Chronic Obstructive Pulmonary Disease (COPD) is the fifth biggest killer disease in the UK, killing approximately 25,000 people a year in England. Premature mortality from COPD in the UK was almost twice as high as the European (EU-15) average in 2008 and premature mortality for asthma was over 1.5 times higher. Although, deaths from asthma have plateaued at between 1000 and 1200 deaths a year since 2000, it is estimated that 90% of deaths are associated with preventable factors. Almost 40% of these deaths are in the under 75-age group. Asthma is also responsible for large numbers of hospital admissions, the majority of which are emergency admissions.
The NHS Companion Document to the Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma sets out the evidence-based interventions that the NHS can take across the five domains to improve outcomes for people with COPD and asthma.
There are a number of specific interventions that have the potential to reduce premature mortality in people with COPD. Each of these has an evidence base, has consensus support from the clinical community and is recommended in NICE guidance and the Outcomes Strategy for COPD and Asthma.
Improvement in mortality will be achieved through the cumulative impact of evidence-based care across the COPD pathway both in long term treatment and during acute episodes (non-invasive ventilation, pulmonary rehabilitation and controlled oxygen treatment). There are five factsheets within the resource (see 6.2 – 6.6) for the following interventions that will have impact as part of a combined approach.
- 6.1 Prevention
- 6.2 Earlier and accurate diagnosis of COPD
- 6.3 Non-invasive ventilation (NIV)
- 6.4 Home oxygen
- 6.5 Controlled oxygen dosing to minimise oxygen toxicity
- 6.6 Pulmonary rehabilitation
Improving smoking cessation could have a significant impact on reducing prevalence of respiratory disease. Significant improvements in mortality for lung cancer can only be made by earlier diagnosis and smoking cessation in the long run. People with lung cancer normally present with common respiratory symptoms (cough, coughing blood and breathlessness). These patients are nearly always seen by a respiratory physician for diagnosis before referral to oncologists and many are admitted as an emergency because the correct diagnosis is not made. This means that we should put emphasis on early and accurate diagnosis of any unusual respiratory symptoms.
Issue: An estimated 2 million people have undiagnosed and untreated COPD. Failure to diagnose is not confined to mild disease. Studies suggest that between 10 percent and 34 percent of the 115,000 annual emergency admissions for acute exacerbation of COPD are in people whose COPD is undiagnosed. These patients are likely to have had significant disabling symptoms for some time, and the acute admission with its 14 percent risk of death within 90 days could have been prevented by earlier diagnosis and proactive treatment. The NICE Quality Standard and the Outcomes Strategy for COPD and Asthma recommend targeted case finding in those at higher risk of COPD.
Suggested Action: Commissioners to explore opportunities for systematic and opportunistic case finding interventions in targeted populations.
Issue: Currently, incorrect diagnosis of COPD is also very common because the diagnostic test is performed poorly. This results in patients receiving inappropriate and expensive treatments (estimated at £29 million per year in England).
Suggested Action: To ensure accurate diagnosis commissioners may wish to explore opportunities to ensure that those performing and interpreting spirometry for diagnostic purposes have attained a nationally recognised level of competence.
Issue: A Cochrane systematic review found that NIV reduces mortality in people with COPD who develop type 2 respiratory failure with a 1 in 8 life saved. This is reflected in NICE Quality Standard and the Outcomes Strategy for COPD and Asthma recommendations. Despite this there is substantial geographical variation in provision of NIV to eligible patients. The COPD Strategy Consultation Impact Assessment found that NIV is a cost-saving intervention.
Suggested Action: Commissioners to consider using contracting mechanisms to promote greater provision of NIV in line with NICE guidelines.
Issue: Supplemental long term oxygen therapy was shown in the 1980s to improve survival in appropriate patients. NICE guidance recommends that people with COPD who have low oxygen saturations should have a comprehensive assessment of the need for supplemental home oxygen. The NICE Quality Standard and the Outcomes Strategy for COPD and Asthma recommend that such assessments are carried out by a specialist home oxygen assessment and review service. The COPD Strategy Consultation Impact Assessment found the provision of specialist home oxygen assessment and review services to be cost saving.
Suggested Action: Commissioners to use contracting mechanisms to promote comprehensive assessments of the need for supplemental home oxygen by specialist home oxygen assessment and review services.
Issue: High flow oxygen is routinely administered to patients in emergency settings. High dose oxygen is contraindicated in people with COPD exacerbations because it can trigger life threatening respiratory failure. There is substantial audit evidence that oxygen overdosing and toxicity is common in people with acute exacerbations of COPD and that significantly higher mortality rates are seen in patients who receive higher oxygen doses.
Suggested Action: Consider scope for use of decision support tools in ambulances and emergency departments and local care bundles.
Issue: A Cochrane systematic review found that pulmonary rehabilitation reduces mortality and readmission rates when delivered after admission for acute exacerbation of COPD. This is reflected in NICE Quality Standard and the Outcomes Strategy for COPD and Asthma recommendations. There is emerging evidence that pulmonary rehabilitation in stable COPD also improves survival. Despite this there is substantial geographical variation in provision of pulmonary rehabilitation to eligible patients. The COPD Strategy Consultation Impact Assessment found that post exacerbation pulmonary rehabilitation is a cost saving intervention.
Suggested Action: Commissioners could seek to promote uptake of pulmonary rehabilitation.