Chronic Obstructive Pulmonary Disease in the Wessex CLAHRC -Respiratory Theme

1. Chronic Obstructive Pulmonary Disease in the Wessex CLAHRC -Respiratory Theme Dr Lucy Rigge, Clinical Research Fellow Collaboration for Leadership in Applied Health Research and Care (Wessex)

2. Dr Lucy Rigge • Clinical Research Fellow with Theme 1, Integrated Respiratory Care, Wessex CLAHRC. • Medical Doctor with nine years experience, specialising in Respiratory Medicine. • Completing a Doctorate of Medicine with the CLAHRC. • Undertaking database and clinical research projects as part of Doctorate of Medicine. • Work clinically with the Integrated COPD team one day/week to maintain clinical competency and extend knowledge of Integrated Care in COPD.

3. Respiratory Theme • Theme Lead: Dr Tom Wilkinson, Academic Researcher and Respiratory Consultant, UHS • The Theme 1 team: respiratory specialist research nurses and physiotherapists, expert patients, qualitative researchers, GPs and respiratory specialist doctors. • Research Partners: local CCGs, Integrated Care COPD team, other local research networks and CLAHRC Methodological Hub. • Our aims: Through patient centred models of care, the Integrated Respiratory Care theme aims to improve identification, prevention and management of asthma and COPD at the earliest opportunity

4. What is COPD? • The end product of damage to the lungs caused by inhaled particles. • Results in cough, breathlessness, sputum production. • Predominantly caused by cumulative years of cigarette smoking in the UK but there are often also components from work-related exposure to inhaled particles and pollutants. • Associated with poorer levels of general physical and mental health than other common chronic diseases e.g. heart disease or diabetes. • Currently over 1 million diagnosed cases in the UK, COPD is responsible for between 25,000 and 30,000 deaths each year.

5. Chronic Bronchitis

6. Emphysema

7. Why does COPD matter? • Responsible for between 25,000 and 30,000 deaths each year and poor quality of life in Great Britain. • Consistently in the top three causes of non-infectious causes of death worldwide, the number of cases continues to rise…. • Leading cause of unplanned hospital admissions nationally. In Southampton City and Portsmouth you are over 1.5 times as likely to require emergency admission with COPD compared to the national average. • It is not curable but it IS treatable. -Real potential to affect change

8. Project areas

9. Why does an early diagnosis matter? • Our research has shown 58% of people saw their GP with respiratory symptoms in the five years before their COPD diagnosis was made. • This group had frequent primary care contacts and 83% had been prescribed respiratory medications prior to their COPD diagnosis. • There are an estimated 2.5 million undiagnosed COPD patients in the UK. Nihilism has been a significant feature in the past regarding GP opinions in case finding for COPD but attitudes are changing… • Doubts still exist about how case finding could be done practically and the evidence base for the effectiveness of consequent early clinical intervention.

10. Case-Finding Project • In two GP Practices we compared electronic search tools and manual reviews of Practice records to compare these approaches to identifying: • Patients with symptoms of COPD but no diagnosis (case finding) • Patients with a diagnosis but poorly controlled symptoms (complex needs) • Two clinics were held in each practice: • Case finding clinics: Assessment by a Respiratory Specialist Nurse using quality assured diagnostic techniques, suggesting a diagnosis and management plan. • Complex needs clinics: Assessment by a Respiratory Specialist Nurse and Doctor, working alongside the GP Practice staff. A personally tailored education session with a Respiratory Specialist Nurse

11. Case-Finding Project-Results • Case finding clinics: • 60% of patients seen met the criteria for a new respiratory diagnosis • An additional 10% had a non-respiratory diagnosis suggested • Complex needs clinics: • 23% patients received a change in diagnosis • 70% patients received a change in medication. • At six month follow-up, 79% less emergency GP appointments, 29% less routine GP appointments, 48% less practice nurse appointments than in the preceding six months. • Cost neutral after nine months.

12. Patient experience “I would like to say how appreciated I was at having the whole procedure to my tests for my breathing done at my own surgery and all under one roof.” “…and then I met the wonderful nurses...and had a consultation. I was given…tablets and just one inhaler for the morning, WHAT a difference, just after one day I felt better than I ever have!”

13. Risk stratification in COPD • Different management strategies suit different patients. Key to this is often control of other physical health, mental health and social difficulties. • Certain patient groups are more likely to develop severe disease than others, these are the patients we need to target to produce the greatest, lasting, impact on quality of life and spending. • Risk scoring systems already exist but tend to be time consuming to perform and do not intuitively provide a definitive management strategy.

14. Risk stratification study • Strategy developed to identify clinical characteristics using coded information in a format common to all GP surgeries. • Analysis of which clinical characteristics best predict future COPD disease deterioration. • This cumulates in an electronic risk stratification tool which utilises clinical information already routinely collected in Primary Care and does not require clinical time to implement.

15. What’s next? • A new larger study to develop and improve evidence around our case finding, early intervention and complex needs work. • Eight GP surgeries • Developing and validating electronic case finding tools • Including the use of diagnostics acknowledged to be of potential use in NICE guidelines but not yet recommended due to a paucity of evidence. • Incorporating the electronic risk stratification work to inform the choice of patients invited for ‘early intervention clinics’. • Developing an evidence base to answer the queries raised by GPs and the COPD community in general around the effectiveness and cost benefit of case finding and early clinical intervention.

16. Any questions?