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Pro-active management

Stephen Gaduzo

GP, Stockport

Plan

• Stratification

• Structured review

• Management of stable disease

• Consistent messages

• Integrated care

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Stratification

Adapted from Sutherland E N Engl J Med 2004; 350: 2689–2697.

FEV

1 (%

of

pre

dic

ted

)

20

50

100

Mild

Severe

Sym

pto

ms

Axis of progression

Lung function normal

Lung function reduced

Asymptomatic

When to start treatment?

3

Early diagnosis & treatment

Annual cost of treatment for COPD patients

Mild £98

Moderate £1021

Severe £3944

Very severe £6475

Prevention – Listen to your lungs

6

4

• Very severe disease (FEV1 <30%)

• On LTOT – or need it but don’t yet have it

• Older (aged >75yrs)

• Reduced mobility / physical activity (MRC)

• Co-morbidities (IHD, CHF, diabetes, depression,

anxiety)

• Previous unscheduled admissions

• Frequent admitters - 60% risk of further admission vs.

10% risk in those having first admission

Garcia Americh Thorax 2006 and 2008

Identifying those at high risk of admission

Severe (FEV1 <50%) or very severe COPD (FEV1 <30%)

Frequent exacerbations ( ≥3 acute exacerbations in the last 12

months especially if associated with hospital admission

Need for NIV

Unremitting symptoms despite maximal therapy

Dependence on oxygen

Co-morbidities

Consider refer for palliative assessment and addition to GSF register

EoL COPD Trigger tool

NHS Salford 2010

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9

School Nurse Training

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Employers engaged by Oct 2012 No. of school nurses

Lancashire FT and partners 113

Liverpool Community Health 90

Bridgewater 100

Stockport 30

Tameside and Glossop 22

Central and Eastern Cheshire 47

Blackpool 25

• Local Authority workforce training • CCG asthma master class • Asthma awareness

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Structured review

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• How many COPD patients have NO

co-morbidity?

• How many COPD patients have NO

co-morbidity?

• 18%

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Most people with any long term condition have multiple conditions in Scotland

Elderly patients

• Compliance with therapy (self)

• MMSE > 24/30 – usual therapy

• MMSE 20-23/30 – may manage inhaled

therapy

• MMSE <20/30 – unable to manage

• Symptom recognition

• Susceptibility to Delirium

Allen SC et al Age and Ageing 1997

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Patient Perspectives

• Under-estimates symptoms

• Under-uses of prophylaxis

• Tolerates poor symptom control

• Has low expectations of therapy

• Confused / lacks knowledge of

correct drug

• Poor adherence

• Bargains with self and you,

trade-off of symptoms vs.

inconvenience

Holgate et al, 2006 BMC Pulmonary medicine 6(suppl 1):S2

Value for money – Cost per QALY

Triple therapy

LABA/LAMA

Pulmonary rehabilitation

Stop smoking support with pharmacotherapy

Flu vaccination in “at risk” population

http://www.impressresp.com/index.php?option=com_docman&Itemid=82

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Pulmonary Rehabilitation

• % of COPD population referred?

• % drop out rate?

Troosters et al ERJ 2010; 19: 24 - 29

Pulmonary Rehabilitation

• % of COPD population referred?

• 1%

• % drop out rate?

• 31%

Troosters et al ERJ 2010; 19: 24 - 29

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Audits

• “Missing millions”

– Age >35, smoker or ex, chest inf/Abx/pred L12m

• MRC 3 or above

– Referred for Pulmonary Rehab?

• Triple Rx (ICS, LABA & LAMA)

– Had smoking cessation, flu jab, considered for PR?

• Exceptions from QOF?

• Prevalence of COPD increasing?

Management of stable disease

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Outcomes Strategy

Respiratory Clinical Pathway Team

Working together to improve respiratory care in the North West

Respiratory health & good lung health

Early accurate diagnosis

Active partnership between HCPs and patients

Chronic disease management

Tailored, evidence-based Rx for the individual

Respiratory Clinical Pathway Team

Working together to improve respiratory care in the North West

Diagnosis Register Education Appropriate treatment Monitor

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Greater Manchester Inhaler Technique

Training

25

http://wires.wessexhiecpartnership.org.uk/video-series/inhaler-technique/

Variation & the power of data

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Stockport PCT

Quit Rate

Stockport PCT 47%

Greater Manchester Cluster Average

46%

NHS NW SHA Average 44%

England Average 49%

Stockport PCT Smoking Prevalence in LTC Patients April 2010-March 2011

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Practice

(reviews)

Exception

reports

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Self management support –

will one size fit all?

• To be activated to be effective self managers our

patients require a high level of knowledge skills

and confidence

• Around 40% of patients are likely to need

additional support to self manage successfully

• By increasing activation step by step our

patients can experience small successes and

steadily build confidence in their ability to self

manage

Hibbard et al Health Serv Res 2005 Hellmans M abstract PCRJ 2012

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Integrated care

• Who’s delivering the service?

• Who’s commissioning it?

• Public Health, Local Authority, Social care?

• What about the patients? Complex needs?

• Consistent messages

• Admission & Discharge bundles

Respiratory Clinical Pathway Team

Discharge bundle

Hopkinson et al Thorax 2011

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Educate and support patients and practice team to

reduce risk of admission

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NW Integrated Care Bundle

Listening to your voice

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Respiratory Clinical Pathway Team

10 messages your Respiratory patients want to give you: 1. Give me consistent messages 2. Know that my COPD journey started a long time before the

diagnosis or before I saw a health professional 3. Realise the time it takes to get my diagnosis right 4. Help me to understand and manage my own care 5. Introduce me and my carer to the right information about my

condition 6. Ensure that when in hospital I get to see a specialist 7. Support groups and networks are very important to me. Make

me aware of them. 8. Provide access to pulmonary rehabilitation to keep me

healthy 9. Show me you care, involve me in my care 10. Boost my confidence in local NHS services that are there to

help me

Full report available on http://www.inspirationnw.co.uk/inspire/respiratory-listening-event

Working together to improve respiratory care in the North West

Aims of NWRCPT:

• Uniform High Level Standards of Care

• Positive Patient Experience

• Confident Commissioning of Effective Services

Patient Passport

• Brings together:

• NICE guidance

• Outcomes Strategy

• Companion document

• Quality Standards

• Patient Voices Top 10

• Patient held

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Walk the 7 steps to the best COPD care

I have COPD:

• I have had my diagnosis confirmed by lung function test performed

by a qualified person

• I feel supported to manage my COPD. I am actively involved in my

care and have the opportunity to discuss how I wish to be treated

• I have been offered help and support to stop smoking

• I know the importance of keeping active and offered the

opportunity to improve my activity through exercise and pulmonary

rehabilitation if appropriate

• I know how and when to take my medicines, and feel able to use my

inhalers and other medicines properly

• I have a written action plan, rescue medication and know when and

how to use them

• I see my doctor or nurse routinely at least once a year for review of

my lung function, medicines and inhaler technique, breathlessness,

activity and oxygen levels, flu vaccination and my action plan