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Respiratory Health

Introduction

The Department of Health  published ‘Living Well for Longer’, 2013, which is about reducing avoidable, premature deaths caused by the big killer diseases.   ‘Premature death’ is death aged under 75 years and it is intended that England’s premature death rates will become the lowest amongst our European peers   Ithas been shown that we have a long way to go.  The Longer Lives website(http://healthierlives.phe.org.uk/topic/mortality)  compares overall and specific disease premature deathsfrom similarly deprived local authorities and shows that Bedford Borough was14 th out of 15 similar local authorities for premature deathscaused by lung disease (1 is the best, 2012-2014).

Influenza, pneumonia and COPD are the main reason for emergency admissions in the over 65s for ambulatory care sensitive conditions.  These are  conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active managmeent, such as vaccination, better self-management, disease management or case management; or livestyle interventions.

There are two main conditions affecting the respiratory tract: Chronic Obstructive Pulmonary Disease and Asthma.

 

Chronic Obstructive Pulmonary Disease

 

Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term that includes chronic bronchitis and emphysema.  It is characterised clinically by airflow obstruction and is usually progressive, not fully reversible and does not change markedly over several months.  This disease is predominantly caused by smoking (Viegi, 2001) and the prevalence is strongly associated with age.  However, other factors, such as occupational exposures, may also contribute to the development of COPD.

 

Facts, Figures and Trends


Numbers of people affected by COPD

National Picture

  • An estimated 3 million people have COPD in the UK and, of those, 2 million remain undiagnosed - mainly those with milder symptoms (Healthcare Commission, 2006)

 

  • COPD is the fifth largest cause of death in the UK.  It causes 30,000 deaths per year and accounts for one-fifth of respiratory mortality.(British Thoracic Society, 2006)

 

  • COPD is the second most common cause of emergency admissions to hospital, is one of the most costly in-patient conditions treated by the National Health Service (British Lung Foundation, 2007) [and is a major cause of morbidity within Primary Care

 

  • With effective services and treatment, exacerbations of COPD can be shortened so reducing the need for hospital admission and improving the outcomes and quality of life for patients (RCP, 2008)

 

  • COPD is often associated with other long-term conditions; 40% of people with COPD also have heart disease, and significant numbers have depression and/or an anxiety disorder(Department of Health, 2011)

 

  • Smoking (NHS Choices, 2015)  is the main cause of COPD and is thought to be responsible for around 90% of cases.  The lining of the airways becomes inflamed and permanently damaged by smoking and this damage cannot be reversed.  Up to 25% of smokers develop COPD

 

  • Fumes and dust- exposure to certain types of dust and chemicals at work, including grains, isocyanates, cadmium and coal, has been linked to the development of COPD, even in people who do not smoke.  The risk of COPD is even higher if you breathe in dust or fumes in the workplace and you smoke

 

  • Air pollution- according to some research, air pollution may be an additional risk factor for COPD.  However, at the moment it is not conclusive

 

Local Picture

The prevalence of COPD in Bedford Borough was 2,375 (1.4%) in 2014/15(QOF, 2015)  an increase since 2009 (Figure 1).  This is mainly due to the population ageing as COPD is strongly associated with age.  The prevalence of COPD over the next 3-5 years in Bedford Borough and nationally are forecast to show a slow increase of about 0.05% per year.

A model estimates that the true prevalence of COPD in Bedford Borough was 3,560.(Eastern Regional Public Health Observatory, 2011).   This means that there may be 1,560 undiagnosed in 2011.


 
Figure 1: Percentage of Practice Populations on register for COPD, trend 2009-2015
 
Respe1a
 
 
 
Source: QOF 20145
 

Harm caused by COPD & projected future position if no action taken

Figure 2: Direct standardised mortality rate for Bronchitis, Emphysema and Chronic Obstructive Pulmonary Disease in Bedford Borough by sex and year

 

Figure 2 shows the directly age-standardised mortality rate (DSR) for COPD for Bedford Borough.  The mortality rate for males is higher than females, though the gap is has reduced over time as the smoking prevalence decreases.  The rates were lower for women compared to England.

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Source: Health and Care Information Centre, 2015

 

Figure 3 shows COPD premature deaths (up to 75 years)  in males and females.  Premature deaths in Bedford Borough among both groups were comparable to England and East of England.   About 4% of all premature deaths are caused by COPD.

 

Figure 3: Premature mortality from bronchitis, emphysema and other COPD (DSR, pooled data), 2011-13

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Source: Heallth and Social Care Information Centre, 2015

Figure 4 shows mortality rates of COPD by age and sex.  The majority of deaths were in the over 75 year age group; in this age group rates for men in Bedford Borough were higher and women were lower when compared with East of England England.  Few were recorded in the 0-34 year age group.

Figure 4  : Age specific death rates from bronchitis, emphysema and other COPD (pooled 2011-2013)

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Source:  Health and Social Care Information Centre, 2015

 

Figure 5 shows  years of life lost due to COPD premature mortality.  Bedford Borough was lower than England for males and females but neither were statistically different.

Figure 5: Years of life lost due to mortality from bronchitis, emphysema and other COPD, 2011-13 (pooled) to the age of 75y

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Source: Health and Social Care Inofrmation Centre, 2015

 

Asthma

Asthma is a chronic inflammatory disorder of the airways with reversible airway obstruction.  There is an increase in airway resistance to certain triggers, for example animal hairs, exercise and cold air.  Obstruction is usually reversible spontaneously or with treatment (Eastern Regional Public Health Observatory, 2011).  In England, 6.0% of people had asthma in 2014/15.

 

Numbers of people affected by asthma

  • Bedford Borough there were 11,483patients registered with their GPs who had been prescribed an asthma medication within 12 months 2014/15 (NHS Choices, 2015). 
  • Bedford Borough has a similar proportion of patients who had asthma to the Bedfordshire Clinical Commissioning Group(see Figure 6)

 

Figure 6: Registered Asthma Patients

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Source: Quality and Outcomes Framework (QOF), 2014/15

It is difficult to define what constitutes asthma.  However, most studies think that there has been an increase in the prevalence of asthma in the UK since 1991, possibly with a reduction in children in recent years(Koshy, 2010)

 

Harm caused by asthma

  • Figure7 shows a time-line of indirectly age and sex standardised asthma emergency hospital admission rates for children up to 16 years.  For the past nine years rates in Bedford Borough have been similar to the national rate.- 
 

Figure 7  Emergency hospital admissions: children with asthma, 2003/4-2012/13

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Source: Health and Social Care Imnofrmation Centre, 2015

Projected future position if no action taken & Scope for improvement

  • As asthma deaths are unusual, it is only iwth a big geographic area it can be seen that it has decreased , although since 2009 the decrease may have become less (England - see Figure 8)

 

Figure 8: Asthma Standardised mortality in England, 1995-2013

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Source:  Health and Social Care Inofrmation Centre, 2015

Psychological conditions such as anxiety and depression may be up to six times more common in people with asthma than in the general population (Thomaset all, 2011),  depression may be present in between 14 to 41% of those with asthma.

 

Current activity and services

COPD

  • The current situation is mainly primary-care led and a community team service giving flexible provision.  Smoking cessation with patients who have COPD as part of their treatment is part of the contract with Bedford Hospital and is being negotiated at Luton and Dunstable Hospital (L&D)
  • QOF had recorded the following for Bedford Borough, 2014/15:

 

o   89.8% patients with COPD had the FEV1 checked in the previous 12 months

o   96.5% COPD patients had vaccination against seasonal flu

o   91.8% of all patients with COPD (diagnosed after 1st April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry in Bedford Borough

o   90.9% of known COPD patients had a review to within the preceding 12 months


 

  • The Acute Respiratory Assessment Service (ARAS) was set up in April 2012 to provide a facility where GPs and Community Matrons can refer patients who experience a flare up of their COPD
  • Stop smoking with pharmacotherapy is a cost effective treatment at £2,000 per QALY ( NHS, 2012)
  • Although Community Matrons have a role in informal admission avoidance for exacerbations, there is no specialist service available. 
  •  Breathe Easy support group helps patients self-manage
  • The Bedford Borough population have access to specialist nursing support and hospice care
  • Public Health England has produced a web-tool called Inhale which brings together much of the information discussed here, both for COPD and asthma (PHE, 2014)
  •  Service for home oxygen assessment and pulmonary rehab


Asthma
  • GPs diagnose most of the asthma cases and largely manage the patients within the practice with the help of a practice nurse
  • 78.7% of patients with asthma in Bedford Borough had a review in the previous 12 months that includes an assessment of asthma control.  This was similar to the results from Bedfordshire CCG (77.0%- see Figure 9)

 

Figure 9 The percentage of patients with asthma who have had an asthma review in the previous 12 months that includes an assessment of asthma control (AST003)

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Source: QoF, 2014/15

 

  • An asthma treatment pathway has been produced, both for adults and children and young people aged 5-12, which includes Bedfordshire CCG Medicine Formulary recommendations.  This is to comply with British Thoracic Society and SIGN guidelines on asthma in which a stepwise approach to asthma treatment is advised
  • Bedford Hospital sees patients with uncontrolled asthma and either Addenbrooke’s Hospital or the Royal Brompton Hospital for specialist asthma
  • The patients have a self-management tool on leaving hospital

 

Local views

COPD

A mapping event took place in January 2010 and there were patient and third sector representatives there.  They contributed fully to the event and the priorities that came out of the event included:

  • Education both for Health Care Professionals and patients
  • Communication across all agencies including links with social care, intermediate care and out of hours
  • Pulmonary Rehab including patients that are hard to reach and personal health plans

 

National and Local Strategies

Scope for Improvement

COPD

  • NHS Outcomes Framework 2011/13 includes reducing premature death rate from under 75 from respiratory disease.  `Enhancing quality of life for people with long-term conditions’ relates to COPD outcomes (Department of Health)
  • An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England (July 2011) (Department of Health, 2011):

 

  • 25% of Disability Adjusted Life Years (DALYS) are attributable to risk factors common to respiratory disease.  Minimising the risk of contracting COPD either by not starting, or stopping smoking, avoiding and controlling risks in the environment and workplace will decrease the cost of healthcare (see chapter on ‘Tobacco Control and Smoking’)

 

  • The NHS Companion Document to the Outcomes Strategy for COPD and Asthma – this describes what the NHS specifically can do to help meet the objectives in the Outcomes Strategy.  The document describes the key interventions and actions that commissioners and providers can take to improve outcomes in that area
  • NICE (2012).  Commissioning guide for people with Chronic Obstructive Pulmonary Disease (COPD) – contain tools concentrating on pulmonary rehabilitation, assisted discharge, supportive & palliative care, commissioning and key clinical and quality issues] (NICE 2012)
  • NICE (2010).  Chronic obstructive pulmonary disease - Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) (NICE 2012)

 

o   Opportunistically testing by primary care: late diagnosis has a substantial impact on symptom control, quality of life, clinical outcome and cost because undiagnosed people receive inappropriate or inadequate treatment.  NICE has estimated the costs and benefits of opportunistically testing smokers or ex-smokers who present at the GP with a chronic cough.  It found that opportunistically testing increased the life-time cost by £35.49 more than not testing and that the cost per QALY(Quality Adjusted Life Year) was £814.56.  This was a crude calculation and the model is quite sensitive to some of the parameters and assumptions.  All costs are for the year 2000/01

o   Exacerbations: Long-Acting Muscarinic Antagonists (LAMA) or Long-Acting β-Agonists together with Inhaled Corticosteroids (LABA+ICS) were found to be the most cost-effective strategy.  The results indicate fairly low uncertainty within individual analyses.  However, the fact that between analyses there is a disagreement about the most cost-effective option indicates considerable uncertainty based on the available clinical evidence

o   O2 assessment: one study studied a cost minimization analysis of providing oxygen by concentrator or cylinder in the home (Heaney et al, 2009).  Their conclusion is that as long as more than three cylinders a month are being used, independent of flow rate or duration of prescription, it is always to cheaper to prescribe a concentrator

o   Pulmonary rehabilitation: two studies estimated the cost effectiveness in the UK.  The cost per QALY was estimated at between £2,000 and £8,000 based on a minimum of four weeks rehabilitations(Wessex Institute, 2009).   Griffiths et al(2001)  undertook an economic evaluation alongside a clinical trial and estimated that pulmonary rehabilitation was cost saving and increased quality of life compared to usual care

o   NICE advises against routinely using mucolytic drugs to prevent exacerbations in people with stable COPD, and anti cough therapy for the management of stable COPD

 

  • IMPRESS: Best Practice Models of Care (2008 and 2009) and IMPRESS Guide to the relative value of COPD interventions (2012) ((Impress, 2011) 

 

The NHS Institute for Innovation and Improvement has identified for where there has been demonstrable evidence of the universal adoption of best practice COPD guidelines, results in 20 – 30% reduction in hospital admissions.(NHS, 2011)

In January 2015, NHS England published three new handbooks to support commissioners and practitioners in planning services for people with long term conditions (LTCs), in order to achieve more effective, personalised care for this group.  They are case finding and risk stratification, personalised care and support planning and multi-disciplinary team (MDT) working http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/ltc-care/


Asthma


 

According to the Scottish Intercollegiate Guidelines Network on the management of asthma (SIGN, 2012):

  • A structured questionnaire should be used and it may produce a more standardised approach to diagnosing asthma in children
  • It is recommended moving straight to a trial of treatment in children with a high probability of asthma, reserving further testing for those with a poor response
  • In those children with a low probability of the condition, consider a more detailed investigation and specialist referral
  • Intermediate probability would be for those whose diagnosis was uncertain or poor response to asthma treatment.  They should be considered for tests of lung function and atopy
  • The aim is to use a stepwise management to control chronic asthma as it has been shown to
  • achieve early control
  • maintain control
  • encourage a step up in treatment intensity when better control is necessary
  • encourage a step down in treatment intensity when control is good


 

What are the key inequalities?

COPD

  • COPD is predominantly caused by smoking hence the main key inequalities are the same for smoking.  Smoking is more prevalent in deprived communities (see chapter on ‘Tobacco Control and Smoking’)
  • Deprived populations have the highest prevalence and the highest under-diagnosis of COPD
  • There are ethnic disparities with Black men in deprived urban areas having particularly high risk

 

What are the unmet needs/ service gaps?

COPD

The gaps below have been identified.  The COPD service was recently re-commissioned in a new model of care on 1 February 2012 taking into account the needs of the population:

 

  • A model estimates that the prevalence of COPD in Bedford Borough is 3,560 and that may mean 1,560 people are undiagnosed
  • There is no expert patient programme.  The patient education and rescue medication prescribing are variable
  • There is no specialist service for the admission avoidance scheme for exacerbation
  • Patients have to be referred before 2pm by ARAS to be seen on the same day.  It is particularly out of hours that there is a requirement for a service

 

Asthma

  • There is a potential for misdiagnosis between asthma and Chronic Obstructive Pulmonary Disease.  This is a national issue
  • Prescribers are often confused about where a particular product fits within the guidelines, which products to use or whether to start a patient when they are experiencing an exacerbation of symptoms.  Quite often patients are stepped up but then not regularly reviewed and stepped down the treatment pathway
  • There is underutilisation of community pharmacy providing patients with asthma prescribed inhalers a New Medicine Service (NMS) or Medicines Use Review (MUR).  They are both free to use that aims to help patients get the most out of their medicines

 

Recommendations

Resource impact

COPD

In accordance with National guidance, cost effectiveness and locally identified gaps (see Best Practice) the following should be considered.  All the gaps above are being commissioned in the new model of care for COPD:

  • Promote  the Smoking cessation services.  COPD is predominantly caused by smoking so reducing the amount of smoking will result in lower COPD prevalence and mortality in the long-term
  • Ensuring that domiciliary care providers are competent to deliver services that meet the needs of people with COPD, eg reablement, wound dressing
  • Ensuring that Adult Services supports plans contain accurate records of their health issues and their medication and makes sure that care providers adhere to people’s medication regimes
  • Ensuring that unpaid carers of people with COPD are identified and referred for statutory and non-statutory support
  • Bedford Borough Council’s Adult Services Directorate now has sports and leisure services in its remit.  This means that sport and exercise opportunities can be tailored and better targeted towards vulnerable people and people affected by inequalities.  Exercise can improve people’s overall health and wellbeing and can improve lung function, thus helping people to manage their COPD better

Asthma

  • Bedford Borough Council’s Adult Services Directorate now has sports and leisure services in its remit.  This means that sport and exercise opportunities can be tailored and better targeted towards vulnerable people and people affected by inequalities.  Exercise can improve people’s overall health and wellbeing and can improve lung function, thus helping people to manage their asthma better
  • Ensring Adult Services  support plans contain accurate records of their health issues and their medication, and makes sure that care providers adhere to people’s medication regimes
  • The Borough Council has a role in reducing road use and has a Greener Transport Plan in place.  Successful implementation of this plan will improve air quality which will help to reduce asthma

 

Bedfordshire Clinical Commissioning Group

COPD

  • Promote the Smoking cessation services.  COPD is predominantly caused by smoking so reducing the amount of smoking will result in lower COPD prevalence and mortality in the long-term.  Smoking cessation is a treatment for COPD
  • The times the ARAS service operates is changed to 11am-8pm, 7 days a week and to expand ARAS to include asthma, bronchiectasis and pulmonary fibrosis. It has been found that patients do not access the service during the working week and if it is to reduce urgent admissions it should increase its opening hours
  •  Promote and strengthen links with Breathe Easy, a support group to help patients self-manage

 

Asthma

  • Consider giving a ‘steroid card’ or similar to support communication of the risks associated with steroid treatment and specific written advice to consider corticosteroid replacements during an episode of stress
  • Local asthma guidelines, incorporating asthma treatment pathways, should be produced to support the local implementation of the BTS/SIGN guidelines, recommendations made in the NRAD report and medicines optimisation
  • The Bedfordshire CCG has plans to meet the NICE quality standards for asthma (QS25) by 2016
  • Patients on regular inhaled corticosteroids being issued with less than 12 inhalers in the last 12 months should be actively sought for urgent review of their asthma management
  • New Medicine Service and Medicines Use Review services provided by community pharmacists are highlighted to patients by primary care health professionals when they prescribe a new inhaler or if they consider a patient would benefit from further support in using their existing inhalers.  These services are little used and we need to optimise their use
  • All Bedfordshire community pharmacies should consider participating in the ‘Complete the Cycle’ scheme that recycles inhalers and use the return of partially used or full inhalers as a prompt for a medicines use review
  • Good communication should be ensured between primary and secondary services, especially within 48 hours of discharge and self-management plan on leaving hospital, for example a single IT system

This chapter links to the following chapters in the JSNA:
 
Tobacco Control and Smoking

 

References

i..  Viegi G (2001).  Epidemiology of Chronic Obstructive Pulmonary Disease (COPD).  Respiration;68:4–19

2.  Healthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease.  London: Healthcare Commission

3.  British Thoracic Society (2006).  The Burden of Lung disease 2nd Edition

4.  British Lung Foundation (2007).  Invisible lives: Chronic Obstructive Pulmonary Disease (COPD) finding the missing millions

5.  Royal College of Physicians of London, British Thoracic Society and British Lung Foundation (2008). 

6.  Report of The National Chronic Obstructive Pulmonary.  Disease Audit 2008, UK Primary Care Organisations: Resources and Organisation of Care)

7.  QMAS March 2011

8.  Eastern Regional Public Health Observatory, 2011.  COPD Prevalence Modelling Briefing Document http://www.apho.org.uk/resource/item.aspx?RID=111137 [accessed 12/01/12]

9.  NHS Choices http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx [Accessed 21/12/09]

10.  Quality and Outcomes Framework (QOF) for April 2010 - March 2011, England.  The Information Centre

11.  Koshy G et al, 2010.  Trends in prevalence of childhood and parental asthma in Merseyside, 1991–2006.  J Public Health 32 (4): 488-495.

12.  Thomas et al.  Asthma and psychological dysfunction.  Prim Care Respir J 2011; http://www.thepcrj.org/journ/aop/pcrj-2011-03-0033.pdf  [accessed 16/01/12]

13.  NHS Comparators

14.  PH England, Inhale- a web-tool containing data including COPD and asthma http://www.inhale.nhs.uk/data-and-tools/ [accessed 07/08/13]

15.  Department of Health

16.  Department of Health (2011).  An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974 [accessed 05/12/11]

17.  Commissioning guide for people with Chronic Obstructive Pulmonary Disease, 2012.  www.nice.org.uk/usingguidance/commissioningguides/copd/copd.jsp [accessed 06/08/13]

18.  National Institute for Health and Clinical Excellence.  NICE, 2010 CG101.  Chronic obstructive pulmonary disease - Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) http://guidance.nice.org.uk/CG101 [accessed 06/12/11]

19.  National Institute for Health and Clinical Excellence.  NICE, 2010 CG101, full guidance, appendix B http://www.nice.org.uk/nicemedia/live/13029/49425/49425.pdf [accessed 12/01/12]

20.  ] Heaney LG et al.  Cost minimisation analysis of provision of oxygen at home: are the drug tariff guidelines cost effective?  29.  Br Med J.  1999; 319(7201):19-23

21.  The Wessex Institute.  Hospital based pulmonary rehabilitation programmes for patients with severe chronic obstructive pulmonary disease.  1999

22.  Griffiths TL, Phillips CJ, Davies S et al.  Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme.  Thorax.  2001; 56(10):779-784

23.  IMPRESS http://www.impressresp.com/ [accessed 05/12/11]

24.  NHS Institute for Innovation and Improvement http://www.institute.nhs.uk/ [accessed 05/12/11]

25. British National Formulary

 

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