Last updated 08/04/2011
Lewisham JSNA:
Chronic Obstructive Pulmonary Disease (COPD)
Supporting info
· Topic Summary
· Data & Trends
· Supporting Documents
Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease[1]. The main symptom of COPD is an inability to breathe in and out properly. This is also referred to as airflow obstruction.
Airflow obstruction is caused by long-term damage to the lungs, usually as a result of smoking, which is the main cause of COPD. As the condition progresses, breathing in and out becomes increasingly difficult, and the patient’s physical ability to carry out normal tasks may be diminished. Symptoms can be exacerbated by air pollution, extremes of temperature, and viral or bacterial infections. There is no cure for COPD, and treatment concentrates on relieving the symptoms.
What do we know?
What is this telling us?
What do we know?
Supporting info
Topic Summary
Data & Trends
Supporting Documents
Facts and figures
Trends
Targets
Performance
Local Views
National and Local Strategies
Current Activity and Services
Facts and Figures
· COPD is the third leading cause of disease burden In Lewisham. It is the third leading cause of death among males and the eighth among females.
· Smoking is the main cause of COPD. The likelihood of developing the condition increases with the duration and intensity of smoking, and the condition generally manifests after the age of 40.
· The Department of Health (DH) estimates that the routine and manual occupational groups represent almost half of the people with diagnosed and undiagnosed COPD in England.
· COPD contributes to the gap in life expectancy between England and Lewisham, as smoking rates are highest in lower socio-economic groups and the number of cigarettes smoked per day is also higher in this group. COPD is the second highest contributor to the gap in life expectancy in men (11.3%) and fourth highest contributor in females (9.1%), with pneumonia the second highest.
· The recorded prevalence of COPD in Lewisham is higher than that of London, and the admission rate for COPD is also higher. Figure 1 below shows how Lewisham compares to London for the COPD-related indicator, where a ratio of 1 is the same as London, above 1 is higher than London and below 1 is lower.
Figure 1: Lewisham COPD and smoking prevalence compared to London (2008/09)
· COPD is a significant cause of hospital admissions and re-admissions in Lewisham.
Trends
COPD Prevalence in Primary Care
In November 2009, there were 2,967 people on GP registers in Lewisham with COPD. This is likely to be a significant underestimation of the actual number of people with COPD, as only 40% of the expected number of COPD cases in Lewisham are recorded on GP registers. Although this is higher than London’s figure of 37%, the figure for England is 56%.
Smoking Prevalence and Related Mortality
Smoking prevalence, and the number of smoking-related deaths in Lewisham, are significantly higher than in England[2]. In the period 2005-07, the rate of deaths attributable to smoking for those aged 35 years and over in Lewisham (265.2 per 100,000 population) was significantly higher than that of England[3], although lower than the 284.5 rate for 2004-6. According to the model-based estimate produced by the National Centre for Social Research, the estimated smoking prevalence in Lewisham is 26.8% - seventh highest in London - compared to the national prevalence of 24.1%[4]. Smoking prevalence among low income groups has not declined.
Hospital Admissions
The number of admissions for COPD has increased in the last year (2009), following a slight a decrease in the previous year (Figure 2). Since 2005, there appears to be no overall trend in COPD admission outside of seasonal fluctuations. In 2009 there were 729 admissions for COPD in Lewisham, and 43% of these patients had more than one admission, with 20% having three or more admissions within the year. Acute COPD admissions were higher than the national rate. In line with the national pattern, 88% of admissions are in people over 60 years. Approximately 54% of the total cost of COPD care is spent providing acute care. The total financial burden of COPD in Lewisham is estimated to be £4,451,524.
Figure 2 Quarterly admissions for COPD 2005-2009
Targets
The only national or local targets for COPD relate to the Primary Care Quality and Outcomes Framework (QOF). The performance of Lewisham practices in relation to these targets is outlined in Table 1. A national COPD strategy, which may include targets in the future, is currently in its consultation phase. There are other targets that may impact on COPD, including uptake of pneumococcal vaccine and influenza vaccine in the over 65s and those with long term conditions such as COPD.
Table 1 Lewisham COPD QOF data 2008/2009
Indicator / Achieve-ment / Numerator / Denominator / CentileCOPD 1
Patients with a recorded diagnosis of COPD / 1% / 2967 / 296735 / 12
COPD 10
The percentage of patients with COPD with a record of FeV1 in the previous 15 months / 79.4% / 2219 / 2795 / 13
COPD 11
The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the previous 15 months / 87.9% / 2018 / 2297 / 3
COPD 12
The percentage of all patients with COPD diagnosed after 1st April 2008 in whom the diagnosis has been confirmed by post-bronchodilator spirometry / 87.9% / 240 / 273 / 16
COPD 8
The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March / 88.2% / 2285 / 2591 / 1
Performance
While Lewisham as a PCT performs reasonably well on the COPD QOF indicators, the recorded prevalence is much lower than expected in some practices. There are also practices, such as Torridon Road Practice in Catford, with low Indices of Multiple Deprivation (IMD) scores and recorded COPD prevalence, but with very high admission ratios for COPD. It is unclear whether this is due to a local issue (such as an older population of smokers/ex-smokers but younger professionals moving into the area decreasing the IMD scores), or whether management in primary care or access to community services could be improved to prevent these admissions.
Spirometry
Spirometry is fundamental to making a diagnosis of COPD and NICE guidelines 2004 recommend spirometry is carried out at diagnosis. The general practice Quality & Outcomes Framework (QOF) 2004 identified that in the first instance a practice should have a register of patients with COPD and secondly all new patients should have the diagnosis confirmed with spirometry including reversibility testing; spirometry then needs to be repeated once every two years. The local QOF data indicate that 79.4% of patients with a recorded diagnosis of COPD have had their Forced Expiratory Volume (FeV1) recorded in the previous 15 months. This can be used as a proxy for access to spirometry, although it should be noted that there are limitations in the use of these data and they should be treated with caution.
An opportunistic spirometry screening service for the early diagnosis COPD was piloted in primary care cluster 3 in 2008. In addition to providing community-based screening, the service aimed to create robust links to smoking cessation and disease management plans, in order to reduce disease progression, admissions and length of stay.
Overall, in the financial year 2008/09, 465 patients were seen through the service.
From this number, 125 cases of disease were detected (27%), of which 99 were classified as obstructed (21%), 80 as mild, 17 moderate, two severe and 26 restricted airways (5.6%). Additionally, 178 patients were given smoking cessation advice and referred to services. Of these, 22 (12.4%) contacted services, and 12 of these quit successfully at four weeks and one after four weeks (&% of the total number given cessation advice).
Community matron evaluation
COPD was identified as an area that community matrons could have impact as many patients have multiple admissions, and a recent case note review of community matrons’ caseloads indicated that 86% of patients had COPD. An evaluation of the community matron role indicated that the role is valued by GPs and patients alike and has an impact on reducing use of primary care GP consultations. Hospital usage, in terms of rate of, in-patient episodes, compare favourably with the control (remainder of population with same diagnostic codes for COPD).
Figure 3 shows that, whereas there is a considerable increase in admissions in the control population from November 2008 to January 2009, the same increase is not present with the patients on the Community Matron’s caseload.
Figure 3 All admissions for COPD vs community matron caseload admissions for COPD trend Sep 2008 to Sep 2009
Local views
A ‘Living with COPD’ information booklet was developed with patients, for patients, and was widely distributed through GPs, community matrons and UHL in 2009.
In December 2009, a stakeholder meeting was held that looked at the current COPD patient pathway, identified gaps in services and provided recommendations on how to improve the service. At this meeting, there was representation from primary care, respiratory consultants, UHL management, commissioners, community matrons, pulmonary rehabilitation, smoking cessation, public health, and respiratory physiology. The views of this group informed the development of the service specification for a community Nurse Consultant post for COPD to work across community and secondary care interface.
This work has since been taken over by the COPD service redesign group. A further stakeholder event and mapping exercise was held in November 2010 which has provided the basis for the development of a new patient pathway.
A focus group was held with patients in December 2010 to discuss the new pathway and their experiences of COPD care. Patients were generally impressed with the pulmonary rehabilitation service and the care they received at Lewisham hospital. Many commented that they had not received much information about their COPD, or had training about how to use their inhalers correctly. Many of the participants did not seem to have been given much advice about how to manage their condition better.
National and local strategies
Local service delivery is underpinned by the values and principles outlined in the following documents:
· The National Service Framework (NSF) for Older People (DOH March 2001)
· The National Service Framework (NSF) for Long Term Conditions (DOH March 2005)
· The Management Of Chronic Obstructive Pulmonary Disease in adults in primary and secondary care (NICE guidance 12, Feb 2004)
· Our Health, Our Care, Our Say - A new direction for community service (DH January 2006)
· BTS Standards of Care Committee Statement on Pulmonary Rehabilitation (July 2001)
· Global Initiative for Chronic Obstructive Lung Disease (GOLD) -Global Strategy for the Diagnosis, Management and Prevention of Chronic Lung Disease Summary (2003)
· Transforming Community Services:- Ambition, Action, Achievement (DOH 2009)
In addition to these, the DH currently has a consultation out on a Strategy for Services for COPD in England.
Current Activity and Services
Lewisham has a local COPD model of care, developed in 2006, to improve community-based diagnosis and management of COPD. This includes:
· provision of spirometry in primary care;
· development of a community team to support patients with COPD;
· rapid access to specialist/secondary care when required for patients.
Whilst aspects of the model have been implemented, specifically spirometry, pulmonary rehabilitation and support from community matrons for COPD patients, other aspects have not, including the development of a community-based COPD service. This is now happening following the appointment of a Respiratory Nurse Consultant in early 2010.
The COPD patient pathway includes:
- primary care diagnosis (through spirometry), management and review
- access to smoking cessation advice and specialist services
- access to specialist community services through the Respiratory Nurse Consultant
- access to secondary care through the chest clinic at UHL
- access to pulmonary rehabilitation
- access to community matrons for those patients requiring extra support to manage their condition and exacerbations
- access to expert patient programmes.
What is this telling us?
Supporting info
Topic Summary
Data & Trends
Supporting Documents
What are the key inequalities?
What are the key gaps in knowledge/services?
What is coming on the horizon?
What should we be doing next?
What are the key inequalities?
· COPD is estimated to contribute 11.3% to the gap in life expectancy between Lewisham and England for men, and 9.1% for women[5]. This equates to about 40 excess deaths per year.
· Smoking prevalence is higher in lower socio-economic groups and therefore COPD prevalence is higher in more deprived areas. However, as smoking prevalence tends to be lower in Black and minority ethnic groups than in the White population, particularly women, the prevalence of COPD in this group is likely to be lower, although no data are available to verify this. There are certain exceptions to this; for example, Turkish and Vietnamese men have high smoking rates.
Figure 3 below shows ethnicity data for hospital admissions for COPD. Over 80% of admissions are in the White population (including Irish, and other White). The next largest ethnic group is the Black or Black British group, with most of these in the Black Caribbean or Black other ethnic groups. Only three patients’ ethnicity was described as Black African. Figure 4 shows COPD admissions by sex.
Figure 3 COPD admissions by ethnic group 2005/6 - 2009/10
Figure 4 COPD Admissions by sex 2006-2009
· GP practices with higher IMD scores tend to have higher COPD prevalence and admission rates than those with lower scores. Table 2 looks at the ratio of selected primary care indicators in relation to COPD, compared to Lewisham. A ratio of 1.00 indicates a similar profile to Lewisham, above 1 is higher than Lewisham and below one is lower than the Lewisham average.