COPD care access

Access to COPD care: A fragmented picture

Available treatments can prevent COPD progression and exacerbations, as well as improve patients’ overall quality of life. Regarding access to care in Europe, the EFA’s 2013 report identified criticalities tied to the scarce availability of pulmonary rehabilitation services and the need for greater collaboration between healthcare providers involved in the treatment of people with COPD. In 2014, EFA published another report entitled “Harmonizing Prevention and Other Measures for COPD Patients across Europe”, which included a survey of 19 European countries [1]. The report revealed significant differences between countries in the types of services provided and reimbursement policies. Furthermore, it highlighted existing inequalities in access to pulmonary rehabilitation services, as well as a lack of inclusion of spirometry in periodical check-ups [1]. Ten years later, access to healthcare services for COPD seems to have generally improved in terms of availability and reimbursements. Access to pulmonary rehabilitation is still an issue in many countries. The Covid-19 pandemic exacerbated the pre-existing scarcity and poor accessibility of pulmonary rehabilitation services, primarily dedicated to the rehabilitation of Covid-19 patients, thereby reducing de facto access for patients with COPD. Furthermore, a personalised approach to managing COPD and interventions promoting patient empowerment and self-management are often overlooked, despite evidence supporting their ability to improve quality of life and adherence to treatments, reduce hospital admissions, and even lower overall mortality [2] [3].

Nevertheless, standards of care for patients in Europe still vary from country to country and, within the same country, from region to region. In addition, a multidisciplinary holistic approach to treatment of a patient with COPD is lacking, despite the fact that the management of COPD remains mostly hospital centred [2] [3].

COPD Patient Testimonial: Teresa Madden, Ireland (English)

Teresa Madden, a member of Limerick COPD Support Group, shares how participating in the SingStrong program, focused on singing for lung health, has helped her manage COPD.

Optimal management of COPD patients: a well-known recipe

Treatment of COPD consists of behavioural adjustments (especially quitting smoking), active living strategies, medications for symptom control, pulmonary rehabilitation, vaccinations, oxygen therapy, and palliative cares; see boxes Box 8 and Box 9 [3]. Optimal management of COPD should encompass a patient-centred multidisciplinary effort involving pulmonary specialists, primary care physicians, pulmonary rehabilitation, respiratory nurses, nutritionists, and social workers. In fact, such programmes are proven to be effective in reducing the burden of COPD.

Primary care should be the first line management for chronic conditions. Access to primary care can reduce exacerbations, disease progression and ultimately the costs related to avoidable hospital admission [4]. Despite the evidence on the importance of primary care in the management of chronic diseases, including COPD, its quality is suboptimal in most countries. This issue is underlined by the high rate of avoidable hospitalisations, which is an indicator of the quality of primary care (Figure 10) [4].

Respiratory nurses have the potential to play a significant role in managing COPD in a variety of ways. They can perform spirometry for early diagnosis and monitoring (see “Early detection and diagnosis”). They can also educate patients by providing information and guidance on their condition and treatments.

Physiotherapists specialised in pulmonary rehabilitation should be an integral part of the overall management of patients with COPD. They can play an important role in promoting the general wellbeing of patients with COPD, with long-term effects on adherence to behavioural changes [3].

Nutritionists should be considered part of the multidisciplinary team to manage patients with COPD. In fact, COPD is associated with both overweight and underweight patients [5]. Balanced nutrition is important for everyday wellbeing, coping in everyday life, enabling exercise, as well as promoting daily activities (e.g., walking) and independent living.

Social workers can identify and anticipate the needs of fragile patients, including financial problems, and advise patients and their caregivers about social support and benefits to which they are entitled.

Management of comorbidities is another crucial part of the COPD treatment. People with COPD frequently have concomitant health conditions (comorbidities) that worsen COPD severity and impact general health and quality of life. The most common comorbidities are heart diseases and lung cancer, which have similar risk factors to COPD, such as smoking. Other common comorbidities are osteoporosis, gastro-oesophageal reflux, skeletal muscle dysfunction, anaemia, and diabetes. COPD also affects mental wellbeing, and patients often suffer from anxiety and depression. Anxiety and depression are important and underdiagnosed comorbidities in COPD [3]. The challenges associated with COPD, including breathlessness, fatigue, and limitations in daily activities, can have a significant impact on a person’s emotional wellbeing. Integrating mental health support into the overall management plan is crucial to address these aspects. This support may involve counselling, therapy, or support groups that provide coping strategies, stress management techniques, and a platform for individuals to share their experiences [6] [7]. Recognising and addressing the mental health needs of COPD patients not only improves their overall quality of life, but also contributes to better adherence to treatment plans and improved health outcomes.

The organisation of healthcare systems has an impact on the quality of care provided to patients with COPD. For COPD patients, optimal access to care should consider:

Availability, i.e., if the services are offered to patients without any restrictions or conditions (e.g., a certain age threshold, lack of a sufficient number of healthcare providers, or short waiting lists);
Accessibility, i.e., whether these services are physically accessible to patients, including short distances to the provider;
Affordability, i.e., the extent to which costs are covered by the healthcare system and if there are measures to cap out-of-pocket payments, which may be particularly cumbersome for patients with chronic conditions.

Figure 10. Avoidable hospital admission rates for asthma and COPD, congestive heart failure and diabetes

Age-standardised rate of avoidable admissions per 100000 population 15+

Source: OECD Health Statistics 2021. Data refer to 2019 or nearest year.

Box 14

Treatments recommended for COPD

The goal of pharmacological therapies available for COPD is to reduce the rate of exacerbations and should be continued by the patients under medical follow-up.

The GOLD guidelines recommend pharmacological and non-pharmacological interventions for the treatment of COPD.

Behavioural changes

Reducing exposure to risk factors (smoking and air pollution). Improving exercise ability to help relieve symptoms.

Pharmacological treatment

Pharmacological treatments depend on the stage of the disease severity and must be monitored and reviewed periodically to ensure that each patient is getting the treatment needed.

Inhaled bronchodilators (both short- and long-acting, also known as SABA and LABA) in association with anti-muscarinic (anticholinergics or LAMA) and/or ICS alone or in combinations.

Oxygen

Long-term oxygen therapy Indicated for patients with severe COPD and with severe hypoxia to increase the oxygen in tissues.

Non-invasive ventilation improves the condition of patients with stable COPD.

Surgery

In selected patients with severe COPD, lung transplantation and lung volume reduction surgery (LVRS) may also reduce mortality.

Pulmonary rehabilitation

Programmes between 8-12 weeks
Tele-rehabilitation
Community-based excersises [3].

Managing and Treating COPD (German)

Key challenges for COPD patients include early symptom recognition, timely diagnosis, and ongoing care. Experts discuss the importance of regular check-ups, rehabilitation, physical activity, and both medical and non-medical therapies, emphasising integrated care across healthcare providers.

Access to care for patients with COPD: major gaps still occurring

Despite improved access to services in most countries, COPD management coordination is still not optimal. Furthermore, during the Covid-19 pandemic, access to healthcare services for COPD patients decreased drastically.

The patients’ organisations surveyed rated access to therapies (drugs and oxygen) positively due to the reimbursement system in place (Figure 11). They also judge access to specialist consultations positively. Nevertheless, management of COPD is primarily hospital centric, and there is a lack of multidisciplinary approach to patients’ care, particularly in terms of a lack of coordination between specialists and primary care services. Long waiting lists and the uneven geographical distribution of pulmonary specialists and specialised centres impair the quality of care for many patients, especially those living in rural areas. The measures enforced to prevent re-hospitalisation are judged “average”. This is probably due to the lack of coordination between hospitals and primary care. Access to rehabilitation is still limited, and community-based programmes to promote a healthy and active lifestyle rely only on the initiative of specialised centres and patient organisations, and often suffer from a lack of funding. Finally, palliative care services are emerging only recently and need to be further implemented. Doctors should be trained to inform patients about these services.

Figure 11. How do you judge access to care for patients with COPD in your country?

Access to state-of-the-art drug therapy (dual and triple therapy)

Access to oxygen therapy at early stages of COPD

Access to specialist care (pulmonologist)

Prevention of re-hospitalisation (follow-up visits)

Palliative care access at the end of life

Management of co-morbidities is included in COPD management programmes

Mental health support for COPD patients is understimated

Box 15

A roadmap to pharmacological interventions for COPD

Dual therapy

Dual therapy in COPD typically involves the use of two different classes of bronchodilators, which are medications that help open up the airways, making it easier for individuals with COPD to breathe. Dual therapy commonly includes a combination of LABA and LAMA
This combination aims to provide more effective and sustained bronchodilation, improving airflow and reducing symptoms [6].

Triple therapy

Triple therapy involves the use of three different classes of medications for COPD treatment, namely: Long-acting beta-agonists (LABA), long-acting muscarinic antagonists (LAMA) and inhaled corticosteroids (ICS).
Triple therapy is often prescribed for individuals with COPD who experience persistent symptoms despite using dual therapy. ICS help to reduce inflammation in the airways. The combination of all three classes of medications aims to provide comprehensive bronchodilation and anti-inflammatory effects, leading to improved lung function and symptom control [6].

Oxygen therapy

Oxygen therapy is a medical intervention commonly used in the management of COPD, especially in advanced stages when individuals may experience low levels of oxygen in their blood. In COPD, the airways become narrowed, and the air sacs in the lungs lose their elasticity, making it challenging for individuals to breathe effectively. This can lead to decreased oxygen levels in the blood, a condition known as hypoxemia. Oxygen therapy is prescribed when the levels of oxygen in the blood fall below a certain threshold, and it becomes necessary to provide additional oxygen to maintain proper bodily functions.

Box 16

Access to treatment – what has changed since 2013

Multidisciplinary approach (including collaborations among specialists and primary care physicians) is still not fully implemented.

Pulmonary centres are still unevenly distributed.

In some countries (i.e., Sweden) the number of centres is being cut.

Management of comorbidities is not included in management of COPD patients.

Reimbursement is in place in all countries, with or without co-payments.

Access to influenza and pneumococcal vaccination is free.

Affordability of COPD treatment: Reimbursement and co-payments

In recent years, access to care has improved, both in terms of reimbursement and access to state-of-the-art treatment. All European countries, whether through different schemes (either centralised or local/regional), provide a form of universal healthcare coverage. In most countries, mandatory statutory health insurance (SHI) covers the healthcare needs of most of the population. In other countries, the central or local government provides healthcare. All surveyed countries have implemented specific measures to reduce out-of-pocket payments for patients with severe chronic diseases, including COPD or COPD-related disabilities (Table 4). Nonetheless, the organisation, payment schemes, services offered, and referral procedures vary greatly across countries. Furthermore, economic barriers still hinder access to care, especially for poor, elderly, and chronically ill people [8].

Specialist visits, oxygen therapy, ambulatory care, annual health checks, hospital care, and rehabilitation for patients with COPD are mostly covered by public healthcare systems. Co-payment may be required depending on the patient’s income and on disease severity. In Austria and Italy, co-payment for drugs is required, unless in the case of very severe stages of COPD. In Spain, treatments are free for patients with a diagnosis of COPD, regardless of the stage of severity. Nevertheless, reimbursement or regulatory restrictions may impair access to newly developed drugs. For example, in 2021, the Italian drug regulatory agency (AIFA) issued a note [12] stating that, while reimbursement for maintenance therapy with pre-established LABA/LAMA combinations is permitted following a GP’s prescription, reimbursement for the triple combination of LABA/LAMA/ICS requires a specific and justified request from a specialist, subject to periodic review. Thus, patients who may benefit from the triple association cannot be reimbursed unless they refer to outpatient public services, leading to an increase in workload for specialists and long waiting times.

Some countries, like Spain and Italy, restrict reimbursement to a specific list of drugs, and it may take some time for any new therapy to qualify for reimbursement. For instance, Spain has recently removed the bureaucratic barrier that impeded access to triple therapy, following the advocacy campaign by patients and HCPs. In the Netherlands, basic health insurance typically covers medications for individuals with COPD. Occasionally, patients may be required to contribute a co-payment toward their medication costs. Additionally, health insurance providers may fully cover the cost of the cheapest version of a particular medication only. This approach can sometimes negatively affect patients’ compliance, particularly if it necessitates a change in medication due to a preference policy. Consequently, the Netherlands issued a set of guidelines to ensure responsible medication alterations. These guidelines limit switching inhalation medications for financial reasons to once every four years, except in cases where it is deemed necessary. Sweden and Turkey require co-payments for hospital visits and medical devices (oxygen concentrator, nebuliser, mechanical ventilator).

Table 4. Reimbursement scheme for COPD patients in the countries surveyed

Country	Healthcare system	Co-payments	Medications	Oxygen	Consultation	Hospitalisation	Pulmonary rehabilitation
			Reimbursements

Austria	Mandatory SHI	7.10 per products for prescriptions					for selected patients
France	Mandatory SHI	Free for patients enrolled in long-term illness scheme
Iceland	Government funding	Exemptions for vulnerable group
Ireland	Two tier reimbursement schemes depending on income (low income may have medicines and medical visits fully covered)	Fully covered if card holder, co-payment with cap without card	Listed medicines
Italy	Government funding	Free for patients enrolled in long-term illness scheme	Listed medicines				for selected patients
Netherlands	Three separate coverage schemes (SHI, regional insurance funding, municipalities)	Co-payment foreseen	Listed medicines (cheaper options)	NA	NA	NA	Only patients GOLD stage 2
Portugal	Government funding	Co-payment or full reimbursement depending on disease severity
Spain	Social security	Some co-payment depending on income, age, disability and retirement status	Listed medicines
Sweden	Government funding	Co-payment. Patients > 85 years of age are exempt	Cap at € 580	NA	approx. €20-40 per visit / in primary care € 9–28 (yearly cap around € 110)	€ 11 per day with reductions in case of severe disease	NA
Turkey	NA	Co- or full payment		Partial	NA	NA	NA

Differences in access to care between urban and rural areas

Disparities between cities and rural or less populated internal areas are still a significant concern when it comes to addressing inequality in access to care across Europe. Discrimination based on geographic location violates the principle of non-discrimination and equal access, exacerbates disparities in health outcomes, and calls for a human rights-based approach to healthcare.

In Sweden, 80% of primary care facilities have a dedicated asthma and COPD outpatient clinic; however, the distribution of these clinics is not uniform across the country, with regional differences ranging from 20% to 100%. In Spain, large cities or some hospitals have implemented pneumology teams, but rural, internal, and less populated areas lack reference hospitals. Austria, Italy, and Portugal also report similar disparities. In France, due to long waiting lists, it is difficult to book a specialist visit, and even access to spirometry testing may be limited. In addition, due to lockdown and the measures against Covid-19 in 2020, access to specialist follow-up visits was restricted with waiting lists that have become even longer than previously throughout Europe. The Swedish National Airway Register (SNAR) estimated that the number of COPD patients receiving care has decreased during the Covid years from 41,000 to 37,000 in outpatient care.

Austria and Turkey also reported difficulties in accessing specialist visits outside large cities. The disparities experienced by patients living in remote, less urbanised, areas are exacerbated by a healthcare organisation that is still largely hospital centric [13].

The disparities between rural and urban healthcare infrastructure lead to significant inequalities in patient care and increase the burden for the patients and their caregivers. It is therefore essential to address these disparities to grant equal access to care, especially for chronic patients. In this context, digitalising certain services may help to close the gap. Nevertheless, digital strategies should consider COPD patients’ demands and concerns. Specifically, they should employ devices that are already familiar to patients. Furthermore, digital transformation should not completely replace face-to-face contact with healthcare providers (see “Digital health solutions for patients with COPD”).

Access to healthcare professionals’ consultations

In most of the countries surveyed, patients with chronic conditions are largely managed by specialists. Generally, pulmonary specialists make treatment decisions and manage exacerbations, whereas primary care physicians are rarely involved in COPD management but are responsible for treating comorbidities. Suboptimal coordination among primary healthcare and specialist services means that patients lose their continuum of care and do not receive a personalised approach to their health status. They may have difficulties reaching the specialists they need. Having to deal with multiple doctors depending on the comorbidities may be cumbersome and even confusing. Many countries, especially those with regional healthcare systems (such as Italy, the Netherlands, and Spain), have reported difficulties in coordination among healthcare professionals. In fact, patients may refer to specialised care in a region other than their residence, making communication among healthcare providers’ more complex.

In recent years, all countries included in this report have launched policies or pilot projects aimed at increasing the role of primary care services in the management of chronic diseases, including COPD, by promoting a more active role in early diagnosis. In Ireland, the reorganisation of the healthcare system is tending toward an increase in primary care services specifically targeted at patients with chronic respiratory conditions. The system consists of local “hubs” dedicated to patients with COPD, offering diagnosis, follow-up, and rehabilitation (see BEST PRACTICE – The Irish National Clinical Programme for Respiratory). In Hungary, the government is implementing bundled payment methods for COPD treatment, consolidating hospital and ambulatory care into a single fee, promoting system efficiency and cost-effectiveness.

Contrary to most countries that are making efforts to increase the role of primary care, the reorganisation of healthcare in some Swedish regions went in the opposite direction, with considerable cuts in the number of primary care services. For instance, in the south of Sweden, the number of primary care services decreased from 79 to 38 in seven years.

Policies and targeted investments are being implemented to reinforce primary care. For example, the national plans under the EU Recovery and Resilience Facility (RRF), a financial instrument of NextGenerationEU – the EU’s plan to emerge stronger and more resilient from the pandemic, are expected to make a significant impact. The effects of these policies will be observed in the upcoming years.

Management of comorbidities

A holistic approach to the management of COPD patients through a dedicated programme would also improve outcomes of concomitant diseases. Unfortunately, for many countries, implementing such an approach remains a distant goal. In fact, in seven out of the ten countries that participated to the survey, the management of comorbidities is not included in COPD management programmes. The poor degree of coordination among HCPs may be stressful for patients and reduce adherence to treatments. Only in Iceland, Ireland, and Sweden the treatment of comorbidities is integrated into the management of COPD.

Furthermore, the mental health of people with COPD is too often overlooked by the healthcare systems and the policy makers. As confirmed by all countries participating in the survey, patients do not receive psychological support as part of routine management of COPD.

Psychological Issues in COPD Patients (Turkish)

Pinar Akin Kabalak highlights common psychological challenges in COPD patients, such as depression and anxiety, and stresses the importance of seeking professional help.

Box 17

Access to care: A sustainable development goal (SDG) for 2030

SDG Target 3.8 is to “Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. The concern is with all people and communities receiving the quality health services they need (including medicines and other health products), without financial hardship.

Best Practice 2

The Irish National Clinical Programme for Respiratory (NCP Respiratory)

The Irish National Clinical Programme for Respiratory (NCP Respiratory) is part of the Irish Integrated Care Programme for Prevention and Management of Chronic Disease (ICPCD) and plays a pivotal role in advancing respiratory care in Ireland. By embracing integrated models of care, engaging with healthcare professionals and patient advocacy groups, and providing essential training and resources, the programme is contributing to a patient-centred, efficient, and accessible approach to prevention, early detection, disease progression management, and optimal care provision.
Some of the main characteristics of the NCP Respiratory are:

Specialist Ambulatory Care Hubs

Specialist Ambulatory Care Hubs have been set up to support the Structured Chronic Disease Management (CDM) programme in general practice. These hubs include 30 Respiratory teams providing a range of services and offering services dedicated to patients, namely diagnosis, follow-up and rehabilitation such as COPD Outreach, consultant-led clinics, and multidisciplinary team meetings.

GP Chronic Disease Management Programme

NCP Respiratory acknowledges the vital role of GPs in delivering the structured CDM Programme in primary care. Since 2020, the programme has shown promising results, with 91% of GPs participating and 91% of patients with chronic diseases managed routinely in primary care. The NCP Respiratory is also actively working to implement an accessible and timely spirometry service for GPs throughout Ireland.

Patient Advocacy Groups

Regular meetings with patient advocacy groups, including COPD Support Ireland, the Asthma Society of Ireland, and the Alpha-1 Foundation Ireland, contribute to a collaborative approach. Patient support groups, advice lines, and ongoing financial support for COPD support groups are integral components.

Training and Resources

NCP Respiratory launched various resources in 2022, including eLearning modules on pulmonary rehabilitation, infographics for patients and GPs, and updates on national guidance documents. The programme also provided training on Dyspnoea Assessment and Management, thereby emphasising the importance of education and collaboration among healthcare professionals.

https://www.hse.ie/eng/about/who/cspd/ncps/ncpr/

‘Breitmaulfrosch sitzend’ (German)

It is a video series in German featuring short and simple breathing exercises to help improve lung function as well as emergency techniques for managing breathlessness. The full series is accessible here.

Access to pulmonary rehabilitation

Pulmonary rehabilitation is recommended by international and national clinical guidelines due to its demonstrated benefits across all grades of COPD severity [3]. It is indicated in all COPD patients, even in the absence of exacerbations. It has been shown to be the most effective therapeutic strategy to improve shortness of breath, health status, and exercise tolerance [3] and should therefore be an integral part of COPD patients’ disease management.

Despite the multiple clinical benefits and strong scientific evidence, the offer of rehabilitation is scarce in many countries. It is estimated that, in Italy and in the Netherlands, pulmonary rehabilitation is offered only to 5% of patients. Multiple barriers prevent full implementation of pulmonary rehabilitation that is in line with clinical guidelines recommendations (Johnston and Grimmer-Somers, 2010). These barriers can concern referral and availability of the programmes, but also patient personal barriers that may discourage accessing and participating in pulmonary rehabilitation programmes Figure 12.

Apart from Iceland and Ireland, the availability of pulmonary rehabilitation (either centres, community-based care, or home care) is insufficient to meet the demand. The lack of training for physiotherapists to specialise in pulmonary rehabilitation is another weak point in most countries, consequently, there are not enough specialists to meet the needs. In Spain, hospitals organise pulmonary rehabilitation, but there is no national strategy. In Sweden, the number of patients receiving COPD-related rehabilitation during hospital visits decreased from 64% to 54% between 2019 and 2022, according to SNAR. The number of specialised centres is still an issue in all countries surveyed, and given the increased demand for rehabilitation due to Covid-19, access to pulmonary rehabilitation for COPD patients has been restricted. Unfortunately, despite robust scientific evidence in favour of the effectiveness of pulmonary rehabilitation, governments are dealing with the increased demand by reducing the duration of the rehabilitation cycle and sessions per person.

However, some improvement has been observed in recent. Rehabilitation is now fully reimbursed in the Netherlands, but doctors rarely refer patients to pulmonary rehabilitation. Portugal has implemented specific legislation (although the results are not yet visible), and the number of centres in Turkey is increasing.

Patients’ organisations play a huge role in promoting and organising educational and self-management activities. The box below provides a few examples of best practices. On the downside, the scarcity and uncertainty of financial support for these activities prevent them from expanding to a wider number of patients who could benefit from them.

Best Practice 3

Access to pulmonary rehabilitation

Ireland

Weekly activity classes offering peer support and HCPs support (48 support groups across Ireland, hopefully it will be extended to 90+ groups).

France

Activities and initiatives for respiratory patients.

Spain

Virtual programmes organised by patients’ associations.

Box 18

What is pulmonary rehabilitation?

Pulmonary rehabilitation is a programme tailored to each individual that includes educational interventions along with physical training. It aims to reduce the physical and emotional impacts a long-term lung condition can have on a person’s life. It improves dyspnoea and the ability to perform physical activities, as well as the patient’s mental wellbeing, by reducing anxiety and depression [6]. Programmes have proven to be effective between 8 and 12 weeks. After medical assessment, a personal programme is prepared.

Typically, pulmonary rehabilitation involves:

Endurance training: like walking or cycling for 20-60 minutes.
Interval training: High intensity activities that include rests.
Resistance training: Like lifting of weights to improve muscle strength in the upper and lower limbs.
Neuromuscular electrical stimulation: exercises using electrical impulses to strengthen the muscles in the legs to improve the patient’s strength and ability to exercise. Suitable for most severe cases.
Inspiratory muscle training: Breathing excercises to strengthen the breathing muscles, to improve muscle strength and the ability to exercise.

Home-based/Community training:

After the programme, it is advisable to keep-up the training and to prolongue itsbenefits. Patients can join community-based programmes, often organised by patients associations or continue the excercises at home.

Tele-rehabilitation

It allows for an alternative to the traditional in-person programmes and its use has increased due to the Covid-19 pandemics. Despite the variety of programmes offered, tele-rehabilitation has similar clinical benefits to those of centre-based programmes [6].

Pulmonary rehabilitation with its core components, including physical exercise training combined with disease-specific education, improves exercise capacity, symptoms, and quality of life across all grades of COPD severity [6]

Pulmonary rehabilitation with its main elements—physical exercise training mixed with disease-specific education—improves exercise capacity, symptoms, and quality of life (GOLD, 2024).

Figure 12. Documented barriers to guideline-based implementation of pulmonary rehabilitation

Physician referral

Guidelines ownership by physicians
Logistical difficulties
Questioning evidence of patient benefit

Access to PR programme

Availability of programmes
Inefficiencies in PR service
Lack of information regarding referral
mechanisms or programme availability

Patient barriers

Travel and weather factors
Insufficient perceived benefit
Poor health
Depression
Perceived disability

Box 19

Facts about pulmonary rehabilitation in patients with COPD

Pulmonary rehabilitation reduces mortality of hospitalised patients if initiated within four weeks after discharge.

Pulmonary rehabilitation helps to reduce anxiety and depression in patients with COPD.

Community-based rehabilitation programmes are as effective as hospital-based programmes.

COPD Patient Testimonial: Living with COPD, France (French)

This COPD patient shares his journey of managing chronic symptoms and the need for oxygen therapy. Supported by his son, they emphasise the importance of early diagnosis, prevention, and access to vaccination.

Access to vaccination

Respiratory infections are among the top causes leading to COPD exacerbations. Furthermore, having COPD increases risk of lower respiratory tract infections. Patients with COPD have a higher risk of contracting respiratory infections than the general population, and the risk increases with COPD severity. Moreover, those with COPD face an elevated risk of developing chronic respiratory infections, which in turn leads to more frequent exacerbations.

GOLD (2024) recommends vaccinations against influenza, pneumococcus, and respiratory syncytial virus to mitigate the risks associated with viral exposure that could exacerbate COPD. Vaccinations against herpes zoster and diphtheria-tetanus-pertussis are also useful to prevent the deterioration of clinical conditions in fragile patients or in those with relevant comorbidities [3]. These vaccinations and Covid-19 vaccine should be offered to all patients with COPD.

According to the European Centre for Disease Control (ECDC), the number of European countries recommending flu and pneumococcal vaccinations for older adults and/or adults with chronic respiratory diseases has increased compared to 2013. Vaccine recommendations for respiratory viruses are currently in place in all countries surveyed, generally as non-mandatory recommendations. Targeted populations and reimbursement policies vary significantly across countries. Notably, in many countries, vaccines are recommended for all advanced-aged populations, not specifically for patients with chronic respiratory conditions. Access to vaccination for older people and for adults with chronic conditions is free or fully reimbursed in all the countries considered, but payment and reimbursement schemes still vary across countries. In the European Union, vaccine administration is paid for by national health services in eight Member States and by national insurance schemes in five Member States. Four Member States reported that patients had to pay for vaccine administration. In one country, vaccines and their administration are paid for by the regional health service (Table 5) [9].

Vaccination against pneumococcal disease for individuals above 60 or 65 years old is recommended in all countries, but it is not funded as part of the national vaccine programme in Austria and Switzerland. Bulgaria and Poland recommend pneumococcal vaccination for adults from the age of 50 years, but the national healthcare system does not cover the cost. Belgium, the Czech Republic, France, Ireland, Spain, and Turkey recommend pneumococcal vaccination in at-risk populations, including people with chronic respiratory diseases (Table 5).

Despite the recommendations in place, the vaccination rate remains below set targets. Barriers to vaccination may include costs, the availability of vaccine centres, or a lack of information. The Netherlands reported that the organisation of vaccination services is not always optimal, and consequently, vaccination is not accessible to everyone. More recently, vaccine hesitancy has become another barrier to vaccination. The reputation of vaccinations in the general public has worsened because of the Covid-19 pandemic [10] [11].

Table 5. Yearly vaccination recommended by country

Country	Flu/Influenza	Pneumococcal	RSV	Covid-19

Austria	Free for all adults	> 61 not funded by NHS	Recommended but not funded by NHS	Free for all adults
Belgium	Free for all adults CD	Free for all adults CD	NA	Free for all adults
Bulgaria	> 65 yo not covered by NHS	> 50 yo not covered by NHS	NA	Free for all adults
Czech Republic	Free for all adults CD	Free for all adults CD	NA	Free for all adults
Finland	Free for individuals at-risk	> 65-84 yo with CD, COPD and asthma free	NA	Free for all adults
France	> 65 yo free	Free for all adults CD	NA	Free for all adults
Germany	> 60 yo free	> 60 yo free	NA	Free for all adults
Iceland	> 60 yo free	> 60 yo free	NA
Ireland	Free for all adults CD	Free for all adults CD	NA	Free for all adults
Italy	Free for all adults CD	> 65 yo free	NA	Free for all adults
Netherlands	> 60 yo free	> 60 yo free	NA	NA
Poland	> 55 yo not funded by NHS	> 50 yo not funded by NHS	NA	Free for all adults
Portugal	> 65 yo free	> 65 yo free	NA	Free for all adults
Serbia	NA	NA	NA	NA
Spain	Free for all adults CD	Free for all adults CD	NA	Free for all adults
Sweden	Free for all adults CD	> 65 yo free		Free for all adults
Switzerland	CD	CD	NA	NA
Turkey	Free for all adults CD	CD	NA	NA
United Kingdom	Free for all adults CD	> 65 yo free	NA	NA

CD: Chronic disease (including COPD), NA: Not available.
Source: Vaccine schedule ECDC 2023. Accessed April 2024.

COPD: Talking About Life and End-of-Life (Dutch)

This video explores living with COPD, addressing emotional challenges and decisions about end-of-life care. It encourages patients to share their concerns and wishes with healthcare providers.

Access to palliative care: a chance to dignify heavy symptoms

Palliative care is a specialised approach that provides comprehensive and supportive care for people facing the challenges of advanced COPD or those with significant symptoms and limitations. Palliative care is not limited to individuals nearing the end of their lives but can be applied at any stage of the disease. Palliative care for respiratory diseases is currently evolving. In 2023, the ERS issued specific recommendations for palliative care towards a more holistic, multidisciplinary, person-centred approach. Palliative care improves the comfort and wellbeing of patients and their caregivers. It is complementary to other routines and should be integrated in the management of COPD to improve patients’ quality of life. It includes managing any physical pain, providing nutritional support, addressing mental wellbeing to cope with emotions or other distress, as well as offering social and spiritual support. It can help to reduce the number of accesses to the hospital and make people feel less burdened by their symptoms. Among the countries that participated in the survey, only in the Netherlands a focus on palliative care for COPD patients was reported.

Best Practice 4

Ireland: Planning for the future with COPD

Healthcare professionals often struggle to discuss end-of-life issues with patients and introduce them to palliative care. “COPD Support Ireland”, an Irish patient association, has released a booklet that offers specific information for individuals living with COPD and their caregivers. The purpose of the booklet is to assist people with COPD in planning for the future, including understanding how palliative care can help them.

COPD Effective Treatments and Prevention (German)

Learn about key therapeutic approaches for COPD, including inhalation therapy, smoking cessation, physical training, and infection prevention. Experts discuss how comprehensive care and preventive measures can improve patients’ quality of life.

Conclusion: Preventing COPD is critical to mitigate its present and future burden

COPD is one of the top leading causes of mortality and disability across European countries, yet it is preventable. The data available reveal a wide variability in terms of prevalence, mortality and DALYs attributed to COPD across the countries considered. These differences may be due to risk factors, such as affordable tobacco products and other exposures to risk factors (e.g., the indoor and outdoor air pollution) that vary significantly across countries.

Notwithstanding the efforts made, particularly in enforcing stricter tobacco control legislation, the prevalence of COPD remains high. Estimates suggest that 49 million people in Europe will suffer from COPD by 2050, corresponding to 9% of all diseases [3]. Given the ageing of the population worldwide, COPD must not be overlooked [17]. In fact, it is estimated that an increase of COPD due to ageing will result in increased costs, both for the patients and for the society (See “The cost of COPD in Europe”).

Despite the increasing prevalence, mortality slightly decreased in most countries. Nevertheless, COPD is still consistently among the top killer diseases. COPD high mortality rates may be due to delayed diagnosis and limitations in accessing therapies. In order to tackle this challenge, spirometry services for early detection of COPD should be made widely available to allow active case detection and access to appropriate treatments. In addition, access to affordable, high-quality pharmacological and non-pharmacological treatments is still not available to all patients [16].

Early diagnosis and the consequent early start of treatment, as well as the availability of new treatments, could increase the chances of survival of patients with COPD. Furthermore, increased awareness and health literacy regarding COPD among healthcare professionals can play a role in increasing survival rates, particularly in terms of early identification of the condition and management of comorbidities [14].

Continuous monitoring of the prevalence and mortality of COPD is of paramount importance in the assessment of the progress made by each country in terms of prevention, control, and treatment. It also helps to measure the efficacy of the actions taken to premature mortality from non-communicable diseases, including COPD, by one-third by 2030, which is one of the Sustainable Development Goals (SDG) of the United Nations 2030 agenda [2].

Recommendations

Guaranteeing Health Equity for COPD Care

To guarantee health equity for COPD, it is essential to scale up both the quality and availability of healthcare services, and to address the increasing shortages in the healthcare workforce.

At national level:

Close gaps in access to COPD care: Address disparities in COPD care whether they stem from rural-urban or disease-specific variations. Harmonise access to COPD care in countries where healthcare services are a regional competence.
Ensure access to timely COPD treatment: Guarantee that COPD patients receive the right treatment at the right time. Ensure affordable access to the full portfolio of COPD care interventions, such as:
1. therapies for COPD,
2. widespread availability of oxygen,
3. smoking cessation programmes,
4. immunization against respiratory viruses,
5. out-patient and community-based palliative care.
Set up national COPD programmes to improve standards of care:
1. Ensure adherence to clinical guidelines for COPD, including frequent monitoring, correct follow-up and patient centred approach based on health outcomes.
2. Establish a mandatory COPD management plan to be agreed between the patient and the physicians.
3. Centralise and ensure coherence in multidisciplinary COPD care, with specific focus on managing common comorbidities, such as other airways diseases, depression, obesity, cardiovascular disease, and osteoporosis.
4. Make pulmonary rehabilitation – both out-patient and virtual – integral to secondary prevention of COPD, ensuring that rehabilitation treatment programmes are systematically offered to all COPD patients following an exacerbation, regardless of their location.
5. Involve patient organisations in the development of national COPD programmes to ensure that patient needs and perspectives are represented effectively.

At European level:

Reinforce primary care for chronic conditions: Continue the investment in reinforcing primary care settings across EU Member States, with specific requirements for high-burden chronic conditions such as COPD and ensure effective integration of the primary care within the broader healthcare system.
Establish EU Centres of Excellence for chronic respiratory diseases: Support the creation of a network of EU Centres of Excellence for Chronic Respiratory Diseases to better connect medical specialities to achieve optimal care, upgrade standards and patient pathways, and catalyse breakthrough interventions, including pulmonary rehabilitation and telemonitoring.
Promote health literacy for chronic respiratory patients: Increase health literacy on the importance of accessing vaccination and immunisation against respiratory virus among people with chronic respiratory disease.
Set ambitious COPD care goals for the WHO Europe region: Establish ambitious pharmacological and non-pharmacological target goals for COPD care in the WHO Europe Region.

References

1. EFA. Harmonizing Prevention and Other Measures for COPD Patients across Europe. 2014.↩

2. Schrijver J, Lenferink A, Brusse-Keizer M, Zwerink M, van der Valk PD, van der Palen J, et al. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2022;1:CD002990.↩

3. GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2024 Report). 2024.↩

4. OECD. Realising the Potential of Primary Health Care. 2020.↩

5. Beijers RJHCG, Steiner MC, Schols AMWJ. The role of diet and nutrition in the management of COPD. Eur Respir Rev. 2023;32:230003.↩

6. Rahi MS, Thilagar B, Balaji S, Prabhakaran SY, Mudgal M, Rajoo S, et al. The Impact of Anxiety and Depression in Chronic Obstructive Pulmonary Disease. Adv Respir Med. 2023;91:123–34.↩

7. Volpato E, Farver-Vestergaard I, Brighton LJ, Peters J, Verkleij M, Hutchinson A, et al. Nonpharmacological management of psychological distress in people with COPD. Eur Respir Rev. 2023;32:220170.↩

8. WHO Europe. Can people afford to pay for health care? New evidence on financial protection in Europe. 2019.↩

9. ECDC. Seasonal influenza vaccination and antiviral use in EU/EEA Member States. 2018. https://www.ecdc.europa.eu/en/publications-data/seasonal-influenza-vaccination-antiviral-use-eu-eea-member-states. Accessed 3 Oct 2023.↩

10. Bossios A, Bacon AM, Eger K, Paróczai D, Schleich F, Hanon S, et al. COVID-19 vaccination acceptance, safety and side-effects in European patients with severe asthma. ERJ Open Res. 2023;9:00590–2023.↩

11. Fekete M, Horvath A, Santa B, Tomisa G, Szollosi G, Varga JT. First booster dose uptake of COVID-19 vaccine and disease-related factors in chronic obstructive pulmonary disease-a cross-sectional survey in Hungary. Ann Palliat Med. 2023;12:516–28.↩

12. Nota AIFA num 99 available here.↩

13. European Observatory on Health Systems and Policies health system reviews. Accessed November 2023.↩

Previous chapter

COPD Early diagnosis

Next chapter

Quality of life with COPD

COPD care access

COPD care access

Access to COPD care: A fragmented picture

COPD Patient Testimonial: Teresa Madden, Ireland (English)

Optimal management of COPD patients: a well-known recipe

Box 14

Treatments recommended for COPD

Behavioural changes

Pharmacological treatment

Oxygen

Surgery

Pulmonary rehabilitation

Managing and Treating COPD (German)

Access to care for patients with COPD: major gaps still occurring

Management of co-morbidities is included in COPD management programmes

Mental health support for COPD patients is understimated

Box 15

A roadmap to pharmacological interventions for COPD

Dual therapy

Triple therapy

Oxygen therapy

Box 16

Access to treatment – what has changed since 2013

Affordability of COPD treatment: Reimbursement and co-payments

Differences in access to care between urban and rural areas

Access to healthcare professionals’ consultations

Management of comorbidities

Psychological Issues in COPD Patients (Turkish)

Box 17

Access to care: A sustainable development goal (SDG) for 2030

Best Practice 2

The Irish National Clinical Programme for Respiratory (NCP Respiratory)

Specialist Ambulatory Care Hubs

GP Chronic Disease Management Programme

Patient Advocacy Groups

Training and Resources

‘Breitmaulfrosch sitzend’ (German)

Access to pulmonary rehabilitation

Best Practice 3

Access to pulmonary rehabilitation

Ireland

France

Spain

Box 18

What is pulmonary rehabilitation?

Home-based/Community training:

Tele-rehabilitation

Physician referral

Access to PR programme

Patient barriers

Box 19

Facts about pulmonary rehabilitation in patients with COPD

COPD Patient Testimonial: Living with COPD, France (French)

Access to vaccination

COPD: Talking About Life and End-of-Life (Dutch)

Access to palliative care: a chance to dignify heavy symptoms

Best Practice 4

Ireland: Planning for the future with COPD

COPD Effective Treatments and Prevention (German)

Conclusion: Preventing COPD is critical to mitigate its present and future burden

Recommendations

Guaranteeing Health Equity for COPD Care

At national level:

At European level:

References

About

What is copd

Burden of copd

Cost of COPD

Disease awareness

COPD Prevention

COPD Early Diagnosis

COPD Care Acces

Quality of Life with COPD

Digital Health for COPD

The Impact of COVID-19 on COPD Care

Recommendations