Are we optimising non-pharmacological interventions for COPD in the London Borough of Waltham Forest?

Problem

‘NHS Right Care Commissioning for Value: October 2016’ identified that, despite a high spend on primary care prescribing for respiratory (£785,000 in 2015-16), quality outcomes in Waltham Forest were poor (1).Chronic Obstructive Pulmonary Disease (COPD) is the most common lung disease in the world and exacerbations of COPD are a prime cause of hospital admission (2).2,899 patients in Waltham Forest had a COPD diagnosis in 2013/14; 0.1% lower than the London North East and Central Area Team prevalence, and 0.8% lower than the national prevalence (3). In the same period, the admissions rate for COPD in NHS Waltham Forest was 13 per 100 QOF registered COPD patients (3) ; 7% higher than the London North East and central Area Team admission rate, and 17% higher than the national admission rate (3).

Approach

1) To identify the non-pharmacological interventions available locally; the extent of patient access and engagement, and whether this affected patient outcomes. 2) Identify the factors patients and the multi-disciplinary team feel are barriers to referral and engagement with these services.3) Inform improvement of the relevant local pathway, involving patients and key stakeholders in primary and secondary care and community based pharmacy and respiratory teams. A retrospective case control study design will compare a randomly selected representative sample of patients with COPD in the borough who received 1) flu vaccination 2) smoking cessation support with pharmacotherapy and/or 3) referral to pulmonary rehabilitation, and compare with a randomly selected and matched sample of patients with COPD who did not receive these interventions, using hospital admission for exacerbation of COPD as the outcome measure. A focus group including patients with COPD and members of primary and secondary care teams will identify perceived barriers to referral and engagement.The results will inform CCG COPD pathway design.

Findings

We hypothesize that non-pharmacological interventions for the management of COPD are not optimised within the borough. We assume:1) Not all eligible patients are referred.2) Not all healthcare professionals interacting with eligible patients are aware of how to engage eligible patients with these interventions, as current pathways are not clear.3) Referred patients do not engage with the interventions for the optimal period.

Consequences

The London Respiratory Team’s COPD ‘Value’ Pyramid states that non-pharmacological interventions are more cost effective than COPD drug treatment, as they have a better cost per quality-adjusted life-year (QALY) impact on patient outcomes (4).Tier 1: Flu vaccination £1,000/QALYTier 2: Stop Smoking Support with pharmacotherapy- £2,000/ QALYTier 3: Pulmonary Rehabilitation- £2,000 to £8,000/QALYWe do not know whether local provision is achieving optimal benefits. This work intends to inform improvements of local provision.