WPŁYW CZYNNIKÓW RYZYKA NA ROZWÓJ PRZEWLEKŁEJ OBTURACYJNEJ CHOROBY PŁUC ORAZ PODSTAWY PRAWNE OPIEKI ZDROWOTNEJ NAD PACJENTAMI Z POCHP NA UKRAINIE
Vasyl M. Mykhalchuk, Averian G. Vasyliev
Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
Introduction: Out of all respiratory diseases COPD is the leading cause of death and is characterized with diffuse non-reversible airway obstruction. Many various components play role in development and progression of this disease, while COPD risk factors play the most prominent role. Further progress in healthcare system development around COPD in Ukraine requires analysis of legislation, regulating pulmonological medical service in Ukraine.
The aim: To analyze the influence of major risk factors on the development of chronic obstructive pulmonary disease and to determine key legislative aspects of the organization of medical care for COPD patients in Ukraine.
Materials and methods: 50 medical literature sources were systematically reviewed as the material for the research of COPD risk factors and their impact on studies disease. Also, an analysis of existing legislative acts regulating the pulmonological medical care in Ukraine, specifically, in patients with COPD, was conducted.
Conclusions: There is a need to develop and implement a set of organizational and medical measures aiming at addressing the priorities of public healthcare, and specifically improvement of the quality of medical care for patients with chronic obstructive pulmonary disease in Ukraine.
Wiad Lek 2018, 71, 1 cz. II, -225
Respiratory diseases still hold their leading position among all diseases globally with regards to burden. Chronic obstructive pulmonary disease (COPD) has a notable special place among those, since presenting a major medical and scientific problem to public communities.
Out of all respiratory diseases COPD is the leading cause of death and is characterized with diffuse non-reversible airway obstruction. COPD and bronchial asthma contribute to 4 million deaths annually, which is three times more than deaths from diabetes mellitus .
Modern science describes COPD as a disease with multifactorial etiology. Many various components play role in development and progression of this disease, while COPD risk factors play the most prominent role.
There is a consensus around key risk factors in the onset of the COPD: tobacco smoking, industrial and household pollution, dust and chemical agents from wood fire, and infectious diseases [2, 3, 4, 5].
Incidence of COPD has increased threefold during the last decade, manly driven by air pollution, spread of tobacco smoking, and population ageing [3, 4].
Tobacco smoking is most frequent etiological factor of COPD [1, 3, 5]. Latest 2018 Global Initiative for Obstructive Lung Disease (GOLD) report emphasize cigarette smoking as the most well studied COPD risk factor .
Some studies shown 6 million deaths occur due to tobacco smoking, and more than 600 thousand die from passive smoking, which makes decrease of the disease incidence inevitably growing. 58% of young men in Ukraine are smokers, with around 46.8% of whom are adolescents of 13-16 years of age (this is the largest proportion among 26 European countries) .
The aim of this paper is to analyze influence of key factors of chronic obstructive pulmonary disease development and progression and to evaluate major legislative aspects of COPD medical care in Ukraine.
Materials and methods
Material for the research of risk factors of COPD were data from more than 50 scientific papers, which describe various factors of chronic obstructive pulmonary disease development. Analysis of current legislation regulating pulmonology medical care in Ukraine, particularly for COPD patients.
Review and discussion
To date there is a large body of scientific knowledge around inhaled industrial/occupational and domestic air pollution, which both play a sizable role in development of COPD. There is a wide spectrum of professions, largely exposed to harmful occupational factors (miners, casters, grinders, electric welders, textile, agriculture, and tobacco production workers etc.).
In NHANESIII (USA) study which included 10 000 adults aged from 30 to 75 years, the prevalence of COPD developed from occupational risk factors was estimated as 19.2%, population of never smokers demonstrated prevalence of COPD of 31.1%. The paper emphasizes the impact of organic and non-organic dust, chemical agents and gases was clearly underestimated from COPD development risk perspective .
In fact, one the first reports, recognizing professional risk factors in development of COPD (toxic and irritating substances, biofuel combustion products, gases, smoke, dust of biological origin) started to be included into GOLD 2012 .
Though still the major risk factor for COPD is tobacco smoking. This risk factor alone per some authors may contribute to 80% of all COPD cases. And there is a disturbing evidence, demonstrating there is an anticipated growth of smokers cohort to more than 3 billion people globally by 2030 .
Some researchers demonstrated low birth weight and individual airway hyperreactivity play role in development of COPD [5, 8].
Some diseases, like tuberculosis and HIV-infection, could also impact development of emphysema in smokers, conditioning other comorbidities as respiratory tract infections and bronchial asthma .
Misdiagnosis of COPD as bronchial asthma (BA) can also widely occur since differential diagnosis is complicated with inflammatory nature of both diseases, affecting small airways and characterized by airflow limitation with close medicinal treatment options. Despite these similarities, these two conditions represent two independent broncho-obstructive diseases with different pathogenesis, and thus different medical management.
BA and COPD are characterized with different etiological factors. While BA has atopy, genetic factors, causing atopic diseases among family members, COPD is mainly (90% of instances) caused by either tobacco smoking or professional harmful factors exposure .
Comorbidities in COPD further contribute to rapid progression of the disease and worsen prognosis and quality of life in affected patients. Wide range of comorbidities is reported in 80% of COPD cases. Around half of patients with COPD have 4 comorbidities and more .
Retrospective analysis of patient medical records in COPD elderly population, conducted by Stupnytska G., has shown arterial hypertension (64,7%), diabetes mellitus (28,5%), obesity (22,4%), ischemic heart disease (19,9%), arrhythmia (16,6%), congestive heart failure (13,8%) as the most frequent comorbidities in this study population .
Some authors believe genetic factors play an important role in COPD onset . According to the research data, association exists between some specific genes (for example α-1-antitrypsin deficiency) and development of COPD, though prevalence of these genetic factors is relatively low in general population.
In general, there are two major groups of development factors of chronic obstructive pulmonary disease: external and internal.
External factors include:
1. Long-term tobacco smoking (smoking index – 10-20 pack years), passive tobacco smoking.
2. Industrial (occupational) and indoor air pollution (pollutants, coal, dust, cadmium, gases and fumes from chemical substances, biomass fuel combustion products used for heating and cooking).
3. Infections (severe infections in children, respiratory infections, HIV).
4. Deficient socio-economic conditions (limited access or restrictions to healthy food, overpopulation, hypothermia, pernicious habits)
Internal risk factors include:
1. Genetic factors (inherited α-1-antitrypsin deficiency).
2. Bronchial hyperreactivity (associated with long-term exposure to tobacco smoking, concomitant bronchial asthma).
3. Incomplete lung development (complications associated with pregnancy, harmful conditions in childhood).
Discussion around healthcare system development around chronic obstructive pulmonary disease in Ukraine is not practical without analysis of legislative norms around this subject matter. Careful review of key aspects of various legislative acts, regulating pulmonological medical service in Ukraine, is required for this purpose.
Major legislative norm describing public relations around healthcare is the Law of Ukraine dated 19.11.1992 #2801-XII “Fundamental Legislation of Ukraine on Healthcare”. This law is based on the Constitution of Ukraine and provides every person with guarantees around natural, inalienable, and immutable rights for healthcare.
The Order of the President of Ukraine dated 07.12.2000 affirmed the “Concept of Ukrainian Population Healthcare Development”, which aimed to ensure provision of affordable, qualified medical care to every citizen of Ukraine. Pursuant to this Order Ministry of Health of Ukraine issued the order dated 28.10.2003 #499 “On Approval of Instructions for Medical Care to Patients with Tuberculosis and Non-specific Pulmonary Diseases”, which established the instructions on diagnostics, clinical classification, and medical management of chronic obstructive pulmonary disease.
According to the Law of Ukraine dated 05.10.2000 #2017-III “On the State Social Standards and the State Social Guarantees” the anticipated unification of quantitative and qualitative requirements to medical care in medical institutions in Ukraine was matched with the development of the Order of the Ministry of Health of Ukraine dated 10.01.2005 #7 “On Approval of Standards of Provision of Medical Care for Specialty “Occupational Pathology” in Outpatient Clinical Institutions”. This order was introducing the standards of medical care to patients with chronic obstructive pulmonary disease or occupational etiology (occupational dust, chemical substances, gases, fumes, and vapors).
Medical care in patients with respiratory tract diseases, particularly with chronic obstructive pulmonary disease, still required further improvement though. Cross-collaborative research among pulmonology experts in Ukraine, lasting from 2005 to 2007, resulted in development of the first modern treatment protocols on the management of pulmonary tract diseases. These protocols were established with two Orders of the Ministry of Health of Ukraine – one dated 03.07.2006 #433 “On Approval of Protocols on Provision of Medical Care for Specialty “Pulmonology”  and the second dated 19.03.2007 #128 “On Approval of Clinical Protocols on Provision of Medical Care for Specialty “Pulmonology” .
The Cabinet of Ministers of Ukraine passed the Resolution dated 17.02.2010 #208 “Some Questions on Improvement of Healthcare System”, which was followed by development of “Unified Clinical Protocol of Primary, Secondary (Specialized), Tertiary (Highly Specialized) Medical Care and Medical Rehabilitation “Chronic Obstructive Pulmonary Disease”. Experts in pulmonology along with other associated specialties professionals and academic institutions collaborated closely with the Ministry of Health of Ukraine to contribute to this detailed clinical protocol, having reviewed and included key aspects from adapted clinical guideline “Chronic Obstructive Pulmonary Disease” as the major source of evidence-based information on management of COPD. The clinical protocol was approved with the Order of the Ministry of Health of Ukraine dated 27.06.2013 #555 “On Approval and Implementation of Medical and Technical Documents on Standardization of Medical Care for Chronic Obstructive Pulmonary Disease” and is now the key regulation around medical care for patients, suffering from COPD .
Since public health preservation is the strategic mission of any state globally, Ukraine boldly positions its strategy around further potential in development of pulmonological service, given a high incidence and prevalence of COPD in Ukrainian population. Main priorities in the COPD management healthcare strategy in Ukraine include disease prevention and further advances in quality of COPD medical care.
Chronic Obstructive Pulmonary Disease progressively has been showing signs of the most serious developing world healthcare issue. Key risk factors for COPD are well established and include tobacco smoking, occupational and indoor air pollution, respiratory infections, inherited or congenital factors, and deficient socio-economic conditions. Frequency and severity of comorbidities (hypertonic disease, diabetes mellitus, cardio-vascular diseases, blood lipid disorders, depression, osteoporosis, tuberculosis, pneumonia) largely impact quality of life and mortality in patients with COPD.
Identification of chronic obstructive pulmonary disease risk factors and their weight in specific populations of interest is an important aspect for further defining the advanced medico-social model of medical care in COPD.
Ukraine has made a notable step in development of relevant and necessary legislation around pulmonology healthcare public service over the last decade, primarily focusing on treatment and rehabilitation of affected population cohort. At the same time, there is a tangible gap in legislative norms aiming at improving specifically the organization of medical care for patients with COPD, which could largely contribute for the benefit of ongoing medical reform in Ukraine.
Further research perspectives exist around development and implementation of complex organizational and medical measures, focusing on priority areas of the state healthcare system, including improving quality and accessibility of medical care for patients with chronic obstructive pulmonary disease.
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9. Nakaz MOZ Ukrainy № 433 vid 03.07.2006 «Pro zatverdzhennia protokoliv nadannia medychnoi dopomohy za spetsialnistiu «Pulmonologia» [Order of the Ministry of Healthcare of Ukraine № 433 from July 03, 2006. «On approval of protocols for the provision of medical aid in the specialty «Pulmonology»] [Electronic source]. Retrieved from: http://www.moz.gov.ua/ua/portal/dn_20060703_433.html, last accessed on 06.12.2017.
10. Nakaz MOZ Ukrainy № 128 vid 19.03.2007 «Pro zatverdzhennia klinichnykh protokoliv nadannia medychnoi dopomohy za spetsialnistiu «Pulmonologia» [Order of the Ministry of Healthcare of Ukraine № 128 from March 19, 2007. « On approval of clinical protocols for the provision of medical aid in the specialty «Pulmonology»] [Electronic source]. Retrieved from: http://www.moz.gov.ua/ua/portal/dn_20070319_128.html, last accessed on 06.12.2017.
11. Nakaz MOZ Ukrainy № 555 vid 27.06.2013 «Pro zatverdzhennia ta vprovadzhennia medyko-tekhnichnykh dokumentiv zi standartyzatsii medychnoi dopomohy pry khronichnomu obstruktyvnomu zakhvoriuvanni lehen» [Order of the Ministry of Healthcare of Ukraine № 555 from June 27, 2013. « On approval and implementation of medical and technical documents on the standardization of medical aid in chronic obstructive pulmonary disease»] [Electronic source]. Retrieved from: http://www.moz.gov.ua/ua/portal/dn_20130627_0555.html, last accessed on 06.12.2017.
This work is a part of the authors contribution to the research, conducted at the Shupyk National Medical Academy of Postgraduate Education – “Substantiation of healthcare subsystem management models and strengthening of public health in Ukraine in accordance with the European strategies” (2014-2019, State Registration Number 0115U002160).
Address for correspondence
Shupyk National Medical Academy of Postgraduate Education,
9 Dorogozhytska Str., 04112, Kyiv, Ukraine