow because of lower patient volumes in a MDC may disincentivize clinicians from participating, as well as restrict research resource availability.

To address these barriers, we have identified a roadmap to the development of a Complex Airway MDC in Canada. First, is the creation of a team of subspeciality leaders from Rhinology, Respirology and Allergy. Each specialty must identify a lead individual to represent their interests in putting the MDC together. This is particularly important in larger centres where they may have multiple subspecialists working at the same site. As outlined from the results of this study, there is a gap in understanding how to best manage upper and lower airway disease. The management algorithm for patients defined with complex airway disease requires consensus among each specialty. Once a defined population and management algorithm is finalized, the team must determine: (1) Who is the referral group? (i.e., primary care, specialists) and (2) What intake form will be used by the referring physician to screen for appropriateness. At the University of British Columbia (UBC), a MDC has been established and the referral group was defined as Otolaryngologists, Respirologists and Allergists. The defined referral base limits the incoming referrals to consist of only complex patients with most diagnostic testing already complete. For example, a patients with AERD would already have PFTs supporting a diagnosis of asthma, a documented allergy to aspirin, and a diagnosis of CRS based on such guidelines as EPOS 2020 (clinical symptoms in keeping with CRS and either endoscopic evidence or CT imaging findings of mucosal changes). For patients with CF, sweat chloride testing would already be done along with possible genetic screening. Otolaryngologists have a different intake form compared to Respirologist and Allergists, as the skillset of each specialty is different (Figs. 1 and 2).

Fig. 1figure 1

Rhinology patient intake form

Fig. 2figure 2

Respirology and allergy patient intake form

Moreover, for the MDC to be successful, the leads of the MDC must define the resources required and what resources are already available. Rather than requesting resources from the health authority/hospital, re-allocation of already available resources was more economical. Common resources used by Respirologists are asthma educators/technicians who provide education, pulmonary function testing, and allergy testing. Re-allocation of this role into the MDC provides a lot of value to the patients (Fig. 3). Another important resource is the clinical coordinator to coordinate the administrative steps between initial referral, timing specialist assessment in clinic and education. A sample patient clinic schedule has been provided to outline the logistical coordination involved (Fig. 4). Furthermore, individual administrative assistants and coordinators at other MDCs in the hospital could also be reallocated for assistant in clinic logistics.

Fig. 3figure 3Fig. 4figure 4

Another possibility is the combination of a clinical/research coordinator role, as the nature of the MDC lends itself well to providing opportunities for research. At UBC, the MDC is viewed as a research clinic and re-allocation of research funds between the three specialties to pay for a research coordinator has been a successful strategy. This helps to manage the clinic and optimize research productivity, which is an effective strategy to circumvent the lack of funding from the health authority and/or hospital to financially support the clinic. Furthermore, with a focus on the research pillar of the clinic, the complex airway MDC also acts as a center for excellence for the development of predictive medicine, markers, and cutting-edge evidence-based treatment strategies.

Most participants in our study would prefer a ‘neutral-based’ clinic location. However, at UBC, we have found that the biggest issue is the capital required to support rhinology equipment, which includes endoscopes, video towers and the support staff required to clean the scopes. Given that the infrastructure is already in place in Rhinology clinics, the MDC was brought to the Rhinology clinic at our institution. In this setup, portable pulmonary function testing and allergy kits were easier to implement into the Rhinology clinic than creating more expensive alternative arrangements. In addition, given the rapid advancement and adoption of telemedicine technology during the COVID-19 pandemic, adding teleconsult and videoconferencing capabilities to MDCs could allow for more versatile inclusion of asthma educators and consulting providers who do not need to conduct any additional in-person diagnostic testing. This could help the establishment of MDCs in community and more rural areas outside of tertiary care academic centers as long as the necessary rhinology, pulmonary, and allergy equipment are available when needed.

Overall, the majority of the decision making and operationalization of the MDC was built around a business model where no further funding was requested. Instead, we relied on a re-allocation of existing resources. This required all three involved specialties to come to the table providing an equal share to the MDC. We have summarized our recommendations for establishing a MDC in the attached figure (Table 7). Above all, cooperative leadership and open communication plays a strong role in the success of MDC.

Table 7 Key points to setting up a MDC Airway Clinic

An additional point of importance after setting up the MDC is how to keep community colleagues involved in the care of these patients. It is our belief that a MDC in an tertiary care center would serve as an important initial touchpoint for patients with complex disease in order to facilitate access to medications such as biologics in a targeted and cost-effective manner. After optimal treatment plans are formed within the MDC, some of these patients could be followed on an ongoing basis by individual community providers and referred back to the MDC as needed.

Major limitations of our study include the sample bias inherent with the method of interviewing and survey distribution. A convenience sample of providers within the principal investigator’s professional network was used to gain access to second degree connections representing an array of Respirologists and Allergists. This sampling method may have, therefore, missed a large cohort of Otolaryngologists, Respirologists/Pulmonologists, and Allergists who may have had differing opinions. However, our results and thematic analysis are consistent with existing literature highlighting the barriers to effectively providing multidisciplinary care in the setting of complex diseases (11, 12). In addition, it may be difficult to reproduce the findings of our study in other healthcare systems outside of North America due to differences in healthcare provider compensation and public vs private insurance coverage.

留言 (0)

沒有登入
gif