The multidisciplinary team (MDT) management of chronic obstructive pulmonary disease in the community (2019)

Type of publication:
Conference abstract

Author(s):
*Ali A.; *Khan T.; *Ahmed J.; *Sesan A.; *Moudgil H.; *Makan A.; *Nawaid A.; *Ibrahim J.; *Crawford E.; *Srinivasan K.S.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2019; vol. 199 (no. 9)

Abstract:
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by progressive airflow limitation that is not fully reversible. It encompasses chronic bronchitis and emphysema. This condition is both treatable and preventable. The incidence of COPD in the UK is estimated to be 3 million out of which 900,000 are diagnosed and 2 million remain undiagnosed. Acute exacerbation of COPD is one of the most common causes of emergency hospital admissions with 115,000 admissions per year with a mortality rate of 12 deaths during hospital stay and 6 dying within 90 days of admission.1&2 In the current state of increased healthcare costs related to hospital admissions, there is a service need to manage patients with long-term conditions in the community through development of specialist teams. The multidisciplinary community team consists of specialist nurses, doctors, therapists and community matrons who deliver services through community clinics, domiciliary visits, pulmonary rehabilitation and MDT meetings[3]. Studies have shown the benefits of promoting self-management and providing care closer to home in terms of reducing unnecessary primary care contacts as well as hospital admissions; thereby reducing mortality [4]. Aim The primary aim was to evaluate the role of MDT in reducing or preventing hospital admissions and secondary aim was to look at overall mortality in this cohort. Method(s): This was a retrospective study looking at the clinical notes and MDT letters for all patients with COPD (with post bronchodilator FEV1 of <70%) discussed in a local MDT meeting at a District General Hospital in the UK. Data on mortality and hospital admissions was obtained from our Clinical Portal, which is an electronic patient information system. Result(s): 151 patients were discussed at the local MDT meeting. 55.6% of females (graph 1) with a mean age of 72 years. After discussion at MDT, the number of hospital admissions were either reduced or remained the same in 65% (n= 98) but only 28% (n=42) of patients had more admissions. Data was not available for 9 patients. 64% (n=96) patients are alive 3 years from the discussion at the MDT meeting. Conclusion(s): Our study suggests that, the approach of community based MDT management of patients with COPD has got the advantage of reducing the healthcare expenditure on this cohort of patients, with no negative effect on mortality. As such, we propose these services to be funded in the near future.

‘getting it right first time’ (GIRFT) in the management of COPD (2019)

Type of publication:
Conference abstract

Author(s):
*Ahmad N.; *Crawford E.; *Srinivasan K.; *Moudgil H.

Citation:
Thorax; Dec 2019; vol. 74

Abstract:
Background GIRFT identifies medicine optimisation to improve efficiencies and cost savings. Reducing prescription of High dose inhaled corticosteroids (HD-ICS) in chronic obstructive pulmonary disease (COPD) helps improve patient care by reducing the incidence of pneumonia. A previous work carried out by this group showed an association between HD-ICS prescriptions and the incidence of pneumonia in COPD patients locally, at the primary care level (Ibrahim J et al,Thorax 2018;73:A114-A115). Following this work, a protected learning time event was held in October 2017 for the region’s general practitioners to highlight the local COPD guidelines, role of community respiratory MDT and a protocol for weaning COPD patients from HD-ICS inhalers. Aim Primary aim was to demonstrate an achievement in cost savings from reduction in pneumonia admissions coupled with reduced HD-ICS prescriptions. Hence, we compared the incidence of pneumonia in COPD patients and HD-ICS prescriptions between April-September of 2017 (P1) and 2018 (P2) in the region of Telford and Wrekin clinical commissioning group. Method Data were obtained on all hospital admissions for pneumonia between April-September 2018 with a secondary diagnosis code J44 indicating COPD, from the information desk of the clinical commissioning group. For the purpose of comparison, we had the data from previous year for the same time period. We obtained data on HD-ICS prescriptions from openprescribing.net Results There were 97 pneumonia admissions in P2 v 123 in P1, thereby indicating an absolute reduction of 21%. The total cost of pneumonia admissions in P2 was 337,233 v 463,779 in P1, thereby achieving cost savings of 126,546 over a period of 6 months. There were 300 less HD-ICS prescriptions in the 14 general practices during P2 as compared to P1. 4 practices with the highest proportion of COPD patients, achieved most reductions in HD-ICS prescriptions (reduction by 281 prescriptions) and at the same time accounting for 32 less pneumonia admissions. Conclusion GIRFT objectives can be achieved through engagement with primary care. In this respect, it is important to achieve integration as we have done in our area. Our effort fully supports development of new care models to achieve efficiencies within the local health economy.

Link to full-text [NHS OpenAthens account required]

Domiciliary NIV (DOMNIV) in a real world setting: A retrospective study in a District General Hospital (2019)

Type of publication:
Conference abstract

Author(s):
*Craik S.; *Nasir A.; *Ali A.; *Moudgil H.; *Srinivasan K.; *Makan A.; *Crawford E.; *Wilson J.; *John N.; *Ahmad N.

Citation:
Thorax; Dec 2019; vol. 74 (Suppl 2).

Abstract:
Introduction: DomNIV in patients with chronic Type 2 respiratory failure results in improved survival. HOT-HMV study produced encouraging results in patients with COPD treated with home oxygen and DomNIV. [Murphy et al, JAMA, 317(21), 2177-2186] DomNIV usage with or without oxygen has been prevalent in our hospital setting over for 10 years. Objective Our primary aim was to look at the indications for prescription of DomNIV in our local hospital. Our secondary aim was to look at overall unadjusted mortality in this cohort and in particular any relationship with different types of oxygen provision.
Methods: We collected data on all patients who have received DomNIV from 2008-2018 with or without oxygen prescription from our local database. Data on mortality was obtained from our Clinical Portal. We used MS Excel and Vassar stats (http://vassarstats.net/) for statistical analysis.
Results: 105 patients commenced DomNIV; 60% were female with a mean (SD) age of 61 (13) years. Indications were Obesity hypoventilation (OH), Overlap syndrome, COPD, Neuromuscular disease, Bronchiectasis and others. 40% of patients did not receive oxygen with DomNIV (wO2), 36% received long term oxygen therapy (LTOT), 15% received overnight oxygen (OO2) and the rest received PRN oxygen. 43% of patients (N=45) died during the study period, of these 40% (N=18) died within the first 12 months. 29% died with LTOT versus 17% wO2 and 0% with OO2 in the first 12 months. This was statistically significant between LTOT and OO2 groups: RR 0.71 (95% CI 0.58-0.87), and also between wO2 and OO2 groups: RR 0.83 (95% CI 0.72- 0.95).
Conclusion: Majority of patients received DomNIV treatment for OH; 36% (N=38) had received long term oxygen therapy (LTOT) along with DomNIV; Patients receiving overnight oxygen with DomNIV survived longer compared to those who had it as LTOT or who didn’t have any oxygen at all.

Link to full-text [NHS OpenAthens account required]

Inhaled corticosteroids and pneumonia in COPD at primary care level (2018)

Type of publication:
Conference abstract

Author(s):
*Ibrahim J.; *Ali A.; *Zeb M.; *Crawford E.; *Makan A.; *Srinivasan K.; *Moudgil H.; *Ahmad N.

Citation:
Thorax 2018;73(Suppl 4):A114

Abstract:
Background Association between inhaled corticosteroids and pneumonia in COPD population is well known.1 And the risk of pneumonia is greatest with the use of high dose inhaled corticosteroids (HD-ICS).2 Hence, further work to reduce the prescription of HD-ICS should be informed by local practices. Aim We aimed to assess the incidence of pneumonia in COPD patients based at primary practices in our region according to their HD-ICS prescriptions. And thereby develop methods to safely wean off HD-ICS in this population. Methods Data was obtained on all hospital admissions for pneumonia between April-September 2017 with a secondary diagnosis code of J44 indicating COPD, from the head of information at our clinical commissioning group. We divided this data at a general practice level. We also obtained data on prescription of HD-ICS at each of the general practices till September 2017 from openprescribing.net. Statistical results were obtained from MS Excel and Vassar Stats. Results There are 14 general practices in the region. There were 123 pneumonia admissions to hospital with a secondary diagnosis of COPD. This included 50% males (n=62) with a mean age (SD) of 75 (9.7) years. There were 5 practices with >10 pneumonia admissions during this period and when compared with those with <10 pneumonia admissions, the median (IQR) COPD population was 107 patients (103-126) v 47 patients (32-69) [p<0.05] with a median (IQR) use of HDICS prescriptions 239 (170-290) v 108 (86-172) [p<0.05]. Conclusion Our data show an association between HD-ICS prescriptions and pneumonia in COPD population at a primary care level in our region. Having looked at the data including GP practices with higher prescriptions of HD-ICS, we have developed an algorithm (figure 1) to wean patients off HD-ICS while at the same time promoting awareness through local interest group meetings. (Figure Presented) .

Link to full-text

Assessment of chronic obstructive airways disease in heart failure : An analysis of current practice (2018)

Type of publication:
Conference abstract

Author(s):
*Muthusami R.; *Mahmoud M.; *Crawford E.; *Makan A.; *Ahmad N.; *Srinivasan K.S.; *Moudgil H.; *Candassamy N.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2018; vol. 197

Abstract:
RATIONALE Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) are global epidemics incurring significant morbidity and mortality with overlapping symptoms & risk factors. Whereas with other coexisting co-morbidities such as with Diabetes Mellitus and Ischaemic Heart Disease, much work has been done to concurrently improve outcomes from both pathologies, whether anything is uniformly undertaken in practice to firstly recognize and secondly improve outcomes from HF and COPD is less understood. The objective here was to establish our current pattern of assessment to identify potential areas of improvement that would enable us to better manage the modern multi-morbid patient. METHODS Electronic medical records of all patients admitted to our District General Hospital (serving fairly static population 250,000) over a 6 month period to end December 2016 and referred internally to our Heart Failure Specialist Team were assessed. Data for all admitted cases were cross-referenced to Electrocardiography (ECHO) and Pulmonary Function Lab Databases. RESULTS 116 patients (63% male) with mean (SD, range) age 74.9 (11.7, 32-100) years had been admitted and of these 37% had died over the subsequent 12 months follow up period. Of the total, 113 (97%) had prior transthoracic cardiac ECHO (updated within a two year window); Mean estimated Left Ventricular Ejection Fraction (LVEF) was 41%. Comparatively, only 31 (27%) patients had undergone Spirometry testing at our centre over the preceding 10 year period and of these approximately half (51%) had shown obstructive spirometry. Collectively, 44 (38%) were known to have any Obstructive Airways Disease with 32 (28%) being COPD but a slightly higher figure at 50 (43%) were on inhaler treatment. . Sub-analysing, the 59 (51%) specifically with Ischaemic Heart Disease as opposed to other causes for Heart Failure (Valvular Heart Disease, Cardiomyopathy etc.) had a higher 12 month mortality rate (49%) as well as higher prevalence of known COPD (32%), higher proportion of patients with obstructive spirometry (65%) and patients on inhaler therapy (45%). Only 2 of the 7 patients on Amiodarone had Spirometry. CONCLUSION The basic provision of spirometry to Heart Failure patients, and in particular those with Ischaemic Heart Disease, needs to be improved with our findings probably consistent with others providing the same models of diagnosis driven care. Our findings are in a population with established Heart Failure and potentially in their final years of life but there may be improved quality of life and care planning, if assessing those presenting earlier.

Consultant-led, collaborative service for people suffering from respiratory conditions (2016)

Type of publication:
Post on the Academy of Fab NHS Stuff website

Author(s):
Nawaid Ahmad

Citation:
Academy of Fab NHS Stuff (www.fabnhsstuff.net/), January 2016

Abstract:
This Future Hospital Programme case study from The Shrewsbury and Telford Hospital NHS Trust outlines the benefits of having a consultant- led service for respiratory medicine.

Key recommendations:

Establish a series of multidisciplinary team (MDT) meetings to discuss the needs of patients with long-term conditions. The MDT should incorporate primary care physicians, mental health, social services and palliative care services to provide a collaborative and exceptional level of care.
Run community-based clinics to reduce hospital admissions as well as help with accurate diagnosis
Propose a long-term management plan for more patients with more complicated health needs and to help with advanced care planning for those patients who are especially ill.

Link to more details or full-text: http://www.fabnhsstuff.net/2016/01/25/your-story-consultant-led-collaborative-service-for-people-suffering-from-respiratory-conditions/

Can hospital early warning score systems be used to predict mortality and readmissions in patients with chronic obstructive pulmonary disease exacerbations requiring hospitalisation? (2014)

Type of publication:
Conference abstract

Author(s):
*Crawford E.-J.T., *A lvarez E., *Moudgil H., *Naicker T.R., *Srinivasan K.S.

Citation:
American Journal of Respiratory and Critical Care Medicine, 2014, vol./is. 189/

Abstract:
Rationale: Predicting mortality in chronic obstructive pulmonary disease (COP D) can be complex as disease progression does not often follow a smooth downward trajectory. Identifying patients with COPD approaching the end of the ir life is important as it allows clinicians to initiate appropriately time d discussions centred around advance care planning and palliative care. High rates of early readmission to hospital (within 30 days of discharge) for patients with COPD is also of some national concern and to date, effective strategies to reduce this readmission rate have been limited. The use of early warning score (EWS) systems are now widespread in UK hospitals and are used primarily to alert nursing and medical staff to the severity of, or changes in, a patient’s condition. This study aimed to understand whether the EWS systems could be used to predict 30 or 90 day mortality, or readmission rates in patients admitted to hospital with a COPD exacerbation. Met hods Data was collected from 73 consecutive patients admitted to hospital over a three month period (May to August, 2013) with an acute exacerbation of COPD. Collected data included early warning scores on admission, discharge and the peak EWS score. Data regarding in-hospital death, death within 30 and 90 days of admission date and readmission within 30 days of discharge was also collected. Results One patient (1.4%) died during their hospital admission. Four patients (5%) had died within 30 days of admission and 11 pa tients (15%) had died within 90 days of admission. 17 patients were re-admitted within 30 days of discharge (23%). There was no significant difference between median admission, peak and discharge early warning scores in those patients who had died within either 30 or 90 days of admission or who were readmitted within 30 days compared to the median values for the rest of th e group (see table). Conclusions According to the findings of this study, measurement of early warning scores cannot be used in clinical practice to p redict readmission rates, 30 or 90 day mortality in patients admitted to hospital with an acute exacerbation of COPD. (Table Presented).