COPDin Primary CareCOPD in Primary Careseeing the opportunity

Context

More long term conditions, which aredisabling: COPD, Heart failure, Diabetes, …

More people, and living longer

More work outside hospitals: early dischargeschemes & reduced length of stay,alternatives to admission.

No change,and see what happens …

“The definition of insanity is doing the same thingover and over again and expecting differentresults.” Albert Einstein

Invest in more people and things: morehospitals, nurses and doctors, drugs, more …

Even if there was more money, just addingmore people and things doesn’t improveresults

Health care systems have evolved around the conceptof infectious diseases, and they perform best whenaddressing patients’ episodic and urgent concerns.

However, the acute care paradigm is no longeradequate for the changing health problems in today’sworld. Both high and low-income countries spendbillions of dollars on unnecessary hospital admissions,expensive technologies, and the collection of uselessclinical information.

As long as the acute care model dominates health caresystems, health care expenditure will continue toescalate, but improvements in populations’ healthstatus will not. ”

WHO, Innovative care for chronic conditions, 2002

“

Oh, nice! Questions and answers!

larger than the moon

4some meetings …

3some meetings …

Not important

2Planning & prevention,

education &relationship building,recreation, proactive

1Crisis, deadlines, …,

putting out fires,reactive, stress, costly

Important

Not urgentUrgent

Question 1 (easy): Which two are not so important?Question 2: Which square is the good one?Question 3: Which square is the bad one?

* to change the nature of

Shifting stuff from square 1 to square 2

from acute care → Preventionfrom hospital → Community & Primary care

Working differently, and better together

transforming* the services we offerdifferent, not more

“a shift from seeing a world that is made ofthings to seeing a world that’s open and

primarily made up of relationships”

P. Senge & J. Jaworski

Crisis - maybeOpportunity - definitely

to improve the quality of servicesand the experience for patients

to develop alternatives in the community andprimary care, reducing admissions

affordable, without spending more money (butspending it differently)

PBC’s agenda:– Empowering frontline staff

– Empowering patients

– Integrated Care Pathways for COPD, Heartfailure & Diabetes

– Single point of contact for Community Services

– Primary & Community Care Teams

– Hospital-at-home schemes– Community Hospitals

– Prevention & early intervention

– Telehealth

What is COPD?

caused by inhaled toxinschronic inflammation, irreversibly damaging

peripheral airways and alveolesairflow obstruction (reduced FEV1)which is poorly reversible, and progressivewhat it means: breathlessness & cough &

disablity & poor quality of life & early death

Smoking causesongoing inflammation:

(1) Proteases destroying small

airways: repair with scar-tissue

(2) Proteases destroying

alveoles: emphysema

(3) Mucus and cough

small airways & alveoli:irreversible damage, irreversible airflow obstruction

Prevalence

2% in Yorkshire and the HumberTrue prevalence probably 3 to 5% or more

Patients are often diagnosed late, in their fifties

* per 100,000

Mortality

5th leading cause ofdeath now

3rd leading cause ofdeath in 2030

In YH 31, vs. 25 forAMI

In YH 31, vs. 26 forEngland

Numbers are /100,000

YH = Yorkshire and the Humber

Causes &Risk factors

Smoking– active

– passive

Other inhaled toxinsSocioeconomic (manual workers), nutritional

factors, childhood infections

Diagnosis

Symptoms:• Dyspnoea• Cough / Sputum• ‘Acute bronchitis’

Risk factors:• Smoking• Occup / Envir Inhalation

SpirometryFEV1 <80% of predicted

FEV1 / FVC <0.7

Age 35+

Spirometry

Is easy, and easy to get wrong

Needs vigorous encouragementMaximal in- to maximal exspiration, 6 secNo coughs or hesitations3 measurements, 2 within 5%

Step 1: FEV1 measured / predicted

Find the measured FEV1 and divide it by the

FEV1 predictedfor this patient.

Example: FEV1 % of predicted

= FEV1 meas / FEV1 pred

= 2 litres / 4 litres = 50%

Step 2: FEV1 / FVC

Again start with the measured FEV1, but this

time divide it by the measured FVC.

Example: FEV1 / FVC (or FEV1 ratio)

= 2 litres / 3 litres

= 66% (or 0.66)

Reduced Volumes (litres)

FVC (FEV)FEV1

Step 3: FEV1 - SeverityFind a copy of the new NICE guideline and

determine the severity of airflow obstruction:

Step 4: FVC Obstruction or Restriction?

FEV1 / FVC <0.7 (or <70%) indicates COPD

A reduced FEV1 in the presence of a normal orincreased Vital Capacity suggests COPD.

A reduced Vital Capacity increases this ratio(>0.7) and suggests a restrictive disorder.

Step 5: FEV1-Reversibility, ? Asthma

Airflow obstruction (FEV1-reduction) in COPD isnot or poorly reversible, but in Asthma it is.

If history makes you think of Asthma, then also doa post-bronchodilator FEV1, after 4 puffsSalbutamol via spacer.

If FEV1 increases by 400ml (0.4l) or more afterSalbutamol, the patient has reversible airflowobstruction and probably asthma.

Consider asthma if: early onset, atopy (hay fever,eczema), wheezing and coughing, symptoms areepisodic, varying from day to day, at night andearly mornings, or exercise-induced

To confirm asthma do:

• Peak flow diary: diurnal or exercise-relatedchanges, improvement with Salbutamol

• Post-bronchodilator spirometry• Post-10days-30mg-Prednisolone spirometry

FEV1: reduction indicates COPD or (ifreversible) Asthma

FVC (FEV): reduction indicates restriction

Symptoms

Which is the least relevant typical for COPDA WheezeB BreathlessnessC CoughD Sputum

Severity

A VCB FVCC FEV1

D PEF

DD Asthma

A FVCB Reversibility of FVCC Reversibility of FEV1

D PEF

DD Restriction

A FVCB Reversibility of FVCC Reversibility of FEV1

D PEF

Moderate COPD

A FEV1 50-80%B FEV1 ratio <0.7C FEV1 ratio 30-50%D FEV1 30-50%

Severe COPD

A FEV1 50-80%B FEV1 ratio <0.7C FEV1 ratio 30-50%D FEV1 30-50%

Breathlessness / Dyspnoea

The main COPD symptom, next to coughThe disabling factor of COPD, next to

exacerbations, affects quality of life, stopspeople going out, or on holidays

Causes panic, which makes people dial 999Improves with Bronchodilators & Pulmonary

RehabilitationGraded with MRC Dyspnoea score

Too breathless to leave the house, or breathlesswhen dressing or undressing

5

Stops for a breath after walking about 100m ora few minutes on a level

4

Walks slower than most people on a level, stopsafter a mile or 15min walking at own pace

3

Short of breath when hurrying on level, orwalking up a slight hill

2

Not troubled by breathlessness except onstrenuous exertion

1

MRC Breathlessness Scale

Mr Smith still picks up a newspaper at thenewsagents every morning, which is just 200or 300 metres down the road, level ground.He has to take his time and stops severaltimes to get his breath.

His MRC dyspnoea score is …

Mrs Miller enjoys a long walk on weekends.She can walk for miles, although when shewalks up a slight hill or walks a bit faster, shehas to stop for a breath from time to time.

Her MRC dyspnoea score is …

Mrs Green goes walking with Mrs Smith, butfinds it a bit frustrating now as she has towalk slower and has to stop for a breathevery ten minutes or so.

Her MRC dyspnoea score is …

Breathlessness, Air trapping & Bronchodilators

COPD patients have pulmonary hyperinflation (air trapping, red) and smaller inspiratory capacity(blue). Hyperinflation worsens with exercise which reduces exercise tolerance (MRC score).

Inhaled bronchodilators improve dynamic hyperinflation, as well as hyperinflation at rest,which improves dyspnoea, reduces the work of breathing and increases exercise tolerance.

Breathlessnes

Anxiety &

Pulmonary Rehabilitation

Empowering

Here’s a little story …

The doctor has his annual appraisal. During themeeting he is given his patient-survey results, and istold that he needs to increase his appointmentlength by a 3 min to address the problem.

- yeah!

Next year, he hasn’t changed a bit. His appraiser hasan idea. The doctor is given some time to mullover the results beforehand, and is asked whatchange he regards as important and achievable …

He now feels so empowerd he starts to empower hispatients, asking them what affects them most,exploring with them …

He even starts to empower nurses and otherfrontline staff, asking them what changes couldmake a real difference to the service …

Elements of empowerment

Provide information, education

Encourage people to take control, make own decisions

or anybody else

“Do you agree or disagreethat the majority of your team possess far more talent,intelligence, capability and creativity

than their present jobs require, or even allow them to use?”

S. Covey

patients & service users(patient perspective)

practitioners & partners(social movement)

managers & leaders(transformational leadership)

Stable COPD

Improve breathlessness with Bronchodilators: short-,long-acting, combined (Salbutamol, Terbutaline,Ipratropium; Salmeterol, Fenoterol, Tiotropium)

Improve breathlessness, fitness, quality of life with regularExercise and Pulmonary rehabilitation

Empower patients, support self managementFor productive cough consider Carbocisteine

No treatment can slow down the decline in FEV1 - onlySmoking cessation can !

Cont.

No treatment can slow downthe decline in FEV1 …

… only early diagnosis & smokingcessation can

Why COPD deaths are still increasing

Diagnose & stop smoking early to slowthe decline of FEV1

COPD exacerbations

Change: sustained worsening from what isnormal for patient

Increase in sputum and darker colour suggestinfection → antibiotics

Increase in breathlessness and cough suggestinflammation and bronchospasm →bronchodilators and steroids

Caused by bacteria, viruses, both, or pollutants

Self-management / GP Visit:– Increase dose and frequency of Bronchodilators

(spacer/neb) +/- add oral Prednisolone 30-40mg

– Add oral Antibiotics for purulent sputum

Hospital-at-home:Hospital admission: if marked dyspnoea,

cyanosis, confusion, high fever, new oedema

Prednisolone30-40mg for 7-14dImproves dyspnoeaand ABGsReduces relapse

Amoxicillin, a Macrolide, Tet or DoxyHalf exacerbations are bacterial (half not)Cochrane: antibiotics reduce deaths by 75% and treatment

failure by 50% in moderate or severe (not in mild)exacerbations

Exacerbation Self Management Plan

Cough and Sputumincrease and

colour dark / green

Start standby course ofAntibiotics

Breathlessnessand Cough

worse than usual

Breathlessnessand Cough

much worse than usual,or worse for over 2 days

Increase your Relieverdose and use it more

often

Increase your Relieverand start standbycourse of Steroid

tablets

Very unwell: If you arereally struggling to

breathe and speak, havechest pain, high fever, orare becoming agitated,

confused or drowsy

Emergency callfor doctor (surgerynumber at any time)

or if necessarycall an ambulance

(999)

Pulse Oximetry (SpO2)

Exacerbation or LRTI: >95% in air is reassuring;if <90% consider admission

?PE: if SpO2 drops after going up flight of stairs,increases chance it is a PE

Spot check models areViamed MD300-D for £70Nonin 9500 for £160Nonin 9550 for £220at bmamedicalsupplies

After exacerbations

Review within 6 weeks:Self management plan (SMP), consider stand-by

boxes of antibiotics and steroids

Optimise management: all Bronchodilators, ICS,mucolytics, theophylline reduce exacerb.

Refer for Pulmonary rehabilitation (PR) if MRC3 or more

Consider for MDT and Telehealth

Consider Inhaled corticosteroids (ICS)

If recurrent exacerbations & FEV1 <50%They improve FEV1 and health status, and reduce

exacerbations by 25%Slightly increased risk of pneunomia

Use high dose & combination with bronchodilatorSeretide Accuhaler 500mcg BDSymbicort Turbohaler 400mcg BDSeretide Evohaler 250mcg

with spacer 2 puffs BD

Acute COPD admissions to Scarborough Hospital 2009/10:• Reduction in admissions compared to predictions• Encouraging results for primary care and community basedinterventions: Local enhanced service, Pulmonary rehabilitation,Training in COPD / Spirometry, Specialist nurse etc.

COPD LES

To improve the diagnosis and management of peopleespecially with more severe COPD, to reduceadmissions

1. Offer spirometry from 35 years onwards withsymptoms and risk factors

2. Code as mild, moderate or severe airflowobstruction based on FEV1.

3. More frequent and structured reviews for thosewith moderate or severe obstruction.

4. All COPD patients: Self Management Plan (SMP)e.g. “COPD and me”

5. Refer to Pulmonary Rehabilitation those whosuffer from breathlessness i.e. MRC score 3 ormore

Why finding alternatives to admissionis such a good thing

Hospitals are not patients’ preferred place of care

Risk of delirium, confusion, nosocomial infections,pressure sores, falls, …

Loss of independence, ‘worse on discharge’, …Poor discharge management causing re-admissions

Hospital care is terribly expensive

And maybe we can prevent the crisis, the patientgetting so unwell in the first place …

Primary & CommunityCare Teams

Shifting stuff from square 1 to 2

Preventing the crisis, and planning for it

Works like the Gold Standards Framework (GSF)

For older and vulnerable people on a practice’s list

Regular meetings of primary care and community staff- GP, PN, Case manager, …

Encourages Community and Primary care workingcloser together

Applying the GSF principles– Identify vulnerable & older patients

– Ask them how they are affected, record theirpreferences, empowerment approach

– Assess management along relevant CarePathway, and do what’s missing

– Plan, what to do if things get worse (COPDexacerbation) and make sure SMP, contacts etcare in place

Estimating the risk of admission in COPD• Previous admissions

• Worsening airflow obstruction (FEV1)

• Worsening breathlessness (MRC score)

• Low BMI

• Increasing age

• Social factors

Hospital-at-home

“ We need to get the skillmix right. “

Work is being shifted into the community. Do theyhave the capacity? They will need more staff, andempowered staff.

Telehealth

Helps clinicians with relevant measurements,does not replace clinician

Informs and reassures patientsUsing the tool markedly reduces admissions,

more phonecalls, ? visits

Tunstall “my medic”

New technology - initial scepticism

“We need assistive technology now”Say the experts - Alan Hansen, Alan Shearer, Gary Lineker, …

Technologycan be fun …

“Nantendo”

… and intuitive.

Integrated Care Pathways

Pulling all the above together

Locally agreed standards, national guidelinesIntegrate care across boundaries of primary,

secondary and community care

Make care predictable for patients and clinicians,

which helps shifting stuff from square …