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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)
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.
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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.
Collaboration for Leadership in Applied Health Research and Care (Wessex)
Chronic Bronchitis
Collaboration for Leadership in Applied Health Research and Care (Wessex)
Emphysema
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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
Collaboration for Leadership in Applied Health Research and Care (Wessex)
Project areas
Raising
awareness
and public
education
Patient’s
preferences
for end of life
care
Complex
case
management
Case finding
and accurate
diagnosis
Risk
prediction
and early
intervention
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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.
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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.
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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!”
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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.
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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.
Collaboration for Leadership in Applied Health Research and Care (Wessex)
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.
Collaboration for Leadership in Applied Health Research and Care (Wessex)
Any questions?
Collaboration for Leadership in Applied Health Research and Care (Wessex)