West Midlands Key Health Data 2008/09
CHAPTER EIGHT: CHRONIC OBSTRUCTIVE PULMONARY DISEASES:
THE EPIDEMIOLOGY, ECONOMICS AND
QUALITY OF CARE IN THE WEST MIDLANDS
Dr Christopher Zishiri and George Fowajuh
Main Body
7: Environment And Health – Outdoor Air Pollution
9: Predictors Of Emergency Department Use At Neighbourhood Level In The West Midlands
8.1 Introduction
Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term covering a range of conditions that include chronic bronchitis and emphysema. It is a condition characterized by airflow obstruction, which is usually progressive, not fully reversible and does not change markedly over several months1. Although asthma is associated with airflow obstruction, it is usually considered a separate clinical entity. Because of the high prevalence of asthma and COPD, these conditions coexist in many patients, creating diagnostic uncertainty2.
The national commitment to tackle the burden of COPD is evidenced by the Chief Medical Officer’s (CMO) Report for 2004, where he called for the development of National Service Frameworks (NSF) for COPD3. He also re-enforced on immediate action against smoking in support for the 1998 government white paper Smoking Kills. The white paper Choosing Health: Making Healthier Choices Easier10 that was published in 2004. Further developments include the publication of NICE guidelines1 in 2004 and the new General Medical Services contract with the Quality and Outcomes Frameworks with COPD included. The British Thoracic Society report (2006)4 and recommendations from the Health Care Commission report (2006)5 were major influences to the government’s call for the development of a national service framework (NSF) for COPD.
8.1.2 Diagnosis
When the lung tissues are damaged as in the case of COPD, the elasticity of the airways is destroyed, terminal bronchioles collapse and alveoli are damaged obstructing the airflow in the lungs. The diagnosis is suspected on the basis of symptoms that include breathlessness and cough and supported by spirometry2.
8.2 Major Risk Factors
8.2.1 Smoking: Tobacco smoking is the major risk factor for COPD. About half of smokers develop some airflow obstruction and 10 to 20 percent develop clinically significant COPD. About 20% of COPD cases are not attributed to smoking. The risk of COPD also increases with passive smoking and maternal smoking is associated with reduced infant, childhood and adult ventilatory function2.
8.2.2 Air Pollution: Urban air pollution may affect lung function development hence a risk factor for COPD. Exposure to particulate and nitrogen dioxide air pollution has been associated with increased cough, sputum production, breathlessness, impaired ventilator function in adults and reduced lung growth in children2.
8.2.3 Occupation: Numerous litigations have been experienced in the UK between British Coal and coal miners. The final judgement recognised the similarities of effects between coal dust and smoking. Intense prolonged exposure to dust and chemicals can cause COPD independently of cigarette smoking, though smoking seems to enhance the effects of occupational exposure. Exposure to coal and other mineral dust have been implicated in the development of chronic airways obstruction2. This has implications on COPD in the West Midlands with regards to previous coal mining in the region.
8.2.4 Alpha Antitrypsin Deficiency: Alpha antitrypsin deficiency occurs in over 50% of patients with COPD who are below the age of 40 years. It is a rare genetic condition and the best documented genetic risk factor for COPD2.
8.3 The Epidemiology of COPD
8.3.1 ICD10 Codes
Chronic respiratory conditions ICD codes J40 to J44 (Table 8.1) were selected for this analysis to satisfy the definition for COPD.
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8.3.2 Incidence of COPD
The incidence rates for COPD are estimated as the ratio of the number of new cases of COPD and the number of person years at risk (per 1000). Person years at risk are equal to the length of follow up for each member of the cohort. One large international European Cohort has estimated the incidence of COPD to be 2.8 cases/1000/year (CI 2.3 – 3.3)9.
8.3.3 Admissions
COPD contributed one percent of all admissions in the West Midlands during 2007/8. Stroke contributed the same percentage and Ischaemic heart diseases (IHD) contributed 2% of all admissions10. This observation supports the need to give special attention to COPD as a major cause morbidity and disability.
Among all respiratory diseases, COPD is the most common cause of emergency admissions to hospital4. Emergency hospital admissions are higher in more deprived communities than affluent communities. About 30% of patients admitted with COPD for the first time will be readmitted within 3 months and 15% of patients admitted will die within 3 months of discharge. The latter figure varies between hospital according to the number of respiratory consultants and community deprivation status5.
Figure 8.1: Age and sex specific admission rates for COPD in the West Midlands Region 2007-08
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Figure 8.1 shows age specific admission rates for 2007/8 in the West Midlands. In both sexes COPD is less common below the age of 40 years. Just like the rest of the country COPD is common above the age of 40 years and it is more common among men.
Figure 8.2: Age and Sex Directly Standardised Admission rates for COPD per 100 000 in the West Midlands 1997-2008
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Admission rates for males are significantly higher than for females during the whole period from 1997 to 2008 (Figure 8.2). The trends are fairly constant for males and are rising for the females. There is a significantly wide gap between admission rates for males and females with the female trends in admissions rising and narrowing the gap since 2003. Admission rates for females are on the increase which could be a result of the increase in smoking among females during the smoking epidemic.
Figure 8.3: Age and Sex Directly Standardised Admission Rates for COPD per 100,000 for PCTs in the West Midlands 2007-08
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Heart of Birmingham PCT has the highest admission rates followed by Sandwell and Birmingham East and North PCTs (Figure 8.3). Herefordshire has the lowest admission rate, followed by Worcestershire PCT and North Staffordshire PCT. There are significantly wide gaps between male and female admission rates in the majority of the PCTs. Much wider gaps are evident in Heart of Birmingham and Sandwell PCTs.
8.3.4 Prevalence
In England and Wales, some 900 000 people have COPD diagnosed. After allowing for under diagnosis, the true number with COPD is likely to be about 1.5 million. COPD primarily affects people above the age of 45 years and the mean age at diagnosis is 67 years and the prevalence increase with age. It is more common in men than women and is associated with socioeconomic deprivation2.
There is evidence that the prevalence of diagnosed COPD is increasing among women in the United Kingdom. In 1990 it was 0.8% and by 1997 it was 1.4%, whereas in men it seems to have reached a plateau since the middle 1990s. These trends in prevalence probably reflect sex differences in cigarette smoking since the 1970s2.
Some authors believe that COPD is probably the number one chronic disease showing the differential effect between higher and lower social groups8.
Figure 8.4: Trends in Annual Prevalence 2001 - 2007: Age Standardised person prevalence rates per 10,000 for COPD
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Figure 8.4 shows trends in the prevalence of COPD in England as reported by practices in their weekly reporting service for the period between 2001 and 2007. There prevalence has been raising and rose steadily from 2001 to 2004. Since 2004 it has been declining. The prevalence rates are almost double what we expect from the QOF data. This data is dependent on timeliness, accuracy and completeness of reports and has been analysed according to ICD 9 (revised).
Figure 8.5: Unadjusted Prevalence of COPD by Strategic Health Authority 2007 – 2008
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The North and South divide is clearly demonstrated by the regional prevalence for COPD in England (Figure 8.5) with the North East having the highest, followed by the North West and London the lowest. London is characterized by large numbers of immigrants who tend to be younger and hence the lowest prevalence of COPD. The West Midlands is the fourth lowest and is significantly lower than the national average.
Figure 8.6: Unadjusted prevalence of COPD by PCT in West Midlands, 2007 - 2008
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Heart of Birmingham PCT had the lowest prevalence of COPD (Figure 8.6). Although this is an unadjusted prevalence, there are other explanatory factors that include the level of case ascertainment for COPD that may be low and the age and sex structure for the PCT. Warwickshire and Worcestershire are the second and third lowest. The highest is Stoke-on-Trent followed by North Staffordshire PCT and Sandwell PCT.
8.3.5 Mortality
COPD causes about 30,000 deaths each year and it is the third cause of respiratory death in the UK, accounting for more than one fifth (23%) of all respiratory deaths5. Excluding cancers of the respiratory system as major causes of respiratory deaths makes COPD a major cause of death second to pneumonias4. More than 90% of COPD deaths occur in those aged over 65 years. Mortality in the UK shows a strong rural urban gradient with high mortality rates in large conurbations in the North of England. There are also social inequalities with men aged 20–64 employed in unskilled manual occupations being 14 times more likely to die from COPD than those in professional occupations5.
COPD is estimated to be the fourth leading cause of death worldwide and the World Health Organisation predictions suggest that it will set to become the third leading cause by 2020 primarily related to changes in smoking behaviours in the developing world and changes in population age structure3.
Between 2005 and 2007, there were 157,030 registered deaths for both males and females in the West Midlands. Of these deaths 7,154 were COPD deaths and this translates to COPD mortality contributing up to 5% of all cause mortality in West Midlands between 2005 and 200710.
Figure 8.7: Age and Sex Specific Death rates for COPD per 100,000 population in the West Midlands 2007-08.
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Mortality for COPD increases with age in both sexes in the West Midlands (Figure 8.7). Mortality from COPD is rare below the age of 40 years and there are no observable sex differences in mortality at that age. There is a gradual rise up to the age of 50 years and then a sharp rise in mortality is evident thereafter showing higher mortality rates in males than in females and almost twice as much in males after the age of 80 years.
Figure 8.8: Trends in mortality (SMR) from COPD 1993 to 2007, based on England age specific rates 2006.
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Figure 8.8 shows trends in mortality from COPD. The standard rates used are England age specific rates for 2006. Data is based on underlying cause of death. Mortality from COPD has been decreasing over the years nationally and regionally. Mortality has been about 5 times higher in 1993 in the West Midlands males than 2007. Mortality for males in England and females in the West Midlands were both 3 and half times higher than mortality in 2007. By 2007, the Standardised Mortality Ratio (SMR) for the West Midlands males was 117 (17% higher than England SMR) and 80 (20% below the England SMR) for West Midlands females.
Figure 8.9: Mortality from COPD, DSR/100 000 for all persons, 2005-07 pooled, all regions
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Figure 8.9 shows directly standardised mortality rates by region. The North East has the highest mortality from COPD followed by North West and Yorkshire and Humber. This is significantly higher than the national average for both sexes. The East of England has the lowest mortality followed by the South West and the South East. This is significantly lower than the national average for both sexes.
Figure 8.10: Directly Standardised COPD Mortality rates per 100,000 for all ages, pooled 2005-2007 by PCT
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Coventry has the highest directly standardised mortality rate for COPD in the West Midlands (Figure 8.10). Although it is not significantly higher than the next seven PCT below it, it is significantly higher than the rest of the PCTs with Herefordshire having the lowest Mortality Rate.
8.3.6 Quality of Care
The indicators that have been used are only proxies to true quality and only limited to the clinical domain of the quality outcomes framework (QOF). Measuring quality is a complex process which would need much more detailed information that meets all the dimensions of quality.
8.3.6.1 COPD Confirmed by Spirometry
NICE guidelines recommend the use of spirometry in the confirmation of COPD diagnosis in all patients. Air flow obstruction is defined as a reduced Forced Expiratory Volume in 1 second (FEV1). A reduced ratio of FEV1 and Forced Vital Capacity (FVC) such that FEV1 is less than 80% predicted and FEV1/FVC is less than 70%. The percentage of patients who have had a measure of FEV1 test can be used as a proxy measure for the quality of care given to COPD patient.
Figure 8.11: Percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing 2007-08
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Wolverhampton PCT has the lowest percentage followed by Coventry and Heart of Birmingham PCT. Solihull PCT has the highest achievement followed by Herefordshire and Worcestershire. There is no PCT below 92% achievement (Figure 8.11).
8.3.6.2 Influenza Vaccination
The Chief Medical Officer and similarly the NICE guidance for COPD recommend that the pneumococcal vaccine and an annual influenza vaccination should be offered to all patients with COPD. This is another proxy measure for the quality of care given to COPD patients.
Figure 8.12: The Percentage of all patients with COPD who have had influenza immunisation in the preceding 1st September to 31st March by PCT 2007-08
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Figure 8.12 shows that Heart of Birmingham PCT had the highest percentage of COPD patients who had influenza vaccine immunization in the preceding 1 September to 31 March for 2006/7. The lowest was Dudley PCT.
8.3.6.3 Inhaler Technique
Figure 8.13: Percentage of COPD patients receiving inhaled treatment where there is a record that the inhaler technique has been checked in the previous 15 months, 2007-08
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Shropshire County PCT has the lowest percentage followed by Wolverhampton and Birmingham East and North. The highest is Heart of Birmingham PCT followed by Walsall PCT (Figure 8.13).
8.3.6.4 Discharge Destinations
Analysis of 2007 Hospital Episode Statistics for the West Midlands showed that the majority of COPD patients discharged from hospital during 2007 go back to their usual place of residence. A few are sent to private care homes or NHS funded care. Strengthening community care is a priority for COPD care and is one of the Health care Commission recommendations to reduce admissions to secondary care.
8.4 Economics
The impact of COPD on the heath care system cannot be underestimated; it accounts for £800 million in direct health care costs each year3. This equates to £1.3 million per 100,000 populations per year. More than half the costs are related to hospital care and costs are as expected, greater for those with more severe disease. COPD is associated with 24 million lost working days per annum, with the cost of lost productivity estimated at around £2.7 billion3. The current Disease Management Information Toolkit (DMIT) (18th July 2008) was used to analyse the economic effects of reducing admission rates and length of stay for COPD.
8.4.1 Average Length of Stay (LOS)
Figure 8.14: Average length of stay for COPD patients by PCTs in West Midlands, 2006/07
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Coventry PCT, Solihull, South Birmingham, Birmingham North and East, Walsall, Warwickshire, Dudley and Worcestershire PCT have an average length of stay above the England average (Figure 8.14). The cost per bed day is £167. There are potential savings from reducing the average LOS in these PCTs to the England average (Table 8.1)
Table 8.2: Potential Savings from reducing average LOS to the England average (2006 – 2007)
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Table 8.2 shows the potential savings that could have been benefited by the PCTs with average LOS above the England average from reducing average LOS to the England average during the year 2006 - 2007.
The effect of reducing the length of stay is a boost in potential financial gains. Such gains can be injected to strengthen community care.
8.4.2 Admission Rates
Figure 8.15: Admission rate per 100 people in the COPD register by PCT in the West Midlands, 2006/7
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dmission rates in Heart of Birmingham PCT, Birmingham East and North, Walsall, Sandwell, Stoke-On-Trent, South Birmingham, Dudley, Wolverhampton and North Staffordshire are above the England average (Figure 8.15). Reducing admission rates to the England average (Table 8.2) will result in the following potential savings, taking the cost per COPD admission to be £1,707.
Table 8.3: Potential savings from reducing admission rates to the England average 06-07
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Table 8.3 shows the potential savings that could have been benefited if the above PCTs average LOS were to be reduced to the England average during the year 2006- 2007.
Reduction in admission rate can be achieved through patient empowerment to self manage; home based treatment for acute exacerbations, pulmonary rehabilitation, triage for admission and early supported discharge schemes which also reduce the length of stay. Resources saved by reducing the rate of admissions and the length of stay in hospital could be directed towards increasing human and material resources for care closer home for COPD.
8.5 Summary
- COPD is an umbrella term for a group of lung diseases which are characterized by airflow obstruction and these include chronic bronchitis, emphysema. Lung damage over a long period of time impairs air flow and caused breathlessness and cough.
- The major risk factor for COPD is smoking. Other risk factors include air pollution, and alpha antitrypsin deficiency in those with COPD below the age of 40 years.
- An estimated 900,000 people have COPD diagnosed in England and Wales. After allowing for under diagnosis the figure is likely to be 1.5 million. In the West Midlands, unadjusted prevalence was highest in Stoke-on-Trent and lowest in the Heart of Birmingham PCT in 2007/08.
- COPD is the commonest cause of emergency admissions among respiratory diseases. In 2007-08, COPD contributed 1% of all admissions in the West Midlands, just like stroke admissions in the same year.
- COPD kills about 30 000 people in the UK each year. More than 90% of these deaths occur in those aged over 65 years. The trends in mortality are however decreasing. In the West Midlands, mortality from COPD is highest in Coventry and lowest in Herefordshire PCT.
- Proxy measures for quality in 2007/08 show that the West Midlands’ performance was significantly below the national average for Spirometry and influenza vaccination. Within the West Midlands, the Heart of Birmingham PCT was the best performer for Influenza vaccination and inhaler technique.
- Reducing the rate of admission and the length of stay in those PCTs who are above the England average can lead to massive potential savings which can be channelled to improving home based care for COPD.
8.6 Recommendations
- COPD is mostly preventable. Targeted smoking cessation services by socioeconomic deprivation are essential as well as the whole population approach in terms of health promotion.
- It is essential to encourage and support all COPD patients who smoke, to stop smoking. All levels of care should audit their smoking cessation services for effectiveness as a quality improvement program.
- COPD patients must be offered effective management as recommended by NICE to reduce morbidity and mortality from COPD. Explicit care pathways, staff training and Spirometry for screening and diagnosis in primary care are an essential quality improvement package.
- Patient empowerment to self manage, home based treatment for acute exacerbations, pulmonary rehabilitation, triage for admission are linked to improved quality of care and reduced admissions. Early discharge schemes are linked to reduced length of stay due to acute exacerbations as long as there is a treatment package and visits by a nurse. Resources saved by reducing the rate of admissions and the length of stay in hospital could be directed towards increasing human and material resources for home based care.
References and Further Reading:
- National Institute for Health and Clinical Excellence. Management of COPD in adults in primary and secondary care. Guideline 12, 2004.
- Dervareax G. ABC of COPD: Definition, Epidemiology and Risk factors. BMJ 2006; 332:1142-1144.
- Department of Health and Chief Medical Officer. On the State of the Public Health 2004.
- British thoracic Society. The Burden of lung Disease. 2nd Edition. A statistics Report from the British Thoracic Society 2006.
- Health Care Commission. 2006. Clearing the air: A national study of Chronic Obstructive Pulmonary Disease.
- Strong P, Lydick E, Silberman C, et al. The prevalence of COPD: using smoking rates to estimate disease frequency in the general population. Chest 2000: 117; 3545-3595.
- Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease study. Lancet 1997; 349:1498-14504.
- COPD: The lack of National Service Frameworks should not allow us to ignore it. BMJ 2003;326: 1046-7
- Marco R, Accordini S, Corsico AC et al. Incidence of Chronic Obstructive Pulmonery Disease in a cohort of young adults according to the presence of chronic cough and phlegm. Am J Respir Crit Care Med 2007:175; 32-39.
- Department of Health. Choosing Health: Making Healthier Choices easier. November 2004