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Cutting COPD admissions: An introduction

Professor Mike Roberts sets the scene for community COPD services and the challenges they face

Professor Mike Roberts sets the scene for community COPD services and the challenges they face

Chronic obstructive pulmonary disease affects an estimated 10% of the UK population over the age of 45 and accounts for about 30,000 deaths a year.

There are about 1.5 million consultations in primary care each year for COPD. It is thought to be the most common diagnosis in emergency admissions to hospital and the second biggest use of inpatient bed-days in the NHS.

About 24 million working days are lost to sickness annually because of this disease and the direct cost to the NHS is just under £1bn a year, with about half of these costs relating to hospital admissions.

The 2008 national COPD audit by the Royal College of Physicians, British Thoracic Society and British Lung Foundation recorded data on the process of care and outcomes for nearly 10,000 acute admissions, as well as data from GP practices. This details the care given to a sample of just under 3,000 COPD patients in the year prior to their admission.

The national picture emerging from this audit raises many concerns. Almost 14% of admitted patients die within the following 90 days and a further 33% are readmitted. On a more encouraging note, 18% of admissions are entered into facilitated discharge schemes, with many having stays of less than three days – resulting in a reduction in median length of stay compared with the previous audit of 2003.

The key question, though, is what can be done to reduce admissions and prevent the dramatic mortality and morbidity associated with serious COPD exacerbations?

Data from the GP survey included in the national audit may offer suggestions for opportunities for intervention. In the sample analysed, in the year prior to admission the median number of exacerbations for a patient was three, and the median number of contacts with their GP practice was 12. In addition, during the four weeks leading up to their admission, 74% of patients contacted their GP and 31% were seen three or more times.

In contrast, the median number of contacts with the out-of-hours service during that preceding year was zero – yet more than 50% of these patients had been admitted to hospital during those 12 months and 33% would be readmitted within the next three months.

So it is evident that community-based services have the opportunity to make interventions during the month before an admission – but what form should these take?

Making better use of targeted interventions, as described in this issue of Practical Commissioning, may be the key to reducing admissions by aborting exacerbations at source. The evidence for effectiveness for nurse-led prevention programmes and self-management schemes has until now been less than convincing, so it is encouraging to read of innovative projects with claims of success.

What is now required is rigorous independent evaluation of such interventions to the level demanded of a randomised trial. Strategies proven to work with a strong evidence base can hen be implemented across the UK.

Professor Mike Roberts is a consultant respiratory physician at Whipps Cross University Hospital NHS Trust and chair of the National COPD resources and outcomes project steering group at the Clinical Effectiveness and Evaluation Unit, Royal College of Physicians

Further reading

The Burden of COPD in the UK

• Effing TW, Monninkhof EM, van der Valk PDLPM et al. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2007, issue 4, art no: CD002990 DOI: 10.1002/14651858

• Taylor SJ, Candy B, Bryar RM et al. Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systematic review of evidence. BMJ 2005;331:1468-5833

• Royal College of Physicians National COPD Resources and Outcomes Project (NCROP) – go to www.rcplondon.ac.uk and click on Clinical Standards

Cutting COPD admissions: an introduction

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