Respiratory disease

Respiratory diseases are those that affect the lungs and breathing. Though this represents a wide variety of different diseases, this chapter focuses on two common conditions, asthma and COPD.

Asthma

Asthma is a common condition in childhood, also affecting adults, that causes coughing, wheezing, chest tightness and breathlessness. These symptoms can suddenly worsen (known as an “asthma attack”). Asthma triggers include viral infections, cigarette smoke, exercise and allergens such as dust mites and pollen. Treatment is usually with inhaled medications. Severe attacks may require hospital treatment and can be life threatening (NHS Choices: Asthma).

It is not fully understood what causes asthma, though it is likely to be a combination of genetic and environment factors. Asthma is more likely in people who have a family history, had a low birth weight or were born prematurely. Childhood exposure to cigarette smoke, particularly if your mother smoked during pregnancy, also increases your risk of developing asthma

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term for emphysema and chronic bronchitis). These are conditions that are more common in those aged over 35. The symptoms include persistent cough, wheeze and shortness of breath. Unlike asthma, the symptoms of COPD are more constant and usually progressive though similarly, exacerbations can be triggered by respiratory infections (NHS Choices: COPD).
The main cause of COPD is tobacco smoke, being the cause for 80-90% of the western population. Other causes include: a family history of COPD, air pollution and occupational exposures such as prolonged exposure to dust and fumes.

What do we know?

The incidence of asthma varies greatly in the developing world (World Health Organisation, 2013). Currently there are 5.4 million people in the UK being treated for asthma; 1.1 million children (approximately 1 in 11) and 4.3 million adults (1 in 12). It is estimated that 75% of hospital admissions and that as many as 90% of deaths due to asthma are preventable (Asthma UK, 2013). While the majority of people with asthma can manage their disease to avoid severe attacks and hospital admission, asthma attacks can be potentially fatal. In 2010, in the UK, 1143 people died of asthma and in Europe, 3 people per day die due to it.

In 2011, Chronic Obstructive Pulmonary Disease (COPD) ranked as the fourth leading cause of death. The World Health Organisation estimates that 65 million people worldwide have moderate to severe COPD and that more than 3 million people died of COPD in 2011 (World Health Organisation, 2013).

It is estimated that in the UK, there are 3 million people with COPD (4.7% of the population) and that 1 in every 8 admissions to hospital is due to it. This shows the disease burden and predictions are that unless urgent action is taken to reduce risk factors, that total deaths from COPD will rise by 30% in the next decade.

Facts Figures and Trends

COPD

Diagnosis

In 2013/14 there were 1,596 Slough residents recorded by their GP as having COPD. This equates to 1.1% of the population, which is lower than the national average of 1.8% with COPD. This, however, only accounts for those people who present to their local doctor and are diagnosed. According to estimates in 2008 of the expected number of people in Slough with COPD (calculated using data on common risk factors such as smoking), almost twice the number diagnosed with the condition may in fact be living with COPD in Slough, meaning that potentially only 55.4% of those with COPD in Slough being identified by their GP.

Management

Of those diagnosed with COPD in Slough, 88% had their disease reviewed in the last 12 months by their GP, this compares to the national average of 80%. Of those with severe COPD (MRC dysponea score ≥3), 90% had their oxygen saturations measured and documented in the previous 12 months which is slightly lower than the national average of 92.7 % (QOF data for year 2013/2014).

Flu vaccination is important in preventing severe illness in those with COPD. In Slough, the most recent data (year 2013/2014) shows that 84.7% of those with COPD received a flu vaccination. This is higher than the 75% overall flu vaccine uptake target and is higher than the national average of 82%.

Outcome

Emergency admissions for COPD, when calculated as a proportion of people registered with COPD in Slough, show that figures are similar to the national average (11.6% in Slough cf. 12% national average). Mortality rates due to COPD, however, are increasing and are significantly higher than the national average as illustrated in Figure 1.

Figure 1 Deaths from COPD in Slough

Figure 1. Under 75 mortality rate from respiratory disease 2009-11 (provisional)

Source: Public Health England – Public Health Outcomes Framework.

Asthma

Diagnosis

In 2013/14 there were 7,783 Slough residents recorded as having asthma by their GP. This equates to about 5.3% of the population, again lower than the national average of 5.9%. This compares to the number of estimated asthma cases predicted to be in Slough of over 12,000 suggesting that 40% of asthma may remain undiagnosed in the population.

Management

Of those listed on the asthma register of GPs in Slough, 74.2% had had a review of their condition in the previous 12 months, this compares with a figure of 70.6% nationally (QOF data for year 2013/2014).

Outcome

As illustrated in Figure 2, over 2012/2013, 2.4% of those on the asthma register in Slough required an emergency admission to hospital, this is significantly higher than the national average of 1.99%. There is a correspondingly high rate of emergency admissions for children with lower respiratory tract infections 531 per 100,000 patients compared with 400 per 100,000 patients nationally. This could reflect shared risk factorsfor poor respiratory health in Slough.

Figure 2. Emergency hospital admissions due to asthma in Slough

Figure 2. Under 75 mortality rate from respiratory disease considered preventable (2009-11) provisional

Source: Public Health England – Public Health Outcomes Framework.

An additional indicator used to measure health needs is the total premature deaths due to respiratory diseases that are considered preventable. The trend in this outcome shows a reduction since 2007 from rates significantly higher than the national average to rates that are now similar to the national average.

National and local strategies (current best practices)

The Outcome Improvement Strategy for COPD and Asthma was published in 2002 encompassing the National Institute for Health and Clinical Excellence guidelines for both COPD and asthma (NICE Guidleline CG101) and the Public Health Outcomes Frameworks.

These documents outline the following key outcomes and priority actions:

  1. To improve the respiratory health and well-being of all communities and minimise inequalities between communities.
  2. To reduce the number of people who develop COPD by ensuring they are aware of the importance of good lung health and well-being, as well as risk factors.
  3. To reduce the number of people with COPD who die prematurely through a proactive approach to early identification, diagnosis and intervention.
  4. To enhance quality of life for people with COPD across all social groups, with a positive experience of care and support right through to the end of life.
  5. To ensure people with COPD receive safe and effective care, which minimises progression, enhances recovery and promotes independence.
  6. To ensure that people with asthma are free of symptoms due to prompt diagnosis, shared decision-making and on-going support and teaching regarding self-management.

What is this telling us?

Slough has more deaths from respiratory disease than the national average in those under the age of 75 as well as more preventable deaths in those under the age of 75. This is primarily thought to be due to there being a higher male population as well as a younger population than the national average. However, many other factors, such as socioeconomic status, race, ethnicity, smoking status, occupation, housing conditions etc. may play a part.

Slough has a lower prevalence of asthma than the rest of East Berkshire and the QOF indicators for asthma are not statistically different to that of Berkshire and England.

For COPD however, Slough has a slightly higher prevalence of disease than the rest of East Berkshire. The CCG values for the percentage of QOF indicators met for asthma and COPD (that means how the patient is monitored) are below the Berkshire and national average.

What are the key inequalities?

Lung disease is a major contributor to health inequalities.

Socioeconomic status

It has been shown that those in the lowest socioeconomic groups are up to 14 times more likely to suffer from a respiratory disease than those in the highest group (Department of Health, 2011).

Ethnicity

The Department of Health’s ‘Outcomes Strategy for Chronic Obstructive Pulmonary Disease and Asthma in England (2012)– Assessment of the Impact on Equalities’ raises the issue of whether current respiratory disease services take into account their patients' cultural differences. Research has shown that a patients' ethnicity can play a major factor in how well their respiratory condition is understood and in how compliant a patient may be with respect to self-management.

There are a number of other factors which may contribute to inequalities:
  • low education and literacy levels
  • cultural differences mentioned above, including language barriers i.e. material needs to be translated
  • populations not being aware of their symptoms potentially leading to a chronic disease and preventable death.

What are the unmet needs/service gaps?

The main underlying cause of COPD is smoking. Smoking is also known to be a major trigger for some cases of childhood asthma, as well as exacerbating acute attacks. Approximately one in five adults in Slough are estimated to be current smokers.

While the recorded prevalence of COPD according to GP registers is 1.1%, it is estimated that the true prevalence of COPD in Slough is 1.8%, which means there may 1,000 cases of undiagnosed COPD in the borough. This highlights the need to educate people and therefore encourage them to attend their GP as soon as they have any symptoms, as early identification is essential to ensure appropriate management and follow-up.

Pulmonary rehabilitation has been proved to improve day-to-day living as well as help to reduce the number of acute hospital admissions for COPD. Therefore an increase in these services would aid a decrease in unnecessary hospital admissions and preventable mortality as well as improve people’s quality of life.

Recommendations for consideration by other key organisations

  • Continue work to reduce the burden of smoking including continuing to disseminate the message regarding the benefits of stopping smoking.
  • Improve the awareness of COPD and asthma in the community.
  • Improve the diagnosis of chronic respiratory diseases in Slough.
  • To continue improving integrated care programmes for those with long term respiratory conditions i.e. COPD and asthma.
  • To provide a pulmonary rehabilitation service that reaches out to as many people who require it as possible.
  • For more information and training to be provided to patients and their family members regarding self-management.