COPD in primary care - HSCR '07 COPD research in a primary care setting Patrick White King’s College London Department of General Practice and Primary Care

COPD in primary care - HSCR '07 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 in primary care - HSCR '07 COPD 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 4 th cause of mortality globally

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 Change in the profile of COPD COPD has come out of the shadow of asthma 2004 NICE Guideline

COPD in primary care - HSCR '07

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

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07

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

COPD in primary care - HSCR '07

National objectives for improving COPD management 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

COPD in primary care - HSCR '07 National objectives for improving COPD management 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

COPD in primary care - HSCR '07 National objectives for improving COPD management 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

COPD in primary care - HSCR '07 National objectives for improving COPD management 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

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 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 :861-6 Eaton T, et al. Chest : Bolton CE, et al. Respir Med : Jones R, et al. Prim Care Respir J : Wolfenden H, et al. Prim Care Respir J :252-5

COPD in primary care - HSCR '07 Specialist reporting of Primary Care Spirometry Aim: 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 care Funded: Research Support Unit of Lambeth, Southwark and Lewisham Primary Care Trusts

COPD in primary care - HSCR '07 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.

COPD in primary care - HSCR '07 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.

COPD in primary care - HSCR '07 Development of a model for the cost-effective care of COPD 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

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 Development of a model for the cost-effective care of COPD 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

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 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 in primary care - HSCR '07 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 in primary care - HSCR '07 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.

COPD in primary care - HSCR '07 National objectives for improving COPD management 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

COPD in primary care - HSCR '07 KCH GSTT Southwark PCT Cluster clinics Other hospitals PR SC PR SC Lambeth PCT 24 

COPD in primary care - HSCR '07 Evaluation Admissions and A&E attendances Quality of life Smoking cessation Service use Outpatient attendance Use of primary care services Smoking cessation service Use of intermediate care services Pulmonary rehabilitation Costs Evaluation Patrick White KCL Roger Jones KCL Craig Davidson GSTT Barry Gray KCH Alistair McGuire LSE/KCL

COPD in primary care - HSCR '07 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

COPD in primary care - HSCR '07 Development of a strategy for the care of COPD at the end of life deaths in England / Wales 2003 compared to 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): Almagro et al. Chest 2002;121(5): Gore et al Thorax 2000;55(12): Edmonds et al 2001 Palliat Med 2001;15(4):

COPD in primary care - HSCR '07 Development of a strategy for the care of COPD at the end of life 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

COPD in primary care - HSCR '07 Development of a strategy for the care of COPD at the end of life 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

COPD in primary care - HSCR '07 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: Mulcahy et al. Fam Pract 2005;22:

COPD in primary care - HSCR '07 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: Elkington, White, et al Pall Med 2005;19:485-91

COPD in primary care - HSCR '07 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.

COPD in primary care - HSCR '07 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