This article was first published in Primary Care Today
In the UK the number of road deaths has fallen from 8000 per year in 1970 to 2000 per year in 2010, a very pleasing statistic. In the same period deaths from Chronic Obstructive Pulmonary Disease (COPD) fell from 60,000 per year to 54,000 per year, not good, perhaps shocking. This statistic masks the fact that there has been a marked decrease in COPD deaths in men and a marked increase in women.
Do we spend as much money detecting and treating COPD as we do on road safety? Maybe not, but we certainly spend a great deal on acute treatment of COPD. At present, COPD is the second most common cause of emergency admission to hospital and is one of the most costly diseases in terms of acute hospital care, posing a clear resource pressure on the NHS. COPD continues to be responsible for over 90,000 hospital admissions a year which, with a mean duration of stay of 10 - 12 days, is close to a million hospital bed days per year.
Over 800,000 people in England have been diagnosed with COPD however it is estimated that over 3 million have the disease and those cases that are diagnosed are mainly moderate or severe in nature. The direct cost of COPD to the UK healthcare system is estimated to be between £810m and £930m per annum and, without change, is set to grow.
The prevalence of diagnosed COPD is about 1.4% in the UK and the prevalence of reduced lung function is about 10%. So what is happening to create all this cost to the NHS? The answer is that COPD is an increasing health problem and one which many studies have shown to be hugely under-diagnosed. This view is reflected in the British Lung Foundation’s ‘Missing Millions’ campaign, designed to help identify the likely millions of people with undiagnosed COPD. Despite these efforts and the focus on COPD given by World COPD Day, COPD continues to register low in public consciousness and continues to be underdiagnosed by healthcare professionals.
COPD is preventable and treatable, although not fully reversible. Its onset is insidious – indeed a person presenting to his GP with a ‘bad chest’ probably has a 30 year history of COPD but was never diagnosed and was unaware he had the condition. Prompt medical intervention could have prevented further abnormal decline in lung function but 30 years later the person could be left with only 10% of their lung function. At this stage there is no going back. The patient soon places heavy demands on the healthcare system for expensive treatments, often including domiciliary oxygen, to extend their life by a few years, or just a few months in some cases.
In the UK, a spirometry study of adults aged over 35 years suggests that more than 80% of those meeting GOLD criteria for COPD reported having no respiratory diagnosis. Even among those with severe or very severe airflow obstruction, less than half were diagnosed. COPD is often misdiagnosed as asthma due to the overlap of symptoms.
Opportunistic case-finding of patients with symptoms and lifestyle limitation is a practical way to help achieve early diagnosis of COPD which can improve quality of life and reduce NHS costs.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines define the severity of COPD primarily in terms of airflow obstruction, reduced forced expiratory volume in one second (FEV1) and the ratio. While these parameters are useful for indicating the stage of the disease, measurable airways obstruction is not the beginning of COPD. Early COPD is the initial, insidious stages of the disease through to moderate airflow limitation at GOLD Stage II – the earliest stage at which many patients typically first seek medical attention. Smoking intervention and other lifestyle change advice can be useful interventions by the physician as the first treatment of COPD.
The Primary Care Respiratory Society (PCRS) is a good source of information on all forms or respiratory disease, including a useful COPD questionnaire in the article by David Price et al., ‘Earlier diagnosis and treatment of COPD’.
For UK physicians, NICE gives useful guidance in their ‘chronic obstructive pulmonary disease pathway’. The NICE website features a comprehensive cost template including LABA and other medication costs.
It has been shown that primary care spirometry not only increases rates of COPD detection, but it also leads to significant improvements in management, without input from secondary care. Many studies have also shown that primary care spirometry testing increases the number of individuals correctly diagnosed as having COPD, supporting prompt medical intervention and better clinical outcomes. Simpler and faster screening methods for case selection can further improve this.
There is currently debate about the usefulness of screening for COPD in primary care. There are many reasons for objections to spirometry in primary care including:
- Screening for COPD used to require a full spirometry examination. A spirometry session is no trivial test, taking up to half an hour in a busy schedule.
- Primary care spirometry is often performed in the practice by primary care staff who may have had little training in performing spirometry. High quality spirometry requires good training, good motivation for the subject and good spirometers.
- COPD screening using spirometry is not a good use of time or money.
These objections can be overcome by the new generation of rapid COPD screening devices such as the Vitalograph copd-6. These simple to use low cost devices accurately, easily and cost effectively screen out those who do not have COPD. They can also help reinforce the smoking cessation message as some of the new generation COPD screening devices incorporate ‘lung age’ as a parameter.
In making a diagnosis of COPD results from a COPD screener, or indeed a spirometer, should not be used in isolation. It must be recognised that individuals with asthma and COPD show considerable overlap in their responses to bronchodilators and corticosteroids. There is no single diagnostic test for COPD. Diagnosis relies on clinical judgement based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry.
- FEV1/FVC ratio less than 0.70
- FEV1% of predicted less than 80%
In order to screen for COPD a device needs to measure and present:
- FVC (or FEV6)
- FEV1% of predicted
- FEV1 ratio
The key parameters for clinical interpretation include:
- COPD classification (stage I - IV)
- Obstructive index
- Lung age is also useful to motivate smokers
|I: Mild COPD||
FEV1/FVC < 0.7
FEV1 >= 80% predicted
|At this stage, the patient may not be aware that their lung function is abnormal.|
|II: Moderate COPD||
FEV1/FVC < 0.7
50% 7gt;= FEV1 7lt; 80% predicted
|Symptoms usually progress at this stage, with shortness of breath typically developing on exertion.|
|III: Severe COPD||
FEV1/FVC < 0.7
30% <= FEV1 < 50% predicted
|Shortness of breath typically worsens at this stage and often limits patients’ daily activities. Exacerbations are especially seen beginning at this stage.|
|IV: Very Severe COPD||
FEV1/FVC < 0.7
FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure
|At this stage, quality of life is very appreciably impaired and exacerbations may be life-threatening.|
The DH has a strategy which sets out six shared objectives to improve outcomes for COPD and asthma through high-quality prevention, detection and treatment and care services. The six shared objectives set out in the strategy are:
- To improve the respiratory health and well-being of all communities and minimise inequalities between communities.
- To reduce the number of people who develop COPD by ensuring they are aware of the importance of good lung health and well-being, with risk factors understood, avoided or minimised, and proactively address health inequalities.
- To reduce the number of people with COPD who die prematurely through a proactive approach to early identification, diagnosis and intervention, and proactive care and management at all stages of the disease, with a particular focus on the disadvantaged groups and areas with high prevalence.
- To enhance quality of life for people with COPD, across all social groups, with a positive, enabling, experience of care and support right through to the end of life.
- To ensure that people with COPD, across all social groups, receive safe and effective care, which minimises progression, enhances recovery and promotes independence.
- To ensure that people with asthma, across all social groups, are free of symptoms because of prompt and accurate diagnosis, shared decision making regarding treatment, and on-going support as they self manage their own condition and to reduce need for unscheduled health care and risk of death.
The DH points out that ultimately the success in delivery of these objectives is dependent on the widespread use of appropriate preventative strategies and on integrated services being planned around the needs of individuals.
Mild COPD is approximately half the cost to treat than moderate COPD and one tenth of the cost of treating severe COPD. Early detection and intervention will, therefore, significantly reduce the cost of the burden of care to the NHS, improve outcomes for patients and reduce socioeconomic costs.
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. www.goldcopd.com
- Shahab L, Jarvis MJ, Britton J, West R. Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax 2006;61:1043-7. http://dx.doi.org/10.1136/thx.2006.064410
- Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). This guideline partially updates and replaces NICE clinical guideline 12. Clinical guidelines, CG101 - Issued: June 2010 http://www.nice.org.uk/guidance/CG101
- Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ. Misdiagnosis of COPD and asthma in primary care patients 40 years of age and over. J Asthma 2006; 43:75-80. http://dx.doi.org/10.1080/02770900500448738
- Chang J, Mosenifar Z. Differentiating COPD from asthma in clinical practice. J Intensive Care Med 2007; 22:300-09. http://dx.doi.org/10.1177/0885066607304445
- Zielinski J, Bednarek M, Gorecka D, et al. Increasing COPD awareness. Eur Respir J 2006;27:833-52. http://dx.doi.org/10.1183/09031936.06.00025905
- Soriano JB, Ancochea J, Miravitlles M, et al. Recent trends in COPD prevalence
- A Gupta, S Church, S Lacey P232 The early detection of chronic obstructive pulmonary disease. Thorax2010;65:A174 doi:10.1136/thx.2010.151068.33 http://thorax.bmj.com/content/65/Suppl_4/A174.2.abstract
- An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974
- HM Government Reported Road Casualties Great Britain Annual Report http://data.gov.uk/dataset/reported_road_casualties_great_britain_annual_report