Yang Xu, Head of Medical, Respiratory at AstraZeneca UK, highlights the need for ICS leaders to look for opportunities to take a proactive approach to preventing COPD exacerbations
This article has been developed and funded by AstraZeneca UK Limited.
Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease1 and the fifth leading cause of death in the UK.2 Across Europe, only Denmark has higher death rates for COPD than the UK.3
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In addition, the disease places a significant burden on the NHS; pre-pandemic, COPD exacerbations were the second most common cause of hospital admissions4 and had a cost to the NHS of £1.9bn a year.5 COPD was identified within NHS England’s (NHSE) healthcare inequalities improvement programme, Core20PLUS5, as a key focus area requiring accelerated improvement,6 and NHSE has previously estimated that applying best practice could avoid 7,800 deaths each year.7
Low political prioritisation of COPD has not helped.8 A recent Ipsos UK survey of over 200 health policymakers across 14 countries, including the UK, showed that only five per cent see COPD as a priority.8 31 per cent of these health policymakers cannot identify COPD as primarily a lung disease.8
The devolution of more responsibility in England to Integrated Care Systems (ICSs) is arguably a further opportunity – making sure health systems respond to the real needs in their communities. But what would COPD care in a system or services which prioritise COPD look like?
It is crucial to spotlight COPD exacerbations, which have a profound impact that goes beyond the lungs – for instance the risk of heart attack is almost four times higher within the 30-day period after an acute COPD exacerbation, compared to those without COPD.9 Real-world evidence, such as that from the EXACOS study,10 as well as a recent consensus from global experts and patients’ representatives,11 all support a more proactive approach to exacerbation prevention.
“A recognition of the risk that COPD exacerbations pose is vital – even a single moderate exacerbation (defined as an exacerbation which does not require hospitalisation) increases the risk of future exacerbations and mortality. This suggests the need for a proactive approach in primary and secondary care to reduce the risk of future exacerbations.” Professor Mona Bafadhel, chair of Respiratory Medicine at King’s College London, director of the King’s Centre for Lung Health and leading COPD clinician.
Currently, one third of COPD patients in the UK are not reviewed by a respiratory team within 24 hours of emergency hospital admission, leaving them at greater risk of inpatient mortality and more likely to miss out on referral for smoking cessation support or a discharge bundle.12 Following an emergency admission, nearly 33 per cent of COPD patients are readmitted within 28 days of discharge,13 even though readmission has been found to be strongly related to post-discharge mortality.14
“Experts are starting to explore the value of patients receiving a structured review following an exacerbation, and where possible, ensure comorbidities are considered in COPD care. Even after hospital admission, specialist input in secondary care can make a difference to patients.” Jane Scullion, independent respiratory consultant nurse, Leicester.
The need for change has been highlighted by those organisations which supported the National COPD Policy Action Plan: Asthma + Lung UK, the Association of Respiratory Nurse Specialists, the Association of Chartered Physiotherapists in Respiratory Care, the National Pharmacy Association, AstraZeneca and the Primary Care Respiratory Society.15 Their message is clear: we must accelerate early and accurate diagnosis; reduce clinical inertia and focus on prevention; and minimise health inequality and variation in care. With services stretched by covid, transformation will be a significant challenge and we want to provide impactful support to help deliver this change.
“Primary care has a vast to-do list but getting COPD care right can have a huge impact for patients. ICSs should think about how they can support primary care to intervene and give patients the best quality care – the potential benefits for the whole system are immense.” Dr Stephen Holmes, GP and former chair of the Primary Care Respiratory Society.
Another key recommendation from the Action Plan calls out the need to minimise health inequalities and variation in care.15 To help with a better understanding of the scale and details of the task, AstraZeneca, guided by input from respiratory experts, fully funded the South, Central and West Commissioning Support Unit to develop COPD heatmaps resources with the ambition to help policymakers, healthcare professionals, providers, and commissioners to explore the variation in COPD outcomes to help inform clinical practice and commissioning across the UK.
There are clearly identified opportunities to move forward with our approach to COPD care in the UK to help address its ongoing burden. Whatever way systems, services, and healthcare professionals choose to achieve change, we cannot just accept the status quo for COPD care.
Health systems are set up to see events in other conditions, like heart attacks and asthma attacks, as key moments where comprehensive action is vital. It is imperative that ICS leaders look for opportunities to take a similarly proactive approach to preventing COPD exacerbations. Industry, patient associations and the medical community stand ready to support and deliver the necessary change. If we can achieve this, we have the potential to improve patients’ lives and prevent unnecessary deaths.
Veeva ID: GB-40012 | Date of preparation: November 2022
References:
1 GOLD. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2022. [Online]. Available at: https://goldcopd.org/2022-gold-reports-2/. Last accessed: October 2022.
2 NICE. 2018. Resource impact report: Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng115/resources/resource-impact-report-pdf-6602803741. Last accessed: November 2022.
3 International Respiratory Coalition. COPD. Available at: https://international-respiratory-coalition.org/diseases/copd/. Last accessed: November 2022.
4 National Institute for Clinical Excellence. 2015. Health and social care directorate, Quality standards and indicators, Briefing paper, Chronic obstructive pulmonary disease (COPD) update. https://www.nice.org.uk/guidance/qs10/documents/briefing-paper. Last accessed: November 2022.
5 NHS England. Respiratory Disease. https://www.england.nhs.uk/ourwork/clinical-policy/respiratory-disease. Last accessed: November 2022.
6 NHSE. Core20PLUS5. Available at: https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/. Accessed November 2022.
7 NHS England. Overview of potential to reduce lives lost from Chronic Obstructive Pulmonary Disease (COPD). A resource to support commissioners in setting a level of ambition on reducing premature mortality. Prepared by Medical Directorate. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/02/rm-fs-6.pdf. Last accessed: November 2022.
8 AstraZeneca. Data on File. Veeva Approval ID REF-160826. August 2022.
9 Kunisaki KM, et al. Am J Respir Crit Care Med 2018;198:51–57
10 Whittaker H, et al. Frequency and Severity of Exacerbations of COPD Associated with Future Risk of Exacerbations and Mortality: A UK Routine Health Care Data Study. Int J Chron Obstruct Pulmon Dis. 2022;17:427-437
11 Bhutani M, et al. Quality Standard Position Statements for Health System Policy Changes in Diagnosis and Management of COPD: A Global Perspective. Adv Ther 39, 2302–2322 (2022). https://doi.org/10.1007/s12325-022-02137-x
12 National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP). COPD clinical audit 2019/20 (people with COPD exacerbations discharged from acute hospitals in England and Wales between October 2019 and February 2020). 2019. Available at: https://www.nacap.org.uk/. Last accessed: November 2022.
13 Morton K, et al. Evaluation of ‘care bundles’ for patients with chronic obstructive pulmonary disease (COPD): a multisite study in the UK. BMJ Open Resp Res. 2019;6:e000425. doi:10.1136/bmjresp-2019-000425
14 Hartl. S, et al. Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit. European Respiratory Journal Jan 2016, 47 (1) 113-121
15 The National COPD Policy Action Plan. November 2021. Available at: http://arns.co.uk/wp-content/uploads/2021/11/CERTIFIED-National-COPD-Policy-Action-Plan.pdf Last accessed: November 2022.
