How effective is it to deliver integrated COPD care at public healthcare facilities: a cluster randomised trial in Pakistan?

How effective is it to deliver integrated COPD care at public healthcare facilities: a cluster randomised trial in Pakistan?

This study, funded by Department for International Development (DFID), was done in partnership with; Provincial Program for Prevention and Control of Non-communicable Diseases & Mental Health; Directorate General of Health Services, Punjab; Nuffield Centre for International Health and Development, University of Leeds UK and World Health Organization (WHO).

Background: In Pakistan COPD prevalence is 2.1% in adults (> 40 years). Despite a focus in health policy integrated COPD care has remained neglected with a wide variation in practice.

 Aim: We assessed whether enhanced care at public health facilities resulted in better control of COPD, treatment adherence and smoking cessation.

Design and Setting: A two-arm cluster-randomised controlled trial in 30 public health facilities (23 primary and 7 secondary) across three districts of Punjab between October 2014 and December 2016. Both arms had enhanced diagnosis and patient recording processes. Intervention facilities also had: clinical care guide, drugs for COPD, patient education flipchart, associated staff training and mobile phone follow-up.

 Methods: We randomised facilities in a 1:1 ratio (sealed envelope independent lottery method) and recruited 159 intervention and 154 control patients (eligibility: diagnosed with COPD, ≥18 years, living in the catchment area). Primary outcome: change in BODE index score from baseline to six-month follow-up. We did not blind staff or patients. ISRCTN 17409338.

Results: Six-month primary outcomes were available for 147/159 (92.5%) intervention and 141/154 (91.5%) control participants (all clusters). Primary outcome results, cluster-level analysis: mean intervention outcome = -1.67 (95% CI: -2.18, -1.16), mean control outcome = -0.66 (95% CI: -1.09, -0.22), and covariate-adjusted mean intervention-control difference = -0.96 (95% CI: -1.49, -0.44; P=0.001).

Conclusion: The findings of this trial and a separate process evaluation study support the scaling of this integrated COPD care package at primary and secondary level public health facilities in Pakistan and similar settings.