COPD Clinical Strategy

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COPD Clinical Strategy

• Anne Moger
• Nurse Advisor
• COPD Clinical Strategy Team
• Department of Health

2
The Context in England

• Within the population of England of 55 million it
  is suggested that up to 4 million people may have
  COPD (Shahab et al, 2006), but only 0.75 million
  people are diagnosed (QOF, 2006/07)
• Smoking is the most common cause of respiratory
  disease. 86 of COPD deaths are attributable to
  it (DH, 2007)
• There is a North/South divide, with COPD more
  frequent in the North of England and in Spearhead
  areas (DH, 2007)
• Deprived populations have the highest prevalence
  and highest under-diagnosis of COPD (GOLD, 2006
  DH, 2007)
• Ethnic disparities
• Highest risks of COPD in Black men in deprived
  urban areas (DH, 2007)
• Gender disparities
• In the UK, the rate of COPD has been increasing
  nearly three times faster amongst women than men
  (BTS, 2006)
• Women are more susceptible to developing COPD
  than men their lung function worsens with less
  duration of smoking or intensity of smoking than
  that of men (BLF, 2005 GOLD, 2006)
• COPD accounts for a considerable part of the life
  expectancy gap between Spearhead areas and
  England as a whole (DH, 2007)

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The context of COPD

• If people stop smoking, receive early diagnosis
  and the right care, COPDs progression can be
  slowed down, enabling people to live healthy and
  active lives for longer

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The context of COPD

• Awareness of COPD is limited
• Within the general population (Bachmann, 2007)
• 89 of people in the UK and even 85 of smokers
  have never heard of COPD (BLF, 2007)
• Poor recognition of early symptoms leading to
  delays in presentation (Wouters, 2003)

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The context of COPD

• Among healthcare professionals
• Gaps in knowledge about COPD Poor recognition
  (misinterpretation of symptoms) and
  under-diagnosis of COPD (Wouters, 2003
  Rutschmann, 2004 Barr, 2005)
• Poor awareness of treatment options, management,
  availability of specialist services (Barr, 2005)
• Negative attitudes and stigma (COPD as
  self-inflicted) (Barr, 2005)
• Poor communication between professionals and
  between professionals and patients (BLF, 2006)

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So what is happening in London
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Things are improving .

• Increase in COPD patients on registers
• 2004/5 69,605
• 2006/7 75,733
• Increase in diagnosis by spirometry
• 2004/5 74.1
• 2006/7 92.4
• Recorded FEV1
• 2004/5 66.2
• 2006/7 79.8
• Documented inhaler technique
• 2004/5 78.6
• 2006/7 90.1

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Prevalence of COPD in London

• Estimated 113,029 people with COPD in NHS London
• COPD may be responsible for 180,000 primary care
  consultations
• 17.3 of patients on COPD registers have been
  admitted to hospital
• 13,470 admissions
• mean length of stay 8.1 days
• 2006/7 HES data

10
Background
Recommendations published in CMOs Annual Report
2004 (published June 2005)

• The Government should continue to pursue strong
  programmes of tobacco control which will be
  reducing the human and financial cost of COPD.
• Consultant expansion programmes should be
  reviewed against the need for respiratory
  physicians at a local level, and adjustments
  made where necessary
• More primary care staff should be provided with
  training in the use of spirometry as a tool to
  detect COPD
• A National Service Framework should be formulated
  for COPD.

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Mortality trends
Coronary heart disease
3.0
All other causes
Stroke
Other CVD
COPD
2.5
2.0
1.5
1.0
0.5
59
64
35
163
7
0
19651998
19651998
19651998
19651998
19651998
Percent change in age-adjusted death rates
proportion of 1965 rate in the USA
NHLBI/WHO 2002
12
2000
2001
2005
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Clinical Strategy Methodology leading to 10 year
programme
Define scope
Epidemiological Economic clinical
Review evidence base
Set Quality Requirements
Identify markers of good practice
Commission work to support implementation
Costing QRs, IA
Sept 08
Implement Strategy
Supporting initiatives
Monitor implementation
Performance management
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A Clinical Strategy for COPD in England

• Outlines a vision for COPD services in England
• Sets quality requirements across all areas of the
  disease pathway
• Sets markers of good practice to guide the
  development of local services
• Process considers how to implement and monitor
  the standards

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What the strategy will include

• Raising awareness
• Focus on prevention and risk reduction
• Early identification, confirmatory diagnosis and
  severity assessment (ongoing)
• Clear care pathways and models of care provision
  including for acute (aggressive management of
  acute exacerbations) and chronic care- Wagners
  chronic care model
• Structured support and action planning
• Recognition of the importance of both
  pharmacological and non pharmacological
  interventions
• Smoking cessation
• Equity of access to pulmonary rehabilitation and
  supportive care
• Access to specialist services at end of life

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What are QRs and MGPs?

• Both
• Evidence based
• Mapped out along the care pathway from prevention
  of disease to end of life care.
• Quality Requirements patient and outcome
  focussed and set out on a high level the type of
  services that patients should expect.
• Markers of Good Practice key interventions and
  service models linked, wherever possible, to
  Social Care Institute for Excellence (SCIE) work
  and NICE guidelines and appraisals

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Example of a Quality Requirement

• All those diagnosed with COPD receive high
• quality care across all stages of their disease
  from
• the point of diagnosis and severity assessment.
• This includes timely, appropriate and effective
• treatment and support to help people manage their
• condition. There is a process of systematic
  review,
• leading to a range of interventions that improve
• wellbeing, limit the effect of exacerbations,
  address
• health and social care needs and prevents
• progression of the disease.

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Example of a Marker of Good Practice

• All people diagnosed with COPD have a
  comprehensive Care Plan that is
• available to other health and social care
  professions. The Care Plan
• adopts a prospective and integrated approach,
  ensuring interventions are
• delivered in a timely manner, by competent health
  and social care
• professionals with access to specialist services.
  It includes the
• Social support required to assist with activities
  of daily living
• Specific social problems that need to be
  addressed or monitored (i.e. welfare benefits,
  work and family matters)
• The need for psychological support and treatment
  of clinical depression
• End of life care needs and specific patient/carer
  wishes
• Treatment and exacerbation plan
• Any other needs
• The plan is developed with input from the person
  with COPD and their
• carer, taking into account the preferences and
  goals of the individual and
• is available to all health and social care
  professions that interact with the
• person.

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Spectrum of COPDPrevention and Awareness

• Promote sustained stop smoking services
• Early identification

The earliest point at which airflow obstruction
may be detected by spirometry

• Raising awareness of early signs and symptoms

Upper limits of normal
Lower limits of normal
Damage
Unaware of lung health
Aware of lung health
No symptoms
Symptoms but no diagnosis
MILDstage
MODERATEstage
SEVEREstage
VERY SEVEREstage
Well
At-risk
With COPD diagnosis

• Roles and responsibilities of employers
• Environmental factors

• Make links with other disease areas, e.g.
  lung cancer, CHD

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Spectrum of COPDScreening, Detection and
Diagnosis
The earliest point at which airflow obstruction
may be detected by spirometry

• Improve Diagnostic accuracy
• Implement case finding strategies
• Consider the case for screening

Upper limits of normal
Lower limits of normal
Damage
Unaware of lung health
Aware of lung health
No symptoms
Symptoms but no diagnosis
MILDstage
MODERATEstage
SEVEREstage
VERY SEVEREstage
Well
At-risk
With COPD diagnosis

• Identify those with A1AT deficiency
• Establish accurate disease registers

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Spectrum of COPDChronic Care
The earliest point at which airflow obstruction
may be detected by spirometry
Review Annually
Review 6 monthly
Review every 3 months
Damage
Unaware of lung health
Aware of lung health
No symptoms
Symptoms but no diagnosis
MILDstage
MODERATEstage
SEVEREstage
VERY SEVEREstage
Well
At-risk
With COPD diagnosis

• Comprehensive care plan for everyone with COPD
• Self-management plans
• Proactive management using disease registers
• Structured assessment using other diagnostics
  every 3 years, e.g. ABG, spirometry, etc.

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Spectrum of COPDAcute Care
The earliest point at which airflow obstruction
may be detected by spirometry

• Improved access to advice when
• symptoms worsen
• Accurate diagnosis and prompt
• assessment of exacerbations
• Use of oxygen alert cards for ambulance
• transfer

Upper limits of normal
Lower limits of normal
Damage
Unaware of lung health
Aware of lung health
No symptoms
Symptoms but no diagnosis
MILDstage
MODERATEstage
SEVEREstage
VERY SEVEREstage
Well
At-risk
With COPD diagnosis

• Assessment for invasive and non-invasive
  ventilation for hypercapnic patients
• Early assessment for early discharge
• Structured treatment whilst in hospital
• Follow-up post exacerbation

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Spectrum of COPDEnd of Life Care

• Access to supportive care for patient and family
  through to bereavement stage
• Managed according to guidelines, e.g. Liverpool
  Care Pathway

• Defined as
• Very severe airflow obstruction (FEV1lt 30
  predicted)
• History of two or more severe exacerbations
  requiring a hospital admission in the preceding
  year
• Housebound by disability (MRC 5)
• Low BMI (lt 20)
• Established respiratory failure or with previous
  ventilation for respiratory failure.

Damage
Unaware of lung health
Aware of lung health
No symptoms
Symptoms but no diagnosis
MILDstage
MODERATEstage
SEVEREstage
VERY SEVEREstage
Well
At-risk
With COPD diagnosis
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Spectrum of COPDMedicines, Devices and
Interventions
Advice on healthy lifestyles, e.g. diet and
exercise Education on COPD Support to remain in
work Ongoing stop smoking support
Referral to pulmonary rehab For MRC gt 3
Regular assessment For presence of
arterial hypoxaemia
Damage
Unaware of lung health
Aware of lung health
No symptoms
Symptoms but no diagnosis
MILDstage
MODERATEstage
SEVEREstage
VERY SEVEREstage
Well
At-risk
With COPD diagnosis
Regular review of psychological needs Referral
for nutritional input where appropriate Regular
assessment for appropriateness of surgical
Interventions Regular assessment for aids and
devices to improve Activities of daily
living Specialist assessment for need to oxygen
therapy
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COPD CS timescale
Spring 06
Summer 06
Autumn 06
Winter 06/07
Spring 07
Summer 07
Autumn 07
2008
2009
Winter 07/08

• Announce
• NSF
• ERG

Publish NSF

• ERG Meetings
• Identify Quality requirements
• and markers of good practice

ERG advice to Ministers
ERG established
DH Draft NSF to Ministers and DA committee
Stakeholder opinions sought
Implement NSF
Systematic review of evidence
DH Policy alignment
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Strategy Products
COPD Strategy
COPD prevention and awareness
Communication Strategy
Equality Impact Assess.
Management of Medicines
Commissioning
Metrics
Workforce
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Implementing the Strategy
Lead Strategic Health Authority?

• Payments
• Quality and
• Outcomes
• Framework
• (QOF)
• Payment by
• Results
• Practice Based
• Commissioning

• Support
• Care Services
• Improvement
• Partnership
• National
• Support Teams

Contact in Each SHA
Taken forward locally by Managed Clinical Network

• Supporting the
• Individual
• Self-care
• Choice
• Information

• Commissioning
• Guidance/toolkit
• World Class Commissioning
• Local needs assessments
• Strategic commissioning

• Monitoring Progress
• Metrics

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Managed Clinical Networks

• Networks at regional (SHA) level and local (PCT)
  level
• Integral part of service design and
  implementation
• Mechanism for patients and clinicians to be
  involved in planning and strategic development of
  services
• Linked to care pathway
• Need clear leadership
• Intrinsically linked into local commissioning
  framework
• Multi agency collaboration

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Gaps in Knowledge

• Lung health assessment at 7 and 14
• Lung health check from age 25
• Case finding approach to be refined
• Aspiration to work towards using Lower Limit of
  Normal (LLN) to improve diagnosis
• Work towards better phenotyping of COPD patients
• Use of technologies to enable patients to
  self-manage
• Evaluation of proposed models of care, e.g. case
  management approach, and regular reviews
• Development of Patient Reported Outcome Measures

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Contacting the COPD Policy Team

• COPD Team
• Room 415 Wellington House
• 133-155 Waterloo Road
• London
• SE1 8UG
• Copd_nsf.dh.gsi.gov.uk