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Needs Assessment for Respiratory Diseases in Hertfordshire

Julia Lisk, July 2013

1. IntroductionRespiratory disease is very common and is a major cause of disability and premature mortality. It is the third leading cause of death in England after circulatory disease and cancer. It is also one of the principal reasons for emergency admission to hospital and, as a result, it accounts for a substantial proportion of NHS expenditure.

Although a substantial proportion of respiratory illnesses are caused by smoking, genetic, nutritional, poverty-related and environmental factors also play a part. This makes for a complex picture that requires specific responses in prevention, management and treatment.

2. Defining respiratory diseaseThe World Health Organisation’s (WHO) International Classification of Diseases (ICD) ‘Diseases of the Respiratory System’ chapter includes a broad range of respiratory diseases, such as acute respiratory infections, pneumonia, influenza, bronchitis, emphysema, asthma, chronic obstructive lung diseases, pleurisy, and pneumoconiosis. However, several other conditions treated and managed by respiratory health professionals in the NHS such as respiratory tuberculosis and respiratory cancers appear in various other ICD Chapters.

Between 2001 and 2010 there has been a gradual decline in mortality from respiratory disease in peopleunder age 75 in the East of England and the two Hertfordshire Clinical Commissioning Groups (CCGs)where an average of relevant district data has been calculated (Chart 1). In Hertfordshire the premature (under 75 years) mortality rate from respiratory disease in 2010 was 21 per 100,000 population in East and North Hertfordshire CCG and 17 per 100,000 population in Herts Valleys CCG. The downward trend in the mortality rate is more apparent at a regional level and in NHS Herts Valleys CCG. Only a slight decrease can be seen in NHS East and North Hertfordshire CCG between 2001 and 2010. From 2007 to 2010 NHS East and North Hertfordshire CCG had a higher mortality rate than both the regional average and NHS Herts Valleys CCG.

Chart 1

Source: Health and Social Care Information Centre Indicators Portal

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3. AsthmaThere are around 1,000 deaths from asthma each year in England and Wales, and around 90% of these are believed to be preventable through pro-active healthcare and support for self-management. Healthcare expenditure on asthma is around £1 billion per year. The national prevalence of asthma based on data from GP QOF registers in 2011-12 was 5.9% of the population. In contrast, in the Health Survey for England 2010, 9.5% of adults and children reported having asthma according to this definition, suggesting that many people with asthma are not included in GP registers.

Most of the care for people with asthma is provided in primary care. The chronic disease management delivered by GPs and nurses is likely to have a considerable impact on outcomes such as symptom control, quality of life, physical and social activity, admission to hospital and mortality. Accurate diagnosis and inclusion on a disease register are essential prerequisites for structured pro-active asthma care. Diagnosing asthma is often difficult: there is no single diagnostic measure, as there is in diabetes or hypertension. Accurate diagnosis requires a careful history and often several consultations with home measurement of peak flow and trials of therapy. Use of inhaler treatment without full assessment and follow-up may relieve some symptoms but mask the diagnosis.

In Hertfordshire in 2011-12 the prevalence of asthma was 5.8%, similar to the regional average of 6.2%. North Herts locality had the highest prevalence of 6.6%, and Welwyn Hatfield locality had the lowest prevalence of 4.9% (Chart 2).

Chart 2

Source: Quality and Outcomes Framework (QOF), Health and Social Care Information Centre (HSIC), 2012

There were 17 deaths due to asthma in 2010 in Hertfordshire, meaning a rate of 0.8 per 100,000 persons, compared to 1.1 per 100,000 persons nationally - small numbers mean there would be no statistically significant difference between the local and national rate.(Source: Health and Social Care Information Centre Indicators Portal)

Asthma is the most common long-term medical condition in childhood. Emergency admissions should be avoided whenever possible. Rising emergency admissions for asthma may reflect an overall rising trend for “zero-day” admissions for all children, such as in paediatric short-stay units. However, even short admissions incur substantial costs and have implications for the child’s quality of life. Reducing the number of emergency admissions for these conditions will help reduce the unplanned time spent in hospital by children.

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4. COPDChronic obstructive pulmonary disease (COPD) is a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have difficulties breathing, primarily due to the narrowing of their airways. It is the second most common cause of emergency admissions to hospital, and one of the most costly inpatient conditions to be treated by the NHS. Over 50% of people currently diagnosed with COPD are below retirement age and 24 million working days are lost each year from COPD.

Most people with COPD are unaware they have the condition. Around 835,000 people in England are currently diagnosed with COPD and a further 2.2 million are undiagnosed. Failure to diagnose is not confined to people with very mild disease: more than 50% of people with moderate COPD have not been detected and around 20% of undiagnosed people have severe or very severe disease. In a national audit in 2008, it was found that 10% of people who were sufficiently ill with their COPD to require admission to hospital had not been diagnosed.

Most of the care for people with COPD is provided in the primary care sector. The chronic disease management delivered by GPs and nurses is likely to have a considerable impact on patient outcomes such as symptom control, quality of life, physical and social activity, admission to hospital, and mortality.Mortality is high in patients who are hospitalised: one in twelve will die during an emergency admission; one in six will die within 3 months.

In Hertfordshire in 2011-12 the prevalence of COPD was 1.4%, slightly lower than the regional average of 1.6% (Chart 3). The localities with the highest prevalence were Stevenage and Lower Lea Valley (the southern part of Broxbourne district), at 1.6% each. The locality with the lowest prevalence was St Albans with 1%.

Chart 3

Source: Quality and Outcomes Framework (QOF), Health and Social Care Information Centre (HSIC), 2012

Mortality from COPD (bronchitis, emphysema and other COPD) varies across the Hertfordshire districts. During 2008-2010, Stevenage district had the highest mortality at 12.6 deaths per 100,000 persons, however due to small numbers this was not statistically significantly higher than Hertfordshire’s rate (8.7 per 100,000 persons) or the regional (8.9 per 100,000 persons) average. Three Rivers and St Albans districts had rates that were statistically significantly lower than Hertfordshire and regional averages, see Chart 4.

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Chart 4

Source: Health and Social Care Information Centre Indicators Portal

5. TuberculosisTuberculosis (TB) is the leading cause of death among curable infectious diseases. TB usually causes disease in the lungs (‘pulmonary’), but can also affect other parts of the body (‘extra-pulmonary’). Only the pulmonary form of TB disease is infectious. Transmission occurs through coughing of infectious droplets, and usually requires prolonged close contact with an infectious case. TB is curable with a combination of specific antibiotics, but treatment must be continued for at least six months.

Around 9,000 cases of TB are currently reported each year in the United Kingdom. The majority of cases are notified in urban centres, amongst young adults, those from countries with high TB burdens, and those with social risk factors for TB. In 2011, London accounted for the highest proportion of cases in the UK (39%) followed by the West Midlands region (11%). Similar to 2010, 74% of TB cases were in peopleborn outside the UK and mainly originated from South Asia and sub-Saharan Africa. Rates in the UK born population continued to remain stable at 4.1 per 100,000 population, suggesting continued transmission of tuberculosis in the UK.

In Hertfordshire for the period 2008-10, the average incidence of 7.9 new cases of TB per 100,000 population was much lower than the national incidence of 15.3 per 100,000 (Chart 5). Watford district had the highest incidence, similar to the national average, at 15.5 new cases of TB per 100,000 population. This reflects the fact that the Watford population has a higher proportion of residents in the South Asian ethnic group than other districts in Hertfordshire. Hertsmere, Stevenage and Welwyn Hatfield also hadhigher incidence rates which are approaching the national average in this time period.

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Chart 5

Source: APHO Health Profiles

6. PneumoniaPneumonia is the clinical manifestation of microbial infection within the lung tissue. It is common and canaffect anyone, but it is more common in people at the extremes of age and with any impairment of host defence. Pneumonia causes a spectrum of illness severity. Most people have non-severe illness and are managed at home. About one in five require hospital management. There were over 170,000 hospital admissions for pneumonia in England in 2010-11. A few people need intensive care and some die. Death may be preventable with appropriate management, but often death is the unavoidable outcome of the natural course of other progressive respiratory, malignant or neurological disease.Chart 6 below shows directly age-standardised rates for mortality due to pneumonia in under 75s from 2008-10. Welwyn Hatfield, Stevenage and Hertsmere districts had the highest rates; however none of the districts had a rate statistically significantly different from the Hertfordshire rate, which in turn was not statistically significantly higher than the regional rate.

Chart 6

Source: Health and Social Care Information Centre Indicators Portal

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7. CostRespiratory disease kills one in five people in the UK and economic and health care costs reach over £6 billion, applying this to the Hertfordshire population gives an annual cost of over £100 million. Major respiratory diseases include tuberculosis, pneumonia, asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, lung cancer, occupational lung disease, sleep apnoea, scarring lung diseases and many others.For the financial year 2009-10, the programme spend on respiratory disease per 100,000 population in West Hertfordshire Primary Care Trust (PCT – roughly matches NHS Herts Valleys CCG) was similar to the England average (Table 1). In East and North Hertfordshire PCT (roughly matches NHS East and North Hertfordshire CCG) it was slightly higher. For the specific conditions, COPD spend per 100,000 was lower in both East and North Hertfordshire and West Hertfordshire than the England average. The programme spend for asthma was slightly higher in East and North Hertfordshire PCT, and lower in West Hertfordshire PCT, compared to the England average per 100,000.

Table 1:

2009-10 programme and condition 00

2009-10 programme and condition spend

spend (£million per 100,0population)

Programme spend for respiratory disease (£m per 100,000 population)

Programme spend for COPD (£m per

100,000 population)

Programme spend for asthma (£m per

100,000 population)

East and North Hertfordshire PCT £ 8.83 £ 1.23 £

£ £

1.79

West Hertfordshire PCT £ 8.46 1.10

£ £

1.54

England £ 8.40 1.31 1.76

Source: INHALE Atlas

http://www.inhale.nhs.uk/

8. PrescriptionsRespiratory medications are costly. For the NHS in England, three of the top five most expensive itemsprescribed are types of respiratory inhalers. Inhalers are effective when used correctly, but they are often used incorrectly, and in surveys it has been found that most healthcare professionals do not know how to teach correct inhaler technique. Poor technique can substantially reduce effectiveness and often leads to unnecessary dose increases. At the same time, a patient’s need for medication can be reduced by interventions such as smoking cessation and pulmonary rehabilitation.

Many respiratory medications are prescribed for both asthma and COPD: when analysing prescribing patterns, it is often impossible to distinguish between the two conditions. In the management of asthma, inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA) have a clearly defined role in improving symptom control and quality of life, and in reducing exacerbations and hospitalisations. Reducing high doses of ICS once a patient is stable is important because high doses are associated with risks of pneumonia, diabetes and osteoporosis.

There has been an increase in the number of prescriptions for drugs to treat respiratory conditions. East and North Hertfordshire PCT experienced a larger increase in the number of prescriptions per population than West Hertfordshire PCT over the five year time period 2005-06 to 2009-10, and a slightly larger increase than that in prescriptions at a regional and national level (Table 2). Chart 7 below shows that the increase in East and North Hertfordshire PCT mirrored the regional increase, whereas West Hertfordshire PCT had only a small increase which stabilised in 2008/09 and 2009/10.

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Table 2: Prescriptions of inhaled corticosteroids per adjusted PCT population

Prescriptions of inhaled corticosteroids per adjusted PCT population

2005/06 2006/07 2007/08 2008/09 2009/10

East and North Hertfordshire PCT 0.36

0

0.39 0.45 0.49 0.50

West Hertfordshire PCT .31 0.33 0.37 0.40 0.40

East of England

England

0.37

0.37

0.40 0.45

0.45

0.49

0.49

0.49

0.490.39

Source: INHALE Atlas http://www.inhale.nhs.uk/

Chart 7

Source: INHALE Atlas

9. Hospital admissionsStructured self-management support including an individual action plan is a key element of chronic disease management. People who have an action plan have fewer hospitalisations, fewer emergency department visits, and fewer unscheduled visits to the doctor than people without. Emergency admissions with a primary diagnosis of any respiratory condition (ICD-10 codes J00-J99) in Hertfordshire have been increasing year on year since 2010/11 (Chart 8). These are shown as a rate per 1,000 registered population.

Chart 8

Source: Mede Analytics, analysed by Public Health Information Team, NHS Central Eastern CSU

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10. References and Further InformationTitle and Year Content Website / Author

Quality and Outcomes Framework (QOF) Prevalence Data, 2011/12

Diagnosed COPD and asthma prevalence data collected by GP surgeries available at Practice and CCG/ locality level

Health and Social Care Information Centrehttp://www.hscic.gov.uk/catalogue/PUB08135

Mortality due to respiratory causes, 2001 to 2010Mortality due to COPD and pneumonia, 2008 to 2010

Mortality due to respiratory causes, COPD and pneumonia, directly-age standardised rate per 100,000 population

Health and Social Care Information Centre Indicators Portalhttps://www.indicators.ic.nhs.uk/webview/

New cases of Tuberculosis, 2008 to 2010

New cases of Tuberculosis per 100,000 population

APHO Health Profiles http://www.apho.org.uk/default.aspx?RID=49802

Programme and condition spend, 2009-10

Programme and condition spend for respiratory, COPD and pneumonia

Inhale Atlas

http://www.inhale.nhs.uk/

Prescriptions of inhaled corticosteroids, 2005/6 to 2009/10

Prescriptions of inhaled corticosteroids per adjusted PCT population

Inhale Atlas

http://www.inhale.nhs.uk/

Emergency admissions for respiratory conditions, 2010/11 to 2012/13

Emergency admissions for respiratory conditions (primary diagnosis ICD-10

-codes J00 J99) per 1,000 registered population

Local NHS data from Mede Analytics, not publicly accessible