Overview of COPD care in the UK

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Overview of COPD care in the UK

• Dr Stephanie Taylor s.j.c.taylor_at_qmul.ac.uk
• DM in the European context, Bonn, January 2007

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Structure of this talk

• Burden of COPD in UK
• Recent organisational changes in the NHS
• Other policy drivers influencing COPD care in the
  UK
• What do we know about current care for COPD in
  the UK?
• In my second talk Ill discuss the evidence for
  the models of care being promoted in the UK

3
The 2 presentations draw on several projects and
sources

• Lung and Asthma Information Agency, LAIA
• NHS RD SDO funded review and survey of nurse
  service innovations for patients with COPD
• 2nd UK COPD Audit 2003 (RCP BTS)
• Evaluation of COPD innovations in Newham (Kings
  Fund NEL SHA)
• Dr Graeme Wilsons work for the North Central
  London Strategic Health Authority
• The Healthcare Commission
• UK Department of Health publications

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The burden of COPD in the UK

• Estimated 900,000 people diagnosed with COPD
• Estimated further 2 million people who are
  undiagnosed
• 1.33 million emergency admissions in 2004 22.2
  admissions per 10,000 popn
• 85 admissions per 10,000 aged 65-74
• 127 admissions per 10,000 aged 75
• (Sources Health Care Commission, 2006, LIAI,
  www.laia.ac.uk)

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HES data for London 2002 03 by diagnosis
Source Dr G Wilson
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(No Transcript)
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(www.oheschools.org/ohech4pg2.html)
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From Oct 2006
Source http//news.bbc.co.uk
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Other policy drivers influencing COPD care in the
UK

• NHS Plan - 2000
• Case management / Community Matrons
• Independent sector
• 2005/8 HM Treasury Public Service Agreement 2004
• Payment by results 2005
• NICE guidance 2004
• National Service Framework (NSF) 2008

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PSA Objective II Improve health outcomes for
people with long-term conditions

• To improve health outcomes for people with
  long-term conditions by offering a personalised
  care plan for vulnerable people most at risk
• to reduce emergency bed days by 5 by 2008,
  through improved care in primary care and
  community settings for people with long-term
  conditions.

(www.hm-treasury.gov.uk/media/70320/sr04_psa_ch3.p
df)
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Payment By Results

• 2006/7 NATIONAL TARRIFF
• Uncomplicated acute admission with COPD
• 48 hr and over 1709 per admission
• Under 48 hr 342
• Multiplied by a factor for local market forces

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Living with longstanding conditions 2005
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What do we know about current care for COPD in
the UK?

• Secondary care
• Intermediate Care/ Interface Care
• Primary Care

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Secondary care 2nd UK COPD Audit 2003

• Sept Nov 2003
• 96 of all eligible Trusts registered (247 acute
  units from within 187 Trusts)
• organisational data
• data on 40 consecutive patients admitted with
  COPD

• Follow up data on patients for 90 days
• Validity checks
• 8013 admissions (7556 individual patients)
• (Price, Thorax 2006, and www.brit.thoracic.org.uk)
  

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Who is admitted with COPD in the UK? I

• 53 male
• Mean age 71 years
• 40 75 yrs or older
• 36 live alone
• 57 in own hone without social support
• 62 significantly limited ability
• (www.brit-thoracic.org.uk)

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Who is admitted with COPD in the UK? II

• 64 previous admission with COPD
• 72 significant other comorbidity
• 38 heart disease
• 39 current smoker
• (www.brit-thoracic.org.uk)

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What is their clinical condition?

• 33 acidotic (pH gt7.35) on admission
• On 83
• 46 hypercapnic
• 31 hypoxic
• Median FEV1 37 predicted (IQR 28-50)
• On 43 (55 had FEV1 within previous 5 yrs)
• (www.brit-thoracic.org.uk)

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What happens to patients during their admission?

• Of the 23 who are acidotic only 37 get
  ventilatory support
• Reasons for not getting ventilatory support
• Unknown 64
• Medically inappropriate 32
• No facilities 4
• (www.brit-thoracic.org.uk)

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Who looked after them?

• 30 admitted under a respiratory consultant
• 47 discharged by a respiratory consultant
• 72 of all units offer every patients admitted
  with COPD access to a specialist nurse
• 62 of units have NIV available on wards
• (NIV non-invasive ventilation)
• (www.brit-thoracic.org.uk)

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Outcomes of patients with acute admission for
COPD in the UK

• 7.4 die during the admission (IQR 5-11)
• 15.3 die within 90 days of admission (IQR 9-21)
• 31.4 readmitted within 90 days (IQR 22-40)
• I.E. A SIGNIFICANT EVENT FOR 46 WITHIN 90 DAYS
• Median LOS 6 days (IQR 3-11)
• Mean LOS 8.3 days
• 40 stay 7 or more days
• 15 stay 14 or more days
• (www.brit-thoracic.org.uk)

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Does organisation of hospital care influence the
outcome of an acute admission for COPD?
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14 organsational factors

• Ward based system of medical care
• Specialist respiratory ward
• Two consultant ward rounds/day
• Specialist triage integrated admissions policy
• Admissions ward
• EDS
• HDU

• gtmedian ICU beds
• ICU outreach
• Invasive ventilation
• NIV
• Rehabilitation programme
• All COPD pt access to respiratory nurse

(Price, Thorax 2006)
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Organisation and outcomes

• Mortality rates lower if more respiratory
  specialists per 1000 beds
• OR 0.67 (95 CI 0.50-0.90) with 4 or more resp
  consultants per 1000 beds
• LOS lower if
• more respiratory specialists per 1000 beds
• EDS
• Other organsational factors
• (Price, Thorax 2006)

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Early/ Supported Discharge Schemes 1

• 44 of units had access to EDS
• 31 of COPD patients in the audit were eligible
  for EDS
• Type of scheme
• Admission avoidance from AE 5
• ESD lt48 hrs 26
• ESD gt 48 hrs 23
• Combination of above 12
• Unknown 34
• (www.brit-thoracic.org.uk)

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Early/ Supported Discharge Schemes 2

• 64 operate 5 day service
• 27 operate 7 day service
• Median LOS in hospitals with no access to EDS 7
  (IQR 4 11)
• Median LOS in hospitals with access to EDS 6
  days (IQR 3-10)
• Median LOS in EDS 7 days (including inpatient
  days)

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Provision of services
RNS services for COPD Spring 2003
234 individual services
118 providing acute care
Candy, IJNS, 2006
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Primary Care QOF Indicators 04/05

• Diagnosis confirmed via spirometry new pts 78
• Diagnosis confirmed via spirometry all pts 75
• Record of smoking status past 15 months 95
• Smoking cessation advice offered (to smokers)
  94
• Record FEV1 in previous 27 months 69
• Inhaler technique checked 79
• Flu vaccine previous Sept March 88
• of available points achieved for each
  indicator)
• (Source Healthcare Commission, 2006)