New JSNA: This is the test site for the new Joint Strategic Needs Assessment

Respiratory

Introduction

Respiratory conditions are diseases that affect the air passages, including the nasal passages, the bronchi and the lungs. They range from acute infections, such as influenza, pneumonia and bronchitis, to chronic conditions such as asthma and chronic obstructive pulmonary disease (WHO, 2015). Respiratory diseases are a major cause of morbidity and death in the UK and worldwide. This JSNA highlights the need for the prevention and early intervention strategies for respiratory diseases and will focus primarily on Chronic Obstructive Pulmonary Disease (COPD) and Asthma.

What do we know?

Chronic Obstructive Pulmonary Disease (COPD) is not one single disease but an umbrella term used to describe chronic lung diseases that cause ongoing limitations in lung airflow. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis.

The most common symptoms of COPD are breathlessness, or a 'need for air', excessive sputum production, and a chronic cough. However, COPD is not just simply a "smoker's cough", but an under-diagnosed, life threatening lung disease that may progressively lead to death.

The primary cause of COPD is tobacco smoke (including second-hand or passive exposure). Other risk factors for COPD include occupational dusts and chemicals (such as vapours, irritants, and fumes) and frequent lower respiratory infections during childhood.

Asthma is a major non-communicable lung disease. When a person with asthma comes into contact with something that irritates their sensitive airways (an asthma trigger), it causes their body to react in three ways:

  • the muscles around the walls of the airways tighten so that the airways become narrower
  • the lining of the airways becomes inflamed and starts to swell
  • sticky mucus or phlegm sometimes builds up, which can narrow the airways even more.

These reactions cause the airways to become narrower and irritated - making it difficult to breathe and leading to asthma symptoms, such as chest tightness, wheezing, or coughing.. The strongest risk factors for developing asthma are firstly genetic - having a parent with asthma, or having a history of (such as eczema or hay fever) or allergies; and secondly environmental triggers such as smoking (active or passive) and environmental pollutants. Whilst nationally 3 people die every day from asthma, two thirds of cases are preventable and with good management of asthma people can enjoy a full and active normal life

Facts, Figures, Trends

COPD is the fifth biggest killer disease in the UK, killing approximately 25,000 people a year in England. Respiratory disease kills one in four people in the UK, and accounts for more deaths each year (153,000) than coronary artery disease (132,000) or non-respiratory cancer (119,000).

Deaths from respiratory disease do not appear to be falling; indeed, the number of females

dying from lung disease has increased by 28% in the last 14 years, while lung cancer has now overtaken breast cancer as the most common cause of cancer deaths in British women today.

About 5.4 million People in the UK are currently receiving treatment for asthma: 1.1 million children (1 in 11) and 4.3 million adults (1 in 12). Although deaths from asthma have plateaued at between 1000 and 1200 deaths a year since 2000, it is estimated that 90% of deaths are associated with preventable factors. Almost 40% of these deaths are in the under 75-age group. Asthma is also responsible for large numbers of hospital admissions, the majority of which are emergency admissions.

In 2011-13, there were 93 premature deaths in Reading from respiratory diseases. This is a rate of 35 per 100,000 people aged under-75, which is now similar to both the national and deprivation decile rate. Reading's pattern of premature mortality rate for men and women mirrors the national picture, with more men dying from respiratory disease. Reading's female mortality rate was below the national rate but has increased since 2008-10, while the male rate has declined (figures 1 and 2).

In Reading 51% of premature deaths were from respiratory disease were considered preventable in 2011-13; this is similar to a national figure of 54% (figure 3).

image1

Figure 1: Under 75 mortality rate from respiratory disease in Reading per 100,000 (male)

Source: Public Health Outcomes Framework (November 2014)

image2

Figure 2: Under 75 mortality rate from respiratory disease in Reading per 100,000 (female)

Source: Public Health Outcomes Framework (November 2014)

image3

Figure 3: Under 75 mortality rate from respiratory disease considered preventable in Reading per 100, 000 (persons)

Source: Public Health Outcomes Framework (November 2014).

In March 2014, the estimated recorded prevalence rates for specific respiratory diseases in Reading were:

  • Asthma - 5.5%; and
  • Chronic Obstructive Pulmonary Disease - 1.0%.

The recorded prevalence of Asthma in Reading reduced slightly from 2013 to 2014, while that of COPD remained the same (figure 4).

image4

Figure 4: Recorded prevalence of respiratory diseases in Reading (2013/14)

Source: Health & Social Care Information Centre; Quality and Outcomes Framework 2013/14

The Quality Outcome Framework measures the recorded prevalence of different conditions and is based on the number of people on GP registers at the end of March. A recorded prevalence rate for Reading has been estimated by using the data from GPs in the Local Authority boundary. This is only a proxy, as it will not include people who live in Reading who are either not registered with a GP or who are registered with GPs outside of the Borough.

National & Local Strategies (Current best practices)

The NHS companion document, "An Outcomes Strategy for COPD and Asthma" sets out the best practice for the NHS and the Local Authority to achieve the relevant objectives from the original strategy, "An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England". "Healthy Lives, Healthy People", recognises the need for a new approach to improving the public's health, which will support prevention.

Breathe! Berkshire West is the respiratory network formed to co-ordinate, integrate and plan services for people with respiratory conditions in the Berkshire west area. The network includes patients and people working in primary and secondary care, community care, medicines optimisation, public health and community pharmacies.

The high-level indicator on mortality from respiratory disease in people under 75 is shared by both the NHS and the Public Health Outcomes Frameworks. As the Outcomes Strategy for COPD and Asthma set out, the areas for action in public health and prevention are:

  • developing prevention strategies for respiratory disease
  • raising awareness of good lung health
  • persuading the public to take lung health seriously
  • ensuring employers (particularly those in 'at risk' environment) are doing all they can to protect staff and encourage good lung health
  • empowering partners/communities to support the process of encouraging prevention
  • targeted campaigns to raise public awareness of respiratory diseases and early symptoms and to encourage early presentation
  • People with COPD and some people with asthma are eligible for the seasonal flu vaccine, and should be made aware by their healthcare professionals.

Current evidence suggests that physical activity participation should be recommended to patients with chronic respiratory conditions, following appropriate pre-screening

As respiratory disease is often associated with other conditions, it is important that both the physical and mental health of people with COPD and asthma are assessed and addressed to ensure that people access care in a holistic way (DOH, 2011).

What is this telling us?

Respiratory disease also places a high burden on the health service, being the most common reason for general practice consultation or emergency medical admission to hospital. A third of the population visits their GP at least once a year because of a respiratory condition.

People with asthma are at high risk of severe disease and complications from flu (or influenza- a respiratory illness that is caused by a virus); though they are not more likely to contract the virus, it can be more serious for people with asthma, even if their asthma is mild or their symptoms are well-controlled by medication. Due to the fact that people with asthma have sensitive airways, influenza can cause further inflammation, triggering asthma attacks and a worsening of asthma symptoms. It also can lead to pneumonia and other acute respiratory diseases. In fact, adults and children with asthma are more likely to develop pneumonia after being infected with the flu virus than people who do not have asthma. Asthma is the most common medical condition among children hospitalized with the flu and one of the more common medical conditions among hospitalized adults (CDC, 2015).

Respiratory disease costs the NHS and society £6.6 billion annually, £3 billion in costs to the care system, £1.9 billion in mortality costs and £1.7 billion in illness costs with COPD, pneumonia and chest infections accounting for more than 2.8million hospital bed-days per year (SEPHO, 2011).

What are the key inequalities?

Respiratory disease is often associated with other conditions; about 40% of people with COPD also have heart disease, and significant numbers have depression and/or anxiety disorders (DOH, 2011).

As with many health conditions, there is a range of inequalities in the outcomes and experience of people with respiratory disease; both mortality and morbidity from respiratory disease in the UK are linked to socio-economic background. Incidence and mortality rates from respiratory disease are higher in disadvantaged groups and areas, leading to worse outcomes and lowering our overall performance (BTS, 2006).

Social inequality accounts for a higher proportion of deaths in respiratory disease (44%) than in any other disease. Research estimates suggest that the Routine and Manual (R&M) occupational group represents almost half of the people with diagnosed or undiagnosed COPD in England. Men from unskilled, manual occupations are fourteen times more likely to suffer COPD than their more affluent peers (BTS, 2006).

Aspects of people's identity and their experiences of inequality interact with each other. For example, people from black and minority ethnic (BME) groups are more likely to live in deprived areas and have negative experiences, both because of their ethnic identity and because of their socio-economic status and living environment. The picture can be said to be worse for smokers from the most disadvantaged sectors of society, where research has shown in some cases (e.g. for people with schizophrenia), smoking prevalence can reach 74%. Around 17% of deaths from flu each year are in people with chronic respiratory disease (DOH, 2015).

What are the unmet needs / service gaps?

All patients with chronic respiratory conditions should be identified and entered on a chronic disease register, to aid intervention strategies such as smoking cessation, influenza vaccinations, anti-pneumococcal vaccination, structured review of prescribing and assessment for entry into rehabilitation programmes.

In the vast majority of cases, lifestyle choices, such as smoking, increases the risk of developing COPD. Respiratory disease could largely be prevented (in the case of COPD and lung cancer) or mitigated (in the case of asthma) by changes in lifestyle behaviours. Smoking cessation is the single most effective and cost-effective way to reduce the risk of developing COPD and stop its progression. Brief tobacco dependence treatment is effective and every tobacco user should be offered at least this treatment at every visit to a health care provider.

Progression of many occupationally induced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases. Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD.

This section links to the following sections in the JSNA:

Long Term Conditions in Children & Young People

Cancer

References:

British Thoracic Society 2nd Edition (BTS, 2006) Burden of lung disease; A statistics report from the British Thoracic Society.

http://www.sepho.org.uk/Download/Public/13157/1/Burden_of_lung_disease2007.pdf

Centres for Disease Control and Prevention (2015): Flu and People with Asthma http://www.cdc.gov/flu/asthma/  

Centres for Disease Control and Prevention: The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services; 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm

Department of Health (2011): An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England

Department of Health (2012): An Outcomes Strategy for COPD and Asthma: NHS Companion Document

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216531/dh_134001.pdf

Jamie F. Burr, Warren Davidson Roy J. Shephard (2012), Physical activity in chronic respiratory conditions; Assessing risks for physical activity clearance and prescription. Journal List Can Fam Physician v.58(7); 2012 Jul PMC3395516 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3395516/ accessed on 19/12/2015

SEPHO (2011): Deaths from Respiratory Diseases: Implications for end of life care in  England http://www.sepho.org.uk/Download/Public/13954/1/Deaths_from_Respiratory_Disease_Final_Report.pdf accessed on 16/12/15

World Health Organisation (WHO) Asthma Fact sheet N°307 (2013)
http://www.who.int/mediacentre/factsheets/fs307/en/

WHO (2016) Chronic obstructive pulmonary disease (COPD) http://www.who.int/respiratory/copd/en/

  

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