Breathlessness

Siân Williams, IMPRESS Programme ManagerJuly 2014

Why breathlessness?

• Looked at a disease - COPD, wanted to start with usual presentation to GP: symptom

• Address multi-morbidity• Address physical and mental

health “parity of esteem”• Improve consistency across specialities

and settings • Integrate approaches locally • Address cost, opportunity cost, value

Source: Mercer et al The Lancet 2012; 380:37-43 (DOI:10.1016/S0140-6736(12)60240-2)

Source: Mercer et al The Lancet 2012; 380:37-43 (DOI:10.1016/S0140-6736(12)60240-2)

Presents opportunity and opportunity cost• Respiratory programme budget

over £4.69bn - up by 6% year to 2012-13

• Cardiovascular programme budget over £6.90bn (0.3% reduction)

• How do you serve local population best with that resource?

• Look at what is most cost-effective (effect on quality adjusted life years) at individual AND population level and also at cost in NHS

Respiratory

35

Quality of life

1

0

.8

A little more on QALYs (Quality-adjusted life years)

30*.5 = 15

QALYs gained

65

.5

Age

QoL 0.8 drops dead age 35Intervention 30 years QoL 0.5

Value for Money triangle & rectangle of population health gain

costs

VfM Value

X

X

X

Population

Health

Gain

Benefit per persone.g. QALYs

Numbers who benefit

Working party drawn from general practice, hospital, psychology, respiratory, cardiology, obesity, mental health specialities

Dr Noel Baxter, GP, Southwark

Dr Angel Chater, Registered Health Psychologist and Sport and Exercise Psychologist, Lecturer in Behavioural Medicine UCL School of Pharmacy Centre for Behavioural Medicine

Dr Mark Dancy, Consultant Cardiologist, North West London Hospitals Trust

Dr Sarah Elkin, Lead in Respiratory Medicine at Imperial College NHS Trust and Honorary Senior Lecturer at Imperial College London

Professor Ahmet Fuat, Professor of Primary Care Cardiology, Durham University, GP, GP Tutor and GPSI Cardiology, Darlington

Dr Steve Holmes, GP Shepton Mallet, Co-chair of IMPRESS

Professor Mike Kirby, Visiting Professor University of Hertfordshire, UK Editor Primary Care Cardiovascular Journal

Dr Basil Penney, GP, Darlington, GPSI Respiratory Medicine and GP Respiratory Lead, Darlington Clinical Commissioning Group

Dr Louise Restrick, Integrated Consultant Respiratory Physician, Whittington Health and Islington CCG, London Respiratory Network Lead

Sam Roberts, Director of Community Academic Partnerships, UCLPartners

Jane Scullion, Respiratory Nurse Consultant University Hospitals of Leicester NHS Trust, Respiratory Clinical Lead Midlands and East

Dr Shahrad Taheri, Bariatric physician and lead for weight management services and senior lecturer in Medicine, University of Birmingham, Birmingham Heartlands Hospital and Royal College of Physicians Action on Obesity nominee

Writers:Chiara De Poli, Department of Management, London School of Economics and Political Science

Siân Williams, IMPRESS Programme Manager

Original meeting facilitated by: Mara Airoldi, Department of Management, London School of Economics and Political Science

Additional contributionsDr Suzanna Hardman, Consultant Cardiologist with an Interest in Community Cardiology, Whittington Health, Honorary Senior Lecturer UCL

Dr David Kingdon, Professor of Mental Health Care Delivery University of Southampton, representing National Clinical Director, Mental Health

Dr Mike Ward, Consultant Respiratory Physician, Co-chair IMPRESS

Dr Vince Mak, Integrated Care Consultant, North West London Hospitals Trust

Maria Buxton, Consultant Respiratory Physiotherapist, North West London Hospitals Trust and Ealing Hospital Trust, Brent

Helen Marlow, Pharmaceutical Adviser NHS England (London)

Sandy Walmsley, Respiratory Nurse Specialist, Solihull Care Trust

Dr Rob Fowler, Consultant physician in respiratory, general and geriatric medicine, Barking Havering and Redbridge University Hospitals NHS Trust

Dr Matt Kearney, Department of Health England

Leah Herridge, Redesign Manager (Long Term Conditions) Pathway Commissioning, NHS Southwark CCG

Mark da Rocha, Service Redesign & Primary Care Development; CVD Lead, NHS Lambeth & Southwark CCGs

Dr Eric Cajeat, NHS Lambeth CCG

Breathlessness: population

Breathlessness affects:• Up to 10% of adult population• 30% of older people• Major cause of attendance at ER but• Only 1% of recorded GP consultations• 2/3 is cardio-pulmonary• Affects 50% obese + 70% obese elderly• Assume all patients anxious to some extent

– how much and why?

Breathlessness: population

• Underdiagnosis of single conditions: COPD, heart failure, depression and anxiety

• Only 18% of people with COPD just have COPD….so one diagnosis may not be enough

• The system not sufficiently effective at diagnosing single conditions

• The scale is large• Solutions will need to: – Segment the population– Take notice of mental health and obesity– Find synergies and build on them– Empower everyone in the system– Avoid expensive solutions such as multidisciplinary

clinics except for those at greatest need

So what does this mean for services?

Breathlessness assessment conclusions about (cost) effectiveness

• Huge gaps in the literature• Little history of sharing evidence across specialities

therefore consensus needed• Identify those who need acute care• Take a good history in a systematic way• It may take more than one consultation: diagnosis isn’t

easy; early diagnosis really isn’t easy• Specifically ask about smoking in an evidence-based

way but don’t ignore non-smokers• Use tests: pulse oximetry, peak flow, spirometry, ECG,

BNP, echocardiography, PHQ4, GPPAQ • Use measurement BMI, waist and neck circumference• Keep the end in sight because intervention success

affected by the assessment process

Breathlessness treatments: (cost) effectiveness

• Strong evidence for treatments for single conditions, much weaker for multiple

• But need more flu vaccination, stop smoking as treatment, support to increase physical activity, referral to programmes of rehabilitation, weight management, NICE-pharmacotherapy

• Locally sensitive: demography, relationships, knowledge, service

IMPRESS breathlessness: resources

• Algorithm and notes to accompany algorithm• Breathlessness IMPRESS Tips (BITs) for:– Clinicians– Patients– Commissioners– Researchers

• Prevalence modelling for breathlessness by condition – How many people with [COPD, HF, anxiety etc] are

breathless– How many breathless people have [COPD, HF, anxiety etc]

So what do we need to do differently when planning?

•Be guided by a right care framework

•Involve many stakeholders

•Foster integration across specialties

Check how local provision matches the IMPRESS algorithm • What do you have in place already• How might you streamline this for every adult with long term

breathlessness? • How does the current system identify and support the

population at risk of poor health outcomes and use of unscheduled care

• Does your analysis highlight gaps that require change? If so, what?

So what do we need to do differently when commissioning?

• Check that primary care has the right: equipment, training, specialist behavioural change services to refer to, time, coding templates

• Provide sufficient programmed rehabilitation

• Ensure equal access by patients with breathlessness, no matter the underlying condition, to high quality end of life care

• Look for opportunities to integrate existing teams and services

• Consider the best allocation of resources to improve your population’s health outcomes

• When specifying breathlessness services, talk to providers about the organisational model and new or extended professional roles and their feasibility and sustainability

Enhance the use of IAPT services

• Apply lateral thinking when activating local resources for breathless people

So what do we need to do differently as clinicians?

• Be as specific and evidence-based with your language as your spirometry/BNP…

• Even if you’ve made a diagnosis, think is that all/only explanation eg intermittent breathlessness….asthma/arrhythmia?

• Discuss with colleagues how to integrate questions into the consultation

• Check how you use well-known tools such as MRC….

MRC example: Grade 3 and 4 (threshold for PR referral)

Is the patient unable to keep up with normal men on the level, but able to walk about a mile or more at his own speed?”

Fletcher 1959

Grade 3: Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

Grade 4: Stops for breath after walking about 100m or after a few minutes on level ground

RCP today

What else?

• Test the algorithm, adapt it, use it• Review rehabilitation programmes eligibility

criteria• Understand how interpretation of tests is

offered: spirometry, echocardiography, BNP in the community and in hospital

www.impressresp.com

Impressions 31 breathlessness