Creating a COPD guide helped me understand how to improve a person’s quality of life
Rachna Chowla, a GP from Southwark and one of the clinical leads for Clinical Effectiveness Southwark (CES), shares what she learnt about chronic obstructive pulmonary disease (COPD), when helping to put together some guidance on this area as part of a borough-wide quality improvement programme.
I realised there was a lot I didn’t know about COPD care
When we are talking about lung health, we know that COPD is considerably more common in disadvantaged communities, due to the association with smoking and outdoor air pollution, which both tend to be higher in deprived inner-city or urban areas.
Four or five years ago, we realised that in Southwark, there was a variation in diagnosis and treatment processes for people with COPD and other long term health conditions. We were also aware of the health inequalities in Southwark. COPD is one of the conditions that causes mortality rates to be higher in the deprived areas of the borough – there is a nine year difference in mortality between people who live in more deprived parts of the borough, versus the least deprived parts.
We were aware of a long-standing programme in east London called the Clinical Effectiveness Group (CEG), which supports practices in providing high-quality, evidence-based care which helps improve outcomes for people with COPD and other long term conditions, and were astonished by what they had achieved. Despite the levels of deprivation in their borough, they were able to get good health outcomes for their population. Their borough is similar to Southwark in that there are similar levels of deprivation – by deprivation we mean people having poor housing, or not having had access to education or employment.
Because of the good results in east London, we sought a grant in 2017 from the Health Foundation to adopt and adapt their programme for Southwark. In collaboration with Southwark Clinical Commissioning Group (CCG) and our two local GP federations, we launched our programme.
Part of my role as part of the programme was putting together guidance for the treatment of COPD. As a GP, the experience of putting this guidance together was interesting because I thought I knew how to look after people with COPD. Actually, I had less of an idea than I thought! I understood the importance of spirometry, but I was unclear on which inhalers to prescribe and when to do so. I also thought that inhalers were the centre-piece of treatment, when in fact they're only one small part of the support people with COPD need. Inhalers are important. They help improve quality of life and reduce hospitalisations, but COPD management is more than just inhalers. It involves health-promotion and health-preservation, and patient education around exacerbation and self-management.
Value based decisions can inform the best type of care for people with COPD
To develop the guidance, I used the London Respiratory Network’s COPD Value Pyramid, which helps you to understand the most cost effective solutions for improving the day to day lives of people with COPD. For instance, if a person living with COPD smokes, supporting them to quit will prevent further damage, making it one of the most valuable interventions a healthcare professional can achieve. Ensuring people with COPD get their flu vaccinations should also be a key priority as flu can trigger exacerbations of COPD and lead to hospitalisation.
Pulmonary rehabilitation is also incredibly valuable as a treatment for patients as it improves quality of life, anxiety, depression, exercise capacity and reduces exacerbations, admissions and in some cases, means that patients live longer, better lives.
When I was putting the COPD Clinical Guide together, I framed all the above in a pathway, detailing what to do from diagnosis to end-of-life care. It describes the principles of COPD management and the interventions that reduce risk of exacerbation or delay disease progression that everyone should be offered - stopping smoking, vaccinations and pulmonary rehabilitation, and what a patient should do if their symptoms are worsening. All of these interventions improve the quality of life for a person with COPD.
Pulmonary rehabilitation makes a big difference
Since finishing this work, my view on COPD care has shifted 180 degrees – we need to think about health promotion and prevention, and not simply prescribe inhalers.
The questions for clinicians to think of are, ‘What can we do to reduce risk or delay disease progression?’ and, ‘How can we improve quality of life?’ I don’t think I ever really understood the difference between reducing risk of exacerbations and actually improving quality of life. I thought inhalers were the only factor in reducing the chance of exacerbations; they do to an extent, but pulmonary rehabilitation is the only intervention with evidence of improving exercise capacity, exacerbations, hospital admissions and mortality.
We try to emphasise the high value interventions in the guidance, but I think there is still a lot of awareness building that needs to happen around this. Pulmonary rehabilitation, also known as ‘Better breathing for life classes’ in our area, is an important intervention and should be offered to all those with COPD who have had a recent exacerbation and were admitted to hospital, and to all those with COPD who have a Medical Research Council breathlessness score of 3 or above (in our area, they accept a score of 2 or above, so it depends on local service provision).
Our local pulmonary rehabilitation group have a powerful, visual way of showing the difference these classes can make. They show how at the beginning of a course a person can walk the length of one London bus, by the end of the course, they can walk between six to eight London bus lengths! That is a huge improvement to someone, especially in terms of their independence and quality of life for a person with COPD.
There are psychological and social benefits to taking part in pulmonary rehabilitation. There can be lots of fear and anxiety involved with the breathing restrictions that come with COPD. The classes help a person understand their body and emotions and listen to them. And the social angle makes a huge difference to a person’s quality of life – they meet people in the same boat (so do not feel alone) and meeting people can inspire and support them.
It’s very easy to lose the wood for the trees when working in primary care
Our work was shown to contribute to improvements for patients in Southwark, across a range of clinical areas. The model is now being scaled to cover all of south east London, supporting 203 GP practices who care for a population of 2.2 million people.
In primary care we get a lot of information thrown at us. Everyone’s trying to do their best but there is a lot that we have to juggle, and it’s very easy to lose the wood for the trees. Developing this guidance taught us that by focussing on what’s most beneficial to people who have COPD their care can be improved. Combining high-value interventions with inhalers for patients and involving them in their care improves their quality of life.