Measures to improve COPD outcomes in Greater Manchester: a multimodal approach

Dr Arpana Verma, Annie HarrisonManchester Urban Collaboration on HealthManchester Academic Health Sciences CentreUniversity of Manchester, UK

Overview

• Setting the scene– Urban health– Who are we

– Rationale for studying COPD• The three studies• Conclusions

Setting the scene

• Greater Manchester– Conurbation of 10 areas– Population 2.6 million– Deprivation– Industrial past and present

Greater Manchester

Index of Multiple

Deprivation Score 2007

Where is this?

www.gapminder.org• Prof Hans Rosling and Google• Free to use “fact tank” • Credit Gapminder as the source

• www.bit.ly/acXjFJ

Wider determinants of health

World Urban vs Rural Population1950-2030

Source: United Nations, Department of Economic and Social Affairs, Population Division (2006).

World Urban Population, 1950-2005 with Projections to 2020 (in billions)

Source: United Nations, Department of Economic and Social Affairs, Population Division (2006).

Manchester Urban Collaboration on Health

VisionVision

“To perform world class research on urban issues for the benefit of

local populations, building real world evidence”

M U C H Manchester Urban Collaboration on Health

EU Commission

€5 million£1.2 million

Urban Health

Knowledge Centre Network

Future

Teaching/Training on Urban Health

Governments

NGOs

Charities

Industry

Tools

The Importance of COPD

COPD and Public Health Tools

• COPD is a complex disease – public health can offer tools to help with evidence-

based decision making• The following demonstrate the utility of the tools

commonly used in the UK as part of routine public health practice– The first is a needs assessment which maps local

needs, demands and service with the evidence-based literature.

– The second is to use a population impact assessment tool to help prioritise interventions in COPD.

– The third is how to evaluate pharmacists to providing support for evidence-based prescribing in COPD.

Healthcare Needs Assessment Of Chronic Obstructive Pulmonary Disease Services In Trafford

A. Verma1, G. Mates2, C. Franco3, L. Davies3, R. F. Heller1, B. Leahy2.

1 University of Manchester2 Trafford Healthcare NHS Trust3 NHS Trafford

Thorax 2007

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idlan

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ands

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nd

area

Smoking prevalence in Great Britain, England, English Regions, Wales and Scotland

1998 2000 2001 2002 2003 2004 2005 2006

0

50

100

150

200

250

300

350

400

450

engl

and

and

wales

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

year

Smoking Mortality Rates for North West region compared with England and Wales

100 99

47

112141

59

105

204

144

191

72 83

0

50

100

150

200

250

value

england and wales

North W

est SHA

Bolton MCD

Bury MCD

Manchester MCD

Oldham MCD

Rochdale MCD

Salford MCD

Stockport MCD

Tameside MCD

Trafford MCD

Wigan MCD

region

Comparative SMR figures for 2006

Series1

Smoking Attributable DeathsGreater Manchester

0

20

40

60

80

100

120

140

Bolton

Bury

Man

ches

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smokingattributabledeaths

Standardised Hospital PrevalenceGreater Manchester

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StandardisedHospitalPrevalence

Questionnaire completed by (n=18)

Practice Nurse,

13, 72%

GP, 2, 11%

Both, 2, 11%

Don't Know, 1,

6%

Results

0

2

4

6

8

10

12

14

16

18

01:01 Smokers Clinic 4 week follow up

• 100% recorded smoking status

• 14/18 (74%) of practices• COPD lead• Nursing resources• COPD register

• Only 8/18 (50%) of practices has COPD trained staff

How does the practice offer smoking cessation support? N=18

At risk group targeted for smoking cessation and then screened? N=18

0

1

2

3

4

5

6

7

8

Not targeted orscreened

Targeted but notscreened

Targeted andscreened

0

2

4

6

8

10

12

14

16

Nurses receivedCOPD training

Nurses receivedspirometry

training

Nurses whoperformedSpirometry

• Only 9/18 (50%) of nurses had received any training in COPD

• 15/18 (83.3%) were trained in spirometry

• 10/18 (55.6%) used it

Who has been trained for spirometry?n=16

• 10/18 (56%) checked diagnosis with spirometry• 17/18 (94%) had access to secondary care• 10/18 (56%) had access to a respiratory specialist nurse• 15/18 (83%) had an agreed management plan with the patient• 16/18 (89%) checked inhaler technique

Education and Management n=18

0 5 10 15 20

Info on condition

What to do

Own illness management

Available support

Fluvac

Pneumovac

Review

No

Yes

Using Population Impact Measures In Chronic Obstructive Pulmonary Disease For Prioritisation Of Resources In TraffordA. Verma1,2 I.Gemmell1 L.Davies2 R.F.Heller1

1 University of Manchester2 NHS Trafford

Journal of Public Health Vol. 34, No. 1, pp. 83–89 doi:10.1093/pubmed/fdr026

The Population Health Evidence CycleThe Population Health Evidence Cycle

Number Needed to Treat (NNT) and the populationNumber Needed to Treat (NNT) and the population

Going from the patient to the populationGoing from the patient to the population

• Population Impact Numbers have been designed to take into account the impact of an intervention on the population as a whole

• Number of Events Prevented in your Population (NEPP)

“the number of events prevented by the intervention in your population”

• Size (and characteristics) of your population

• Frequency of the condition in your population

• Baseline risk of death in next year (or whatever other outcome measure you want to use)

• Relative Risk Reduction (from the literature)

• Best practice treatment levels (from guidelines)

• Current treatment levels in your population

NEPP NEPP

N * Pe * [Pd *] BR * RRRN * Pe * [Pd *] BR * RRR

N = no. of people in population of interest

Pe = prevalence of the disease in the population

Pd = Population with disease (not needed)

BR = baseline risk of a cardiac event in 5 years

RRR = relative risk reduction associated with treatment

AimsAims

In line with the new BTS/NICE guidelines in COPD, we

examined the number of admissions prevented in the

Trafford population aged over 65 years by increasing

the uptake of influenza and pneumococcal

vaccination

DataData

• Population size and incidence

– Office of National Statistics

– Trafford PCTs data

• Relative risk reduction from meta-analyses data

– 0.330.33 for fluvac [Kelly et al 2004]

– 0.480.48 for pneumovac [Nichols 1999]

ResultsResults

• The current level of immunisation in

• >65-year olds for fluvac and pneumovac

– 72% and aim to increase this to 90%

• The population size for Trafford

– Total = 225,000

– Aged >65 = 45,000

– Pe = 90% - 72% = 18% or 0.18

– BR is 4.3 hospitalisations/1000 or 0.0043

N * Pe * [Pd *] BR * RRRN * Pe * [Pd *] BR * RRR

Fluvac

45000 * 0.18 * 0.0043 * 0.33

Pneumovac

45000 * 0.18 * 0.0043 * 0.48

An online tool for calculating PIMs has been developed and is available at

www.phsim.man.ac.uk

ButBut• Trafford average LOS for COPD

– 11.1 days• Cost of a bed day

– £300– Without any intervention

Fluvac (95%CI)

Pneumococcal (95% CI)

Pe 0.18 0.18

BR 0.0043 0.0043

RRR 0.33 (0.27-0.38)

0.48(0.16-0.62)

NEPP 11.5 11.5 (9.3 to 13.8)(9.3 to 13.8)

16.7 16.7 (8.3-24.7)(8.3-24.7)

Potential Cost saving*

£38,000£38,000 £56,000£56,000

*The potential cost savings need to be considered in light of other factors e.g. cost of programmes to improve uptake.

ThereforeTherefore

• If we were to increase the vaccine uptake from 72% to 90% in our >65 year population

• we would prevent 11.5 and 16.7 admissions/year at a cost saving of £38,000 and £56,000/year

• Different populations with differing demographics, immunisation rates and baseline risk will have differing results which will influence policy making decisions

ConclusionConclusion

The utility of PIMs is to help prioritise and implement national guidelines based on recent

evidence and local data by comparing the different cost savings afforded by reducing the

number of admission prevented

Are pharmacists reducing COPD’s impact through smoking cessation and assessing inhaled steroid use?

A. Verma1, A. Harrison1, P. Torun1, J. Vestbo1, R. Edwards2, J. Thornton1

1 University of Manchester, UK2 University of Otago, New Zealand

Respir Med. 2012 Feb;106(2):230-4. Epub 2011 Sep 7.

UK Recommendations

• NICE/BTS COPD 2004 guidelines recommend• COPD patients who smoke should be encouraged to stop at

every opportunity• Inhaled corticosteroid should be used only among patients with

moderate to severe COPD• Pharmacists should identify smokers and provide smoking

cessation advice.

• Methods• A self-completion questionnaire was sent to 2080 community

pharmacists from the 2005 pharmacist census database.

Results

• Of the 1051 (50.5%) respondants• 37.1% mentioned COPD as a risk from

smoking most or every time• 54.5% sometimes or rarely• 19.6% routinely asked about smoking status

when dispensing COPD medication

• Pharmacists with more than 20 years experience were more likely to have read the Guideline compared to pharmacists with 10 years or less (OR: 1.54; 95% CI: 1.13 to 2.10)

• Pharmacists who had read the NICE Guideline (46.8%) were around twice as likely to mention COPD as a risk of smoking, ask about COPD if inhaled corticosteroids were dispensed and ask about smoking routinely if COPD medication was dispensed. (p<0.005).

Results

Yes%

(95% CI)

No%

(95% CI)

Need to improve knowledge on COPD management

81.1(78.6 to 83.4)

18.9(16.6 to 21.4)

Training would be beneficial 91.5(89.7 to 93.1)

8.5(6.9 to 10.3)

Table-1: Community pharmacists’ opinions on improving their knowledge further

Read NICE COPD Guideline

Yes %

(95% CI)

No%

(95% CI)

Ask about smoking routinely if COPD medication dispensed (n=1036)

27.2(23.4 to 31.4)

12.9(10.3 to 15.9)

Ask at least sometimes whether COPD/Asthma diagnosed if inhaled corticosteroids dispensed (n=1041)

11.0(8.5 to 14.2)

6.0(4.3 to 8.3)

Mention COPD at least sometimes as a risk from smoking (n=1042)

49.5(45.1 to 53.9)

22.1(18.7 to 25.8)

Table-2: Relationship between reading the COPD Guideline and compliance with the recommendations among community pharmacists

• NICE guidelines encourage some community pharmacists to carry out smoking cessation and educational interventions– We recommend further dissemination to

encourage other pharmacists of their role

Conclusions

Conclusions for the multi-modal approach

• Resources are limited and reducing in many aspects of healthcare

• A multi-modal approach for COPD is essential• Baseline activity and needs/demands• Prioritisation of interventions• Evaluation of interventions