COPD in primary care - HSCR '07 COPD research in a primary care setting Patrick White King’s...

COPD in primary care - HSCR '07

COPD research in a primary care setting

Patrick WhiteKing’s College London

Department of General Practice and Primary Care


COPD Modern name for chronic bronchitis

and emphysema Caused by inhalation of noxious

particles - 80%+ caused by smoking Prevalence is uncertain but probably

between 5% and 10% of population Prevalence of doctor diagnosed

COPD in UK is currently 1-1.5% of population


COPD

23500+ deaths per year compared to 28,000 deaths caused by lung cancer

Biggest cause of admissions in UK and especially in London

Soon to become 4th cause of mortality globally


Recent major advances in management Smoking cessation Pulmonary rehab Long term oxygen therapy Inhaled drugs

Inhaled short-acting bronchodilators Inhaled cortico-steroids Inhaled long-acting anticholinergics Inhaled long-acting beta-agonists


Change in the profile of COPD

COPD has come out of the shadow of asthma

2004 NICE Guideline


Change in the profile of COPD

COPD has come out of the shadow of asthma

2004 NICE Guideline 2005 Introduction of COPD targets

into the new contract for GPs


National objectives for improving COPD management

QOF indicators updated 2006 COPD register % of all patients in whom diagnosis has been

confirmed by spirometry including reversibility testing

% of all patients with an FEV1 in the previous 15 months

% of all patients with a record of inhaler technique in the previous 15 months

% of all patients with a record of influenza vaccination in previous Sep - Mar


Change in the profile of COPD COPD has come out of the shadow

of asthma 2004 NICE Guideline 2005 Introduction of COPD targets

into the new contract for GPs 2005 CMO’s annual report

announced a new National Service Framework for COPD


Change in the profile of COPD COPD has come out of the shadow of

asthma 2004 NICE Guideline 2005 Introduction of COPD targets into

the new contract for GPs 2005 CMO’s annual report announced a

new National Service Framework for COPD 2006 Health Commission - Clearing the

air: A National Study of Chronic Obstructive Pulmonary Disease



Healthcare commission PCTs to lead improvements Focus on areas of deprivation Access to care Models of structured care Reduce admissions and length of stay Improve access to pulmonary

rehabilitation Improve palliative care of COPD


Current research issues Understanding the cellular and

molecular mediators of the disease Developing new molecules to block

disease progression Evaluating effectiveness of current

drugs and treatments Improving disease recognition Improving the delivery of services


Primary care priorities Proportion of population with COPD

for which there are useful interventions

Strategy for the screening, diagnosis, and surveillance of COPD

Development of a model for the cost-effective care of COPD

Development of a strategy for the care of COPD at the end of life


Strategy for the screening, diagnosis, and surveillance of COPD

Role and delivery of lung function testing – spirometry – in primary care

Spirometry is the basis of the diagnosis and assessment of severity of COPD

GPs receive an incentive payment for getting it done in their patients

GPs have difficulty providing effective spirometry

Schermer TR, et al. Thorax 2003 58:861-6 Eaton T, et al. Chest 1999 116:416-23 Bolton CE, et al. Respir Med 2005 99:493-500 Jones R, et al. Prim Care Respir J 2005 14:169-71 Wolfenden H, et al. Prim Care Respir J 2006 15:252-5


Specialist reporting of Primary Care SpirometryAim: To assess the feasibility and

usefulness to primary care of remote electronic specialist reporting of primary care spirometry

How? Comparison of reporting by primary care clinicians and respiratory specialists of consecutive spirometry tests performed in primary careFunded: Research Support Unit of Lambeth, Southwark and Lewisham Primary Care Trusts


Feasibility and usefulness of specialist reporting?

Feasibility of remote reporting of lung function was assessed by frequency of electronic mailing of completed tests.

Usefulness was assessed by measuring agreement (Cohen’s kappa) between primary care clinicians’ reports and those of specialists.


Feasibility and usefulness of specialist reporting? 6 practices – 312 tests Clinically significant disagreements:

in acceptability of 41% tests (κ=0.07) in diagnosis of 39% tests (κ=0.39) in severity in 35% tests (κ=0.51)

The quality of spirometry in participating practices was so unsatisfactory that remote reporting of tests may be an important means of establishing adequate spirometry Accepted White P, et al Br J Gen Pract 2007.



What is effective in COPD? Smoking cessation Pulmonary rehab Long term oxygen therapy Inhaled drugs

How can they best be delivered? Identify the patient Provide effective structured care


What obstacles to testing structured care interventions in COPD?

Good theoretical models Good examples of other disease models NSFs in a variety of areas have adopted

structured care even with poor evidence

The main concern has been about credibility of an experimental model and sustainability


Key £-costs in COPD

Admissions A&E attendances Out-patient attendances Out-of hours contacts Primary care contacts Indirect costs – time lost from

work, costs of care, costs to carers



Complex intervention Specific goals within an overall strategy

are well supported Uncertainties about key elements No evidence to support the overall

stategy Uncertainties

Sustainability Overall effectiveness of a model of care


Conflicts between policy and research sometimes work!

Modernisation Agency of the NHS

Pursuing Perfection Programme[Institute of Health Improvement in the

US]

Development site for better COPD care at King’s College Hospital


Development of a COPD community initiative in Lambeth and Southwark

Lambeth PCT, Southwark PCT, King’s College Hospital NHS Trust, and Guy’s and St Thomas’ NHS Trust formed a partnership to develop a new COPD pathway

Commissioned a detailed analysis of current COPD patient services and costs

Devised a new COPD pathway across primary and secondary care


COPD Patient Pathway Project

Improve community services for moderate disease and prevent disease progression

Improve hospital and community services for severe disease to reduce admissions, readmissions, and length of stay


COPD Patient Pathway Project

access to 24 hour telephone support and 5 days/wk home visiting for severely affected patients

close follow-up and early discharge of admitted patients

community assessment of all moderate and severe COPD sufferers Diagnostic/severity assessment, smoking

cessation, pulmonary rehabilitation, and drug optimization.



Healthcare commission PCTs to lead improvements Focus on areas of deprivation Access to care Models of structured care Reduce admissions and length of stay Improve access to pulmonary

rehabilitation Improve palliative care of COPD


KCH

GSTTSouthwark PCT

Cluster clinics

Cluster clinics

Other hospitals

PR

SC

PR

SC

Lambeth PCT

24


Evaluation

Admissions and A&E attendances

Quality of life

Smoking cessation

Service use

Outpatient attendance

Use of intermediate care services

Pulmonary rehabilitation

Smoking cessation service

Use of primary care services

Costs

Evaluation

Patrick White KCL

Roger Jones KCL

Craig Davidson GSTT

Barry Gray KCH

Alistair McGuire LSE/KCL


Comparison sites

For admissions and hospital services St George’s Hospital Lewisham Hospital

For quality of life and primary care services Wandsworth PCT primary care teams Lewisham PCT primary care teams


Development of a strategy for the care of COPD at the end of life 25673 deaths in England / Wales 2003

compared to 28749 from lung cancer Mortality in severe COPD between 36%

and 50% at 2 years Heavy burden of symptoms Symptoms are more severe than lung

cancer but services are limited with virtually no end of life care

Connors et al. Am J Respir Crit Care Med 1996;154(4 Pt 1):959-67 Almagro et al. Chest 2002;121(5):1441-8.

Gore et al Thorax 2000;55(12):1000-6. Edmonds et al 2001 Palliat Med 2001;15(4):287-95.



What is the experience of COPD at the end of life

What involvement do GPs have with COPD patients at the end of life

What palliative care needs might these patients have?

How might an intervention be devised to improve end of life care in COPD



Funding has been from Guy’s and St Thomas’ Charity

Partners: Professor Irene Higginson, Dr Polly

Edmonds, Department of Palliative Care and Policy at KCL

Professor John Moxham, Division of Asthma and Allergy, KCL


GPs' views of discussions of prognosis in severe COPD. Most GPs acknowledged a need to discuss

prognosis in severe COPD The palliative care approach of open

communication, whilst seen to be relevant to severe COPD, was not applied routinely

Uncertainty among GPs as to patients’ views of the discussion of prognosis was a barrier

Elkington et al. Fam Pract 2001;18:440-44. Mulcahy et al. Fam Pract 2005;22:538-40.


The health and social service needs of COPD patients in the last year of life

Among 209 respondents (52%) many patients who died from COPD lacked surveillance and received inadequate services from primary and secondary care in the year before they died

Elkington, White, et al Resp Med 2004;98:439-445.

Elkington, White, et al Pall Med 2005;19:485-91


Prospective study of palliative care needs of COPD Identify patients with severe COPD in

practices in Lambeth and Southwark Qualitative study to develop an interview

administered questionnaire Quantitative study of 200 patients with

severe COPD (lung function less than 30% expected) assessing palliative care needs, respiratory QOL, anxiety and depression, pain, use of services, impact on carers.


New work in COPD Screening/ diagnosis/ surveillance

Cluster randomised controlled trial of specialist reporting

Structured care of COPD COPD register / Prognosis and disease

progression End of life research

Follow up study of patients identified in prospective COPD study

Study of communication preferences of patients with advanced COPD with respect to information and prognosis

COPD in primary care - HSCR '07 COPD research in a primary care setting Patrick White King’s...

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