Efficient Management of Cough

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In the present issue of the Canadian Respiratory Journal, Field et al (1) publish an interesting and provocative paper outlining the results of a trial of chronic cough management by allied health professionals, in this case Certified Respiratory Educators. This is an adaptation of the old technique of having patient care delivered by health care professionals other than physicians; it has long been a model in the Canadian North, on First Nations reservations and in the military. It is often touted as a way to control rampant medical costs, particularly in the United States. It seems almost self-evident that there are many things performed by physicians that do not require an MD degree, and because physicians are expensive and frequently in short supply, an efficient health care system would relieve them of these tasks. It also has the potential to improve patient care because allied health professionals are frequently able and willing to spend more time with patients and perhaps, to listen to them more attentively. Nick R Anthonisen How does one set up a system of care by allied health professionals? I would argue that one must first settle on the scope of their practice. If a medical problem can be sharply defined, and an appropriate decision tree generated to solve it, management of the problem can theoretically be assigned to a nonphysician. However, patients are patients, often without sharply defined problems, and initial impressions regarding the problem and its solution may be erroneous. Thus, it is important for caregivers to be able to recognize difficulties, and having a medical background is important to operating such a system safely. Field et al (1) postulated that chronic cough represents a problem that could be sharply defined, and that Certified Respiratory Educators could choose alternative methods of management correctly. They compared the outcomes of chronic cough management by physicians with those obtained by Certified Respiratory Educators, who are allied health professionals with special training and knowledge in respiratory diseases. Approximately 500 patients referred to their clinic for chronic cough were initially screened to eliminate those with abnormal chest x-rays, known lung diseases or cancers, and “worrisome” symptoms such as weight loss. Interestingly, nearly one-half of the referrals had positive screens and were, therefore, not eligible as patients with chronic cough of unknown cause. The screen was apparently performed by physicians and checked by the educators. Of approximately 200 patients who were entered into the study, only five were subsequently found to have underlying lung disease – four with bronchiectasis, and one with interstitial lung disease. Patients entering the study underwent spirometry and a quality of life questionnaire assessing the consequences of their cough, and were randomly assigned to either physician or educator care. The educators counselled the cigarette smokers and changed the medications of those on drugs that can cause cough. Based on their judgment, the physicians/educators decided whether the patients had postinfectious cough, rhinitis, asthma or gastroesphageal reflux, and treated them accordingly. At the end of the study, patients assigned to the educators did at least as well as those assigned to physicians in terms of symptom improvement. Indeed, educators’ patients more commonly improved than did those of the physicians. Results were not brilliant in that approximately one-third of the patients did not improve after eight weeks of therapy, but as Field et al (1) point out, these were patients with extensive medical histories of futile efforts to control cough, in whom one would expect a low success rate. Certainly, I do no better. Care processes for educators and physicians differed in that wait times for the educators were less than one-half that of physicians, and educators saw the patients more often than the physicians. Both of these are probably good, and the latter feature may have had something to do with the slightly greater success of the educators. It would be hard to argue that educators managing these patients did not improve the efficiency of care of chronic cough. We should think about how similar care could be applied to other diseases, as is done in many asthma and COPD clinics already. The problem in applying this type of care often lies in funding – someone has to pay for the educators, because they cannot bill the health authority, and the authority may regard them as an added cost as opposed to a cost substitute. To the extent that the latter is truly the case, such an attitude is short-sighted, to put it mildly.