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Respiratory Investigation

r e s p i r a t o r y i n v e s t i g a t i o n 5 0 ( 2 0 1 2 ) 9 8 – 1 0 3

2212-5345/$ - see frohttp://dx.doi.org/10

nCorresponding aJapan. Tel.: þ81 3 52

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journal homepage: www.elsevier.com/locate/resinv

Original article

Long-term management of chronic obstructive pulmonarydisease: A survey of collaboration among physiciansinvolved in pulmonary rehabilitation in Japan

Takashi Motegia,b, Kouichi Yamadaa,b, Takeo Ishiia,b, Akihiko Gemmaa, Kozui Kidaa,b,n

aDepartment of Internal Medicine, Division of Pulmonary Medicine, Infectious Diseases and Oncology, Nippon Medical School, Tokyo, JapanbRespiratory Care Clinic, Nippon Medical School, Tokyo, Japan

a r t i c l e i n f o

Article history:

Received 8 February 2012

Received in revised form

31 May 2012

Accepted 28 June 2012

Available online 10 August 2012

Keywords:

Chronic obstructive pulmonary

disease (COPD)

Medical collaboration system

Pulmonary rehabilitation

Survey

nt matter & 2012 The Ja.1016/j.resinv.2012.06.004

uthor at: Nippon Medica76 2325; fax: þ81 3 5276 2kkida@nms.ac.jp (K. Kid

a b s t r a c t

Background: This study evaluated the implementation of pulmonary rehabilitation (PR),

and the extent of the collaboration between primary care and chest physicians involved in

the management of chronic obstructive pulmonary disease (COPD) in Japan.

Methods: The survey was conducted in 2006 via post and facsimile and included all medical

institutions approved by the Japan Respiratory Society.

Results: In total, 176 institutions responded (response rate, 27%); a PR program was

conducted at 55.1% of these institutions throughout Japan, but with regional differences.

The mean duration of each session in an outpatient setting was 30 min with 2 sessions per

week, and the mean length of hospitalization was 2–3 weeks. Although 33% of the hospitals

adopted PR programs, on a scale from none (0) to maximum achievement (100), the

accomplishment score was 48. Similarly, the mean satisfaction level score for collaboration

was 44. The main problem arising with regards to chest physicians’ referral to general

physicians was the reluctance of patients or family members (88%). Chest physicians

believed that general physicians should perform early screening of patients and manage

early exacerbations, including educating patients of the need to discontinue smoking.

Conclusions: Most chest physicians in Japan were not satisfied with the status of long-term

COPD management. PR for COPD patients and collaboration between primary care physicians

and specialists remain problematic in Japan. Moreover, there are widespread regional differ-

ences in terms of implementation. Sharing and implementing appropriate clinical information

with primary care physicians according to current clinical guidelines should be emphasized.

& 2012 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.

1. Introduction

Chronic obstructive pulmonary disease (COPD) is the third

leading cause of chronic mortality worldwide and by 2020, is

expected to become the fifth leading cause of loss of dis-

ability-adjusted life years [1]. The prevalence of COPD is 6.3%

panese Respiratory Socie

l School Respiratory Ca326.a).

among the general Asia-Pacific population over 30 years of

age [2], and the age-adjusted prevalence rate is 8.6% for the

population above 40 years of age, which corresponds to 5.3

million patients with COPD in Japan (Nippon COPD Epide-

miology study) [3]. Thus, the economic burden of COPD is

significant [4,5]. On the basis of a previous study [3], the total

ty. Published by Elsevier B.V. All rights reserved.

re Clinic 4-7-15-8F, Kudan-minami, Chiyoda-ku, Tokyo 102-0074,

r e s p i r a t o r y i n v e s t i g a t i o n 5 0 ( 2 0 1 2 ) 9 8 – 1 0 3 99

annual cost of COPD management in Japan is estimated at

approximately US$7 billion [6].

Most COPD patients are treated by primary care physicians

who may also be actively involved in public health campaigns

such as smoking cessation campaigns [7,8]. However, this

may pose problems in terms of both proper diagnosis and

long-term management, including early detection using

spirometry and non-pharmacological interventions such as

pulmonary rehabilitation (PR) [9–11]. Both modes of treat-

ment require an effective collaboration between primary care

physicians and specialists. Inadequate collaboration among

medical institutions and a lack of cooperation in the manage-

ment of COPD patients may lead to problems [12]. We

conducted a preliminary survey of PR centers in Japan and

found that compared to Western countries, Japan faces

several practical problems [13]. A survey conducted by the

Japan Respiratory Society (JRS) in 2005 [14] revealed that only

one-third of the medical institutions possessed network

systems for healthcare in local regions, indicating a lack of

effective collaboration. The aim of the present study was to

evaluate (1) the status of PR implementation for COPD

management and (2) the extent of interactive collaborative

communication between primary care and chest physicians

in terms of COPD management in Japan in 2006.

2. Methods

2.1. Survey hospitals

The survey included the respiratory departments of specialized

medical institutions and educational facilities approved by the

JRS in 2006. Approximately 654 institutions were surveyed, and

information regarding these institutions was obtained via an

official notice [http://www.jrs.or.jp/home/, accessed in December

2006]. The questionnaire was dispatched in April 2007 by post,

and the participants were asked to respond via facsimile or

post. The respondent was primarily the doctor-in-charge of the

pulmonary division, who was selected as a qualified chest

physician and training instructor via the official JRS notifica

tion. In general, each of the qualified medical institutions

approved by the JRS was required to (1) have at least 1

instructor who was a full-time JRS-qualified chest physician,

(2) have more than 20 beds for hospitalization, (3) follow a

JRS-approved educational curriculum, and (4) routinely provide

detailed autopsy reports. Reminder letters were not sent to the

institutions that did not respond to the first mail out.

2.2. Survey items

The questionnaire comprised two major parts pertaining to

COPD management, namely PR programs and the present

status of collaboration medical institutions. Questions

regarding the problems encountered in general practice with

respect to COPD management were also included.

2.3. Problems and PR status

The respondents were asked to describe problems routinely

occurring in clinical settings during the treatment of COPD

patients and the status of PR at their institution. Questions

pertaining to the type of rehabilitation program such as

inpatient or outpatient, frequency, and composition were

also asked. The respondents were asked to score their

satisfaction level with regards to COPD management and PR

on a numerical scale ranging from 0 (very unsatisfactory) to

100 (very satisfactory).

2.4. Collaboration among medical institutions

The questionnaire included questions pertaining to referral

rates from or to other medical institutions regarding COPD

management within a local community, and problems that

occurred during collaboration or in the process used for

collaboration. Furthermore, the respondents were asked to

score their satisfaction level with regards to the liaison status

among institutions on a scale ranging from 0 (very unsatis-

factory) to 100 (very satisfactory).

All questionnaires used in the research project were pre-

approved by the JRS.

2.5. Statistical analysis

Data were collected and analyzed using Microsoft Excel 2003

(Microsoft Inc., Tokyo, Japan). The response frequency and

referral rates are presented as proportions, and the results of

the questionnaire are summarized in terms of absolute

numbers as well as proportions. The satisfaction level scores

were expressed as mean values and ranges. We determined

the correlation between the referral rates and the satisfaction

level with regard to inter-institutional cooperation by using

Pearson’s correlation coefficient. All p-values were deter-

mined using 2-sided tests, and po0.05 was considered sta-

tistically significant.

3. Results

Of the 654 JRS-approved institutions approached, 176

responded (response rate, 27%). These included 131 general

hospitals, 29 university hospitals, and 16 community hospitals.

3.1. Pulmonary rehabilitation

Of the 176 respondents, 97 institutions (55.1%) conducted PR

programs. Disparities in the distribution of qualified hospitals

(Fig. 1A) and the distribution of hospitals conducting PR

programs were observed (Fig. 1B). A total of 53% of respondents

conducted PR programs for inpatients and outpatients; PR

programs exclusively for inpatients or outpatients were con-

ducted at 43% and 4% of institutions, respectively. At most

hospitals, outpatient PR programs consisted of 2 sessions per

week with each session lasting 30 min (range, 10–90 min). The

inpatient programs consisted of 2, 3 sessions per week, with

each session lasting 30 min (range, 15–90 min) in most hospi-

tals (Table 1). PR programs were provided as a clinical pathway,

and had been organized in advance by 33% of the hospitals. PR

was funded by a government medical insurance scheme at 87%

of the hospitals, and the remaining 13% provided PR free of

charge. The average PR accomplishment score at each hospital

Fig. 1 – (A) Map of the distribution of Japan Respiratory

Society (JRS)-approved hospitals in Japan. The legend

indicates the number of hospitals present per prefecture in

each category. A wide disparity was observed with regards

to the distribution of hospitals. (B) Percentage of JRS-

approved medical institutions conducting pulmonary

rehabilitation (PR) in Japan.The legend indicates the

percentage of hospitals per prefecture in each category. A

wide disparity was observed in terms of the percentage of

hospitals conducting PR and the distribution of hospitals.

Table 1 – Structure of pulmonary rehabilitationprograms.

CPR for outpatients n %

Duration per session (n¼53)

o30 min 12 22.6

30 min 20 37.7

31–60 min 4 7.6

60 min 14 26.4

Z60 min 1 1.9

Irregular 2 3.8

Frequency of sessions (n¼51) (per week)

o1 12 23.5

1 11 21.6

2 15 29.4

3 4 7.8

Z4 3 5.9

Irregular 6 11.8

CPR for inpatients n %

Duration per session (n¼62) (min)

15 3 4.8

20 13 21.0

30 28 45.2

30–60 14 27.4

Z60 1 1.6

Length of hospitalization in weeks (n¼69)

o1 4 5.8

1–2 16 23.2

2–3 29 42.0

3–4 2 2.9

Z4 9 13.0

Irregular 9 13.0

CPR¼comprehensive pulmonary rehabilitation.

r e s p i r a t o r y i n v e s t i g a t i o n 5 0 ( 2 0 1 2 ) 9 8 – 1 0 3100

was 48 (range, 0–100). The 79 hospitals that did not provide a PR

service planned to provide it in the future, and the current

unavailability was due to an inadequate work force (90%), the

unprofitable nature of the program (35%), or because

the hospitals did not meet the necessary criteria listed by the

medical insurance agencies for reimbursement (25%). Thirty-

five percent of the respondents thought that PR should be

provided by small clinics or daily care services. Furthermore,

most respondents (86.9%) thought that PR should ideally be

conducted by physiotherapists (PTs) rather than physicians

(61.3%) or nurses (35.0%).

3.2. Problems and status of inter-institutionalcollaboration

The mean rate of referral of patients from other medical

institutions was 47.9% (across all departments), and the rate at

which patients were referred back to minor medical institutions

such as non-specialized hospitals or private clinics was 40.7%

(across all departments). For respiratory departments alone, the

rate of reverse referral was 26%. The mean satisfaction level

score for collaboration was 44 (range, 1–90). The referral rates

from specialized hospitals to clinics did not correlate with the

satisfaction levels (r¼0.176; p¼0.135).

The main problem regarding referrals from specialized

hospitals to local non-specialized hospitals or private clinics

was the reluctance of patients or family members (88%).

Furthermore, 50% of the respondents claimed that local

hospitals or private clinics refused to accept patients from

specialized hospitals (50%), whereas 29% of the respondents

indicated that they were unable to find good local hospitals or

private clinics for patient referral (Table 2). The predominant

mode of communication used by the institutions was tradi-

tional on-paper letters; few used electronic mail (e-mail,

9.4%) or shared electronic medical charts (2.3%). Clinical

conferences were conducted by 54.4% of institutions to

discuss typical or problematic cases, but collaborative prac-

tices between specialists and primary care physicians existed

at only 19% of the same institutions. The respondents

reported that the major issues that need to be resolved for

future collaboration include the sharing of information

regarding issues in COPD management common to both

sides (65.1%) as well as the need to arrange action plans for

acute exacerbations (59%).

Doctors from specialized hospitals believed that general

physicians should manage early exacerbations, educate

patients of the need to discontinue smoking, and perform

early screening of patients (Table 3).

Table 2 – Problems with referral to general physiciansreported by chest physicians at specialized hospitals.

Questionnaire items Percentage of total number of

respondents (Total number¼176)

Reluctance of patients and

family members

88.0

Refusal of general

physicians to collaborate

with chest physicians

49.4

Unavailability of general

practitioners

29.5

Lack of reliable general

practitioners

19.9

Inadequate time for referral

to general practitioners

16.3

Table 3 – Tasks that chest physicians expect generalphysicians to perform.

Questionnaire items Percentage of total number of

respondents (Total number¼176)

First aid 72.9

Smoking cessation 67.1

Screening by history taking 58.5

Home medical care 55.0

Hospitalization decisions 54.1

Screening with spirometry 50.0

Terminal care for advanced

patients

45.3

Patient education regarding

daily exercise and

nutritional care

35.3

Pulmonary rehabilitation-

based exercise training

22.4

Table 4 – Problems with medical management of COPD inspecialized hospitals.

Questionnaire items Percentage of total number of

respondents (Total number¼176)

Terminal care for advanced

patients

47.3

Lack of caregivers 43.6

Time availability 38.2

Lack of general

practitioners

35.8

Lack of hospital manpower 30.8

Patient’s incomprehension

of the disease

27.9

Emergency response 24.8

Lack of appropriate

education among general

practitioners

24.8

Lack of continued home

care

24.8

Increased economic liability 16.4

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3.3. Problems with COPD management at qualifiedmedical institutions

Chest physicians from large hospitals encountered problems

with COPD management in terms of terminal care for

severely affected patients, an inadequate work force for

patient care, busy daily work schedules, and an inadequate

number of general physicians (Table 4). The mean satisfac-

tion level score for COPD management was 62 (range, 10–100).

4. Discussion

In the present study, we report the results of a survey of the

present status of COPD management in Japan, particularly

(1) the extent of implementation of PR and (2) the extent of

interactive collaborative communication between primary care

and chest physicians in the management of COPD. To the best

of our knowledge, the present study is the first to survey the

collaboration among institutions that has led to noteworthy

findings. We conclude that both PR implementation for the

management of COPD and collaboration between institutions

remain low in Japan, and that there are regional differences in

the enforcement of PR implementation. A survey in the

Japanese White Paper on Home Respiratory Care (The White

Paper) in 2005 revealed that 49% of the respondents conducted

PR programs (response rate, 54%) [14]. Although the response

rate in the present study was approximately 50% of that

reported in the White Paper, the proportion of institutions that

conducted PR programs was comparable (55.1%), which con-

firms the precision of our data to a certain extent.

According to the White Paper, medical collaboration in local

areas for patients receiving long-term oxygen therapy was

reported by 36% of responders in 2005 and by 31% in 2010 [15].

Similar rates in 2005 and 2010 suggest that although the concept

that medical collaboration is a necessity is well understood, it

remains a local activity and has not been extended throughout

the country. Several explanations for this phenomenon were

found in the present study (see below).

4.1. Continuation of pulmonary rehabilitation

We previously surveyed PR programs in 1995 [13], and found

that PR was inadequate in Japan. In particular, we reported

that PR for outpatients was provided after the patients had

undergone a few weeks training during hospitalization. This

probably occurred because collaboration is difficult for out-

patients, mainly because of an inadequate work force. In the

present study, 35% of the respondents wished to provide PR

for outpatients without hospitalization. In Europe and North

America, outpatient PR and home-based rehabilitation are

extensively and efficiently provided [16–18]. The present data

indicate that although a remarkable disparity exists in the

distribution of PR centers, the total number of institutions

providing PR has increased in the period between 1995 and

2006. Jones et al. recently reported similar problems for PR of

COPD patients in the UK [19]. The National Institute for

Health and Clinical Excellence clinical guidelines in the UK

recommend that PR be offered to all patients who consider

themselves functionally disabled by COPD (usually a Medical

Research Council dyspnea scale score Z3) [20], and similar

r e s p i r a t o r y i n v e s t i g a t i o n 5 0 ( 2 0 1 2 ) 9 8 – 1 0 3102

recommendations were prescribed in the JRS guidelines [21].

Nevertheless, the implementation of PR in Japan is inadequate.

The present data suggest that PTs carry out more appro-

priate PR than other medical staff members. Rehabilitation

programs in Canada and the US are supervised by respiratory

physicians, but those in the UK are mostly coordinated by

PTs, which may partly contribute to the extended multi-

disciplinary nature of rehabilitation provided by the UK

National Health Service [22,23].

These data suggest that a foothold is required in each local

area in order to extend PR in this country. Although this foothold

does not need to be a JRS-approved institution, it should be

supported by academic staff members such as specialist chest

physicians and, importantly, the intervention should be per-

formed by pulmonary PTs. Furthermore, such medical services

should also be arranged for rehabilitation of musculoskeletal or

cerebrovascular diseases. In the future, the reimbursement

system for PR should be improved and an educational system

should be appropriately established for PTs in this area.

4.2. Problems pertaining to chest physicians

The present survey noted that the number of chest physicians

responsible for conducting PR at small hospitals or clinics was

limited because most chest physicians work at large hospitals.

This discrepancy may be due to the fact that the mean number

of medical doctors in Organization for Economic Co-operation

and Development (OECD)-member countries is 3.1 per 1000,

whereas in Japan it is 2.1 per 1000 [24]. A total of 3.3% and 7.6%

of medical doctors are chest physicians at large hospitals and

clinics, respectively. Thus, the number of qualified chest

physicians is lower than the number of doctors who belong

to other departments [25]; this may increase the workload of

non-affiliated chest physicians. This discrepancy should be

urgently resolved to ensure that there are an adequate number

of ‘‘next generation’’ chest physicians.

4.3. Lack of efficient collaboration

The present data indicate that chest physicians in Japan are

not satisfied with the current level of cooperation between

large specialized hospitals and small non-specialized hospitals

or clinics in terms of long-term COPD management. Although

the chest physicians believed that one of the main reasons for

the poor cooperation status was the reluctance of patients to

cooperate, previous reports indicate that patient satisfaction

was higher among patients who could access programs and

facilities at all times [26]. Casas et al. [27] have reported that

cooperation in terms of comprehensive intervention by nurses,

specialists, and general practitioners by using discharge plans

does not significantly affect the mortality rate but does reduce

the chances of re-hospitalization. Implementation of COPD

guidelines for general practitioners through communication at

various conferences has increased the use of spirometry for

the early detection of COPD and has decreased the overuse of

inhaled corticosteroids [28]. Taken together, data from this as

well as previous studies strongly suggest that collaboration

among medical institutions is essential for long-term COPD

management and for improving patient quality of life [29].

Discharge or action plans for acute exacerbations should be

based on individual clinical data and be organized by team

members at collaborating institutions. The present data also

indicate that the use of information technology (IT) such as

e-mail or sharing of electronic medical charts is presently

limited. Therefore, IT-based techniques should be actively imple-

mented to enable widespread access to promising methods,

plans, and data among team members involved in COPD

management [30]. In the present study, few methods were

available for assessing the efficacy of collaboration among

institutions; nevertheless, the data suggest that patients do not

prefer reverse referral from specialists to local primary care

physicians. However, improved and more objective methodolo-

gies are required to address this issue in further detail.

4.4. Necessity of the success of future plans for medicalcollaboration

A major obstacle against referral to medical clinics was the

refusal of patients because they hoped to continue their

therapy at large teaching hospitals as opposed to small clinics.

This trend is due to a drawback of the Japanese medical

insurance system that guarantees free access to any medical

institution at the same cost. To compensate for this deficit, the

quality of management of patients with COPD by non-specia-

list physicians must be raised. Therefore, continuous encour-

agement of collaboration between non-specialists and

specialist physicians is required. In this regard, the Japan

Medical Association (2010) has established an organization

for the promotion of COPD and has provided the following

teaching material: Essence of COPD Management (http://dl.

med.or.jp/dl-med/nosmoke/copd_essence.pdf). On the other

hand, non-specialist physicians may refuse to provide care

for patients with more severe COPD, who may have been

referred from specialist physicians because these patients are

at a higher risk. To improve this situation, a continuing educa-

tion system should be established or new information should

be provided to the non-specialist group by the specialist group;

this implies that each specialist should be asked to enter into a

continuous collaboration in order to provide this information.

A regional cooperation pathway or the utilization of convenient

IT devices such as those used for telemedicine would be useful.

4.5. Limitations and study design

The present study has several limitations. First, the survey

response rate was just 27%. This was a major deficit of this

study, and previous reports on the surveillance of COPD in

Japan have experienced similar problems. For example, aware-

ness of COPD among general physicians or chest physicians in

Japan has been reported as 23–30% [31], and another study

revealed that it was approximately 40% among general physi-

cians [32]. These findings suggest that low awareness of COPD

among general physicians or even among chest physicians in

Japan influenced the low response rate in this study. Second,

because the survey was administered to JRS-approved institu-

tions, each respondent was requested to answer questions

from the viewpoint of their respective institution and not to

divulge personal opinions. Third, regional differences may have

been present in terms of eagerness to perform PR. The present

survey was conducted among a limited number of institutions

r e s p i r a t o r y i n v e s t i g a t i o n 5 0 ( 2 0 1 2 ) 9 8 – 1 0 3 103

that were accredited by the JRS; such institutions are generally

national or municipal hospitals that employ chest physicians.

Thus, the status of PR in non-JRS-approved hospitals was not

adequately assessed in our study, and this survey should

therefore be extended to the entire country.

5. Conclusions

Inter-institutional cooperation, which is essential for the treat-

ment of COPD patients, remains primitive in Japan, and large

local disparities in the performance of PR were observed.

Therefore, this study suggests that the establishment of a

new collaborative system is urgently required. This system

should include means by which the relevant medical informa-

tion for each patient can be obtained via an efficient regional

cooperation pathway or IT-based methods.

Conflict of interest

Authors have no potential conflict of interest.

Acknowledgment

This study was supported by the Environmental Restoration

and Conservation Agency of Japan.

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