Respiratory Disease

Introduction

The World Health Organisation defines respiratory diseases as “diseases that affect the air passages, including the nasal passages, the bronchi and the lungs. They range from acute infections, such as pneumonia and bronchitis, to chronic conditions such as asthma and chronic obstructive pulmonary disease” World Health Organisation (external link).

The UK has the second highest death rate in Europe from respiratory diseases Department of Health 2011 (external link). Evidence shows asthma has become more common over the last 30 years possibly as a result of our changing lifestyles, homes with central heating and fitted carpets with little ventilation and diets with fewer fresh foods. A European Commission survey European Observatory on Health Systems and Policies (external link) has reported that 13% of people over the age of 15 years in the UK have had asthma at some point in their lives. The National Asthma Campaign reports similar statistics putting the number of Britons diagnosed with the condition at eight million; London Health Observatory (external link)

Chronic obstructive pulmonary disease (COPD) is a lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible (see footnote 1). The prevalence of COPD increases with age; it is rare before 35 years of age. It remains the fifth most common cause of death in England and Wales, accounting for more than 28,000 deaths in 2005 and is the second largest cause of emergency admission in the UK, with one in eight (13,000) emergency admissions to hospital as a result of COPD. One fifth (21%) of bed days used for respiratory disease treatment are due to chronic obstructive lung disease, such that COPD accounts for more than one million 'bed days' each year in hospitals in the UK NICE 2013: Chronic obstructive pulmonary disease quality standard (external link).

The primary cause of COPD is smoking. Smoking and deprivation are closely associated and some of the gap in life expectancy gap in areas can be accounted for by COPD (see footnote 2).

This chapter focuses only on respiratory diseases. Details on housing, environmental factors, smoking and infectious diseases, cancer, excess winter deaths are covered in other chapters. Lung cancer is covered in the JSNA cancer chapter.

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Key issues and gaps

  • Haringey residents are three times less likely than people living with the highest premature COPD death rate to die from COPD before they turn 75. (Haringey COPD Pathway Profile 2012 - external link).
  • The emergency admission rate for COPD is statistically lower than the national average which is not significantly different from the previous years. (Haringey COPD Pathway Profile 2012 - external link).
  • Length of hospital stay for COPD patients has decreased since the last year and it is now statistically similar to the national average (Haringey COPD Pathway Profile 2012 - external link).
  • Over 40% of Haringey COPD patients return to hospital within 90 days. Readmission rates within 90 days of an emergency admission for COPD are statistically similar to the national average (Haringey COPD Pathway Profile 2012 - external link).
  • Patients with long-term conditions need to be supported to stop smoking, currently less than 20% of people with long-term conditions have been recorded as being offered smoking cessation advice.
  • In 2012, 4.6% of Haringey patients had asthma compared to 6% nationally. Further work needs to be undertaken as to whether there is an under-diagnosis of asthma in Haringey.
  • The hospital admission rate for COPD is lower than the national average, whereas the recorded prevalence of COPD is lower than the national average.
  • The hospital admission rate for pneumonia and influenza is significantly higher than that observed in the rest of London (153.39 vs 114.81 per 100,000 population)
  • In comparison to London and national average, men in Haringey had significantly lower incidence of lung cancer (55.5 per 100,000 compared to 56.5 per 100,000 in England and 55.9 per 100,000 in London)  London Health Programmes (external link).
  • Respiratory spend per weighted head of population was £56 in Haringey CCG from 2011-12 compared to £84 pound in England (Spend and outcome factsheet 2011/12 Haringey Teaching PCT - external link)
  • There are approximately 100 more outpatient follow-up appointments per 100.000 population than the national average (189 vs 281 per 100,000) (Whittington Health)
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Who is at risk and why

Asthma is more common in developed countries, where up to 10% of children have the disease. In children, the chance of developing asthma is approximately double when one parent has asthma compared to children whose parents don't have asthma. An estimated 75% of hospital admissions for asthma are avoidable and as many as 90% of the deaths from asthma are preventable (Asthma UK - external link). The mortality rate from asthma is about 2-3 per 100,000 per year.

The primary cause of COPD is smoking, accounting for more than 85% of cases. Roughly 1% of COPD is associated with alpha – 1 antitrypsin deficiency (a genetic disease manifesting in a protein deficiency), usually in association with smoking. Figure 1 shows that the recorded prevalence of COPD is higher in east Haringey, a similar map of the pattern of smoking in Haringey is shown in the JSNA for smoking. Some ethnic groups are more likely to smoke; on average Irish and Bangladeshi men have higher smoking levels than the general population.

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Figure 1: Recorded prevalence of COPD in Haringey (2011-12)

See COPD Profile Haringey (external link) (PDF, 288KB) for larger map and more information on COPD in Haringey

Risk factors for COPD, other than smoking, include indoor air pollution (such as solid fuel used for cooking and heating); outdoor air pollution; occupational dusts and chemicals (vapours, irritants, and fumes); frequent lower respiratory infections during childhood (Department of health (DH), 2010).

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The level of need in the population

The UK has one of the highest prevalence rates for asthma in the world, along with New Zealand, Australia and Ireland (Masoli et al 2004). In 2011-12, 4.6% of the registered population in Haringey had asthma compared to 5.9% nationally. Asthma is very common, especially in children, on average there are two children with asthma in every classroom. One in 8 children under 15 with asthma symptoms experience attacks so severe they can't speak (Asthma UK 2011).

Data from the East of England Public Health Observatory (EROPHO); shows that COPD accounted for 5% of all cases seen in general practice (reference).

In 2011, there were 2094 people diagnosed with COPD (caseload of Haringey COPD respiratory team). This compares unfavourably to the modelled COPD prevalence of 7,747 people. There is a multitude of reasons for the four-fold difference between the observed versus expected prevalence of COPD. Patients may be less likely to present to their GPs with mild symptoms, particularly when they are reluctant to stop smoking. GPs also may be unwilling to discuss lifelong chronic disease management in patients with a relatively mild chest infection.

Figure 2: Mortality from respiratory diseases in Haringey (1993-2010)

In Haringey, in the last 15 years deaths from pneumonia have fallen significantly (figure 2). Unlike national and London trends, Haringey has seen significant fluctuations in mortality from bronchitis and emphysema but it has dropped from 5.78 to 0.44 per 100,000 population. Haringey has seen a significant decrease of 66% in deaths from pneumonia, compared to 43% for London and 26% nationally.

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Current services in relation to need

The majority of cases of COPD, asthma and other respiratory diseases are managed in the community by primary care. Acute cases will be managed by respiratory teams within the acute trusts. Exacerbations of COPD are managed primarily by primary care, with the Haringey community respiratory team providing home support, pulmonary rehabilitation and oxygen support.

In Haringey, there are 2,094 patients with COPD and the community respiratory team currently supports 6.5% of these patients through home support and/or pulmonary rehabilitation programme. The community respiratory team consists of two band 7 respiratory physiotherapists, a band 6 nurse, a band 3 healthcare assistant and sessional psychology (0.1), occupational therapist and dietician. Due to the demands placed on the service, the team sources an additional band 7 locum physiotherapist.

The five elements of the service are listed below:

1) Pulmonary rehabilitation

Pulmonary rehabilitation (PR) is an evidence based service that reduces morbidity, mortality and hospital attendance (see footnote 3). From the Cochrane Review of PR, one life was saved for every six treated, and one admission was avoided for every four treated (see footnote 4).

There are many components to the PR service forming an integrated multi-faceted programme. There are two PR centres within Haringey borough offering a rolling programme; Lordship Lane health centre and Hornsey Central neighbourhood health centre  both are well-equipped for the provision of evidence-based PR programme. Both centres make provision for high and low intensity physical exercise PR programme, which are tailored to patient’s individual need. The Haringey community respiratory PR programme (HCRT-PR), formerly provided by NHS Haringey, is now part of the Whittington Health. Approximately, 70% of referrals are received from Haringey GP, 25% from North Middlesex Respiratory Consultants and 5% from Whittington Hospital.

HCRT-PR Provision

  • 2 rolling Programmes (8 weeks long, twice weekly)
  • 12 places available in each programme (24 places available at any given time)
  • 50 weeks of ongoing PR per year

The following staff members deliver the PR programme

  • Specialist respiratory physiotherapist
  • Dietician
  • Clinical psychologist
  • Respiratory nurse
  • Respiratory assistant
  • Smoking cessation advisor
  • GP and respiratory consultants (For optimum medical management pre PR and for referrals)

HCRT-PR service has a capacity to assess 48 patients (12 patients in each class, in 2 sites) per month (i.e. able to assess 576 patients a year) across 2 centres, but the rate of did not attend and declined patients affects total number of patients assessed every year. Based on the assumption that 80% of patients complete their PR programme and attend the maximum of 16 sessions of PR, the maximum throughput per year is 180 patients.

2) Home Support

The aim of the home support service is:-

  • Providing education to patients with COPD about their condition
  • Identifying any clinical changes which indicate a relapse early enough to start appropriate treatment
  • Liaising with patients GP to ensure appropriate prescription of steroid and antibiotics
  • Supporting GPs to diagnose and manage COPD in the community and thereby avoiding patients having to attend consultant outpatient appointments, where this is clinically safe and appropriate
  • Supporting early discharge of COPD patients from acute hospital and ensuring appropriate and safe management in patients own home, including interventions to support medication compliance

All the patients have the team’s mobile phone number and can access the service immediately within working hours. The patients under the care of the community respiratory team are mainly at the severe end of the spectrum of COPD, often housebound, and very limited by their illness.

3) Oxygen Review

  • The team monitors the database on oxygen prescribing, for those patients with very severe disease, improved compliance, ensuring oxygen is prescribed to the patients who could most benefit and reducing the dependence of hospital based outpatient appointments are all key aims of the service.

4) Spirometry Service

The team receives in excess of 500 referrals for Spirometry per year from the Haringey GP practices

5) Acute exacerbation COPD pathway

The community respiratory team has run a two month pilot project to improve the management of patients diagnosed with an acute exacerbation of COPD. The outcomes of the service have been encouraging, which has led to a continuation of the service from November 2013 till April 2014 funded through short-term winter pressure funds.

6) Long term exercise group

Public Health has commissioned the community respiratory team to offer an evidence-based  long-term exercise programme to patients who have successfully completed a PR programme in the previous twelve months.

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Service users and carers opinion

Service users have been involved in pathway design of COPD service as part of the work by North Central London respiratory group. User’s opinions are also sought by Whittington Health and through primary care via GP questionnaires. The topics discussed ranged from primary care, intermediate care, spirometry, pulmonary rehabilitation, smoking cessation including others.

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Expert opinion and evidence base

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Projected service use in 3-5 years and 5-10 years

Using modelling techniques, 7,747 people in Haringey should have chronic obstructive airways disease. Currently only 27% of that number are actively been treated for COPD. Smoking is closely linked to both the development and prognosis of COPD. Smoking cessation is the ‘most important intervention to slow down the disease progression of chronic obstructive pulmonary disease.’ (Hoodgendoorn 2010) and will determine how many people develop COPD over the next 10 years It is therefore impossible to accurately predict the service use for COPD, as it is interdependent on the number and rate of smoking quitters.

The total annual cost of COPD to the NHS is estimated to be £491,652,000 for direct costs only and £982,000,000 including indirect costs. The average cost per patient is £819.42 per annum, of which 54.3% is due to inpatient hospitalisation, 18.6% for treatment, 16.4% for GP and specialist visits, 5.7% for accident and emergency visits and unscheduled contacts with the GP or specialist and 5% for laboratory tests.

The mortality from other pneumonia has fallen significantly over the last 15 years. The JSNA section on infectious diseases provides more detail on predicted service use.

For asthma, new treatments and good patient education have a significant effect on disease progression and ultimately service use. Further work needs to be undertaken to predict future service use.

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Unmet needs and service gaps

Haringey is within the lowest percentile for COPD prevalence in London. The modelled versus recorded prevalence is 6.2 in 2011. The London average is 3.9 and the value for the biggest mismatch in recorded versus modelled prevalence is 6.2.

Overall, whilst the COPD emergency admission rate in Haringey is statistically similar to the national average, the admission rate among patients on a COPD register is significantly above the average. This may be indicating a need to consider how patients are managed once identified (Haringey Profile NHS - external link). There is considerable variability across Haringey in terms of QOF performance targets as 14 GP practices have not diagnosed COPD in their practice population since April 2011

Once admitted for COPD, patients from Haringey spend significantly longer in hospitals that other patients in England; this is over four days more than the local authority with the shortest length of stay. Over one third of Haringey patients admitted for COPD return to hospital within 90 days. Both this issues and the one above may indicate scope for considering current arrangements for community based support (Haringey Profile NHS - external link).

Smoking has been identified as an underlying cause of COPD, cases of childhood asthma and some cases of exacerbations of pneumonia. It is an absolute priority to support quitters and educate people on the risks of smoking. The JSNA on smoking has a more detailed description on the needs of this group of the population. Work needs to be targeted to particularly ethnic groups, such as Irish and Bangladeshi men, who are known to have particularly high rates of smoking.

The mismatch between observed and expected prevalence of COPD has highlighted the need to identify new cases of COPD in the community. Early identification of COPD is important to ensure appropriate treatment and offer people smoking cessation advice and access to pulmonary rehabilitation.

Interventions need to be particularly targeted to pregnant women and families to reduce the level of asthma in the families. Many asthma admissions, and ultimately deaths are preventable. Access to good educational resources is essential for parents, teachers and children to enable them to better understand and seek treatment for their condition.

COPD interventions, such as pulmonary rehabilitation and home support, have good clinical to support improved community disease management and reduced acute admissions. Efforts need to be made to increase the number of patients accessing pulmonary rehabilitation services. The referral rate to PR service is incongruent to the perceived need in Haringey.

Spirometry service is not adequately commissioned and managed in Haringey as referrals to the respiratory team indicate. It might also mask the gap between modelled prevalence and actual prevalence.

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Recommendations for consideration by commissioners

  • To continue to invest in stop smoking services and to encourage more Haringey residents to quit smoking, with particular focus on particular ethnic groups, users of mental health services and pregnant women.
  • To support commissioning to identify and diagnose new cases of COPD and asthma in primary care
  • To ensure that there is adequate access to spirometry in Haringey to support early diagnosis of COPD
  • To ensure there is active case finding that is effective in closing the gap between recorded and expected prevalence
  • To commission sufficient pulmonary rehabilitation services to meet local need
  • To commission services to provide better education to parents, children and schools on the causes and management of asthma
  • To reduce ,length of stay in hospitals and readmission rates there could be greater community support for patients and families
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Recommendations for further needs assessments

Conduct a needs assessment of COPD in Haringey

Further work to improve use of spirometry in Haringey

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Key contact

Dr Nicole Klynman, Assistant Director of Public Health - email nicole.klynman@haringey.gov.uk

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Footnotes:

  1. WHO COPD definition (external link)
  2. An Outcome strategy for Chronic Obstructive Pulmonary disease (COPD) and Asthma in England. Department of health, 2011 (external link)
  3. British Thoracic Society. IMPRESS guide to Pulmonary Rehabilitation. 2011 (PDF, 3 MB)
  4. Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2011, Issue 10 (external link)
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References:

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