Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease causes significantly more mortality and morbidity than other causes of airflow limitation in adults ¹ but is underdiagnosed and under-recognised. The World Health Organization estimates that chronic obstructive pulmonary disease is the fourth leading cause of death worldwide, with 2.74 million deaths in 2000, and this burden is growing rapidly. ² The main cause is cigarette smoking, and the United Kingdom is now experiencing the ravages of a past high prevalence of smoking in its ageing population. Costs for 1996-7 showed that the NHS spent more than £818m ($1.3bn; €1.2bn) on the disease. ³

In the United Kingdom chronic obstructive pulmonary disease accounts for as many as one in eight medical admissions. ¹ Emergency admissions for chronic obstructive pulmonary disease have recently risen dramatically, contributing notably to the hospital bed crisis. ⁴ Annual admissions peak in early January, due, in part, to increased respiratory illness, acute exacerbations, and reduced primary care support over the holidays. ⁵,⁶

The prevalence of chronic obstructive pulmonary disease is greatest in socioeconomically deprived people; the differential effect between higher and lower social groups is perhaps greater for chronic obstructive pulmonary disease than for any other disease. ⁵ The number of undiagnosed people with the condition in the United Kingdom is unknown, but in the United States one estimate is that only 14-46% of all cases are diagnosed. ⁷ Chronic obstructive pulmonary disease is underdiagnosed partly because many people do not consult their general practitioners or do not reveal all their symptoms unless specifically asked. ⁸ Patients often regard their symptoms as a result of age or lack of fitness and do not seek treatment, or they perceive treatment to be ineffective. Surprisingly, people with undiagnosed disease do not necessarily have less severe symptoms than those whose disease has been diagnosed. ⁵

The main advantage of early diagnosis is that patients may be persuaded to stop smoking. One study found that respiratory function, as measured by FEV₁, in people with for chronic obstructive pulmonary disease who continued to smoke declined by more than twice as much per year as in those who had stopped smoking. ⁹ Earlier diagnosis should be encouraged by reviewing smokers with relevant symptoms and re-evaluating people with a diagnosis of asthma over the age of 40, who may potentially have irreversible airways obstruction.

Evidence based approaches ¹³

• Primary care based healthcare professionals with specialist training in respiratory disease, chronic obstructive pulmonary disease treatment, spirometry, and smoking cessation

• Increased level of smoking cessation services

• Spirometry available for screening and diagnosis in primary care of those at risk (smokers with respiratory symptoms, those with asthma aged over 40)

• Registry of patients

• Pulmonary rehabilitation services in primary and secondary care

• Hospital at home and integrated care between primary and secondary care for managing non-life threatening moderate to severe exacerbations

• Palliative care services for terminal disease

• Packages of home support including regular home nursing care and social services for severe disease

Patients with severe chronic obstructive pulmonary disease put the greatest pressure on hospital beds. Interventions such as smoking cessation, pulmonary rehabilitation, and triage for admission or home based treatment for acute exacerbations are linked to improved quality of life and reduced admissions. Early discharge schemes have shown that time spent in hospital due to acute exacerbations can be reduced if patients have support at home in the form of an appropriate treatment package and regular visits from a nurse. ¹⁰ Resources saved by reducing the number of admissions to hospital could be directed towards increasing the number of nurses and nursing time available for home based care.

The government has pledged to reduce health inequalities in its policy statement for the NHS, Saving Lives: Our Healthier Nation. ¹¹ However, the lack of priority at a national level for respiratory disease is leading to inequalities in care at a local level. This may be compounded as national priorities for other diseases and “technologies” distracts attention and resources away from respiratory disease. ¹² Recent well accepted treatment guidelines for chronic obstructive pulmonary disease urge the use of spirometry and reversibility testing for diagnosis and monitoring. ¹ Yet many general practices do not have adequate training or access to this simple and inexpensive procedure. ¹³

We have seen an important change in emphasis, coordination, and resources for coronary heart disease as a result of its national service framework. It is time for a similar approach to respiratory disease. Centrally driven NHS policy on respiratory disease could prioritise local resources needed to manage this condition effectively.

The National Institute for Clinical Excellence, in association with the British Thoracic Society, is currently developing clinical guidelines for managing chronic obstructive pulmonary disease. These are expected to be issued in 2004 and may lead to an improved standard and consistency of care with less variability in practice and outcome, yet delaying service planning until the guidelines are issued will not help people who now have the disease. Those planning to improve the care of people with chronic obstructive lung disease should take heed of recommendations on good practice. Many, good evidence based examples exist of approaches to local coordinated care (see box). ¹³

Making chronic obstructive pulmonary disease a local priority needs leadership and cooperation. The failure to make it a national priority should not prevent us from addressing this growing problem at a local level. If action is not taken now, the problem will add to the increasing pressure on already limited resources, and many people with an unpleasant crippling disease will continue to receive inadequate support and treatment.