Modelling the prevalence, healthcare costs and number of deaths in chronic obstructive pulmonary disease in England and Scotland

Introduction Chronic obstructive pulmonary disease (COPD) has emerged as a major policy focus for health systems throughout Western Europe. This reflects the increased prevalence, associated healthcare utilisation and costs of COPD, and the potential to substantially improve outcomes through achieving reductions in smoking. The aim of this PhD was to develop projections for the prevalence, healthcare costs and number of deaths in people with COPD in England and Scotland over a 20-year horizon (i.e. from 2011 to 2030). Methods I undertook a phased programme of work, which began with a systematic review of the published and unpublished literature to identify models that were suitable for estimating and/or projecting the prevalence and disease and economic burden from COPD. This involved searching Medline, Embase, CAB Abstracts, World Health Organization (WHO) Library and Information Services and WHO Regional Indexes, and Google over the time period 1980-2013. The models were then critically appraised for their quality of reporting. From these, I selected the Dutch Model developed by Erasmus University for generating projections. Suitable data sources from both England and Scotland were identified, sourced and carefully processed in order to run the modelling exercises. Rates of incidence and prevalence were calculated using English and Scottish healthcare datasets and population data were obtained from the Office for National Statistics (ONS) and the General Register Office for Scotland (GROS). Relative risks for all-cause mortality among people with COPD were calculated from the Clinical Practice Research Datalink and mortality data were obtained from the ONS and GROS. The Model was thus adjusted to apply to England and Scotland. I then travelled to the Netherlands to work with the developers of the Dutch Model and ran a baseline model and an array of sensitivity analyses with modified inputs to the Model. Finally, my Rotterdam colleagues calculated uncertainty intervals for some of the estimates using probabilistic analysis. Results Using the probabilistic means and uncertainty intervals, in England, the modelled prevalence of diagnosed COPD among males of all ages in 2011 was 1.8% (95% uncertainty interval 1.8-1.9) increasing to 2.0% (1.7-2.1) by 2030. In females, in England, the baseline estimate was 1.8% (1.7-1.8) in 2011 increasing to 2.4% (2.0-2.6) in 2030. In Scotland, the modelled prevalence among males was 1.9% (1.8-1.9) in 2011 and this was projected to stay the same at 1.9% (1.7-2.2) by 2030. In females in Scotland, the estimated prevalence was 2.2% (2.1- 2.3) in 2011 and was projected to increase to 2.5% (2.1-2.7) in 2030.Using the Model I estimated that overall in 2011 there were a total of 952,000 (941,000-966,000) people with diagnosed COPD in England and 106,000 (103,000-110,000) in Scotland and that these numbers would increase to 1,325,000 (1,117,000-1,408,000) in England in 2030 and 125,000 (113,000-136,000) in Scotland in 2030, respectively. The greatest increase in COPD was projected to be in females over 65 years of age in both countries. The total annual direct healthcare costs of COPD in England were projected to increase from £1.60 (95% uncertainty interval 1.18-2.5) billion in 2011 to £2.35 (1.85-3.08) billion in 2030. In Scotland, costs were projected to increase from £170 (128-268) million in 2011 to £210 (165-274) million in 2030. These costs were calculated in terms of 2011 costs without the application of any economic trends (i.e. no annual increase applied for inflation). The number of deaths among people with COPD in England was estimated to be 99,000 (93,000-129,000) in 2011, increasing to 129,000 (126,000-133,000) in 2030. In Scotland there were estimated to be 10,000 (9,000-12,000) deaths in 2011, increasing to 14,000 (13,000-15,000) in 2030. The Dutch Model demonstrated a 39% increase in the number of people with COPD in England and a 17% increase in Scotland between 2011 and 2030. It provided an estimate of a 30% increase in deaths among people with COPD in England and of a 43% increase in Scotland. Overall, there was a projected 46% increase in the direct healthcare costs required to care for people with COPD in England and a 23% increase in Scotland between 2011 and 2030. The reasons for these differences are largely due to higher COPD-related excess mortality in Scotland and to differences in the data used for populating the model in both countries. Conclusions There are likely to be substantial increases in the number of people with COPD, associated morbidity, direct healthcare costs and mortality in both England and Scotland over the next two decades. These increases in numbers will predominantly occur in females over 65 years of age and are likely to have substantial societal impact in terms of organising the health and social care for this frail population

Telehealthcare for chronic obstructive pulmonary disease

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a disease of irreversible airways obstruction in which patients often suffer exacerbations. Sometimes these exacerbations need hospital care: telehealthcare has the potential to reduce admission to hospital when used to administer care to the pateint from within their own home. OBJECTIVES: To review the effectiveness of telehealthcare for COPD compared with usual face‐to‐face care. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, which is derived from systematic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO; last searched January 2010. SELECTION CRITERIA: We selected randomised controlled trials which assessed telehealthcare, defined as follows: healthcare at a distance, involving the communication of data from the patient to the health carer, usually a doctor or nurse, who then processes the information and responds with feedback regarding the management of the illness. The primary outcomes considered were: number of exacerbations, quality of life as recorded by the St George's Respiratory Questionnaire, hospitalisations, emergency department visits and deaths. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion and extracted data. We combined data into forest plots using fixed‐effects modelling as heterogeneity was low (I(2) < 40%). MAIN RESULTS: Ten trials met the inclusion criteria. Telehealthcare was assessed as part of a complex intervention, including nurse case management and other interventions. Telehealthcare was associated with a clinically significant increase in quality of life in two trials with 253 participants (mean difference ‐6.57 (95% confidence interval (CI) ‐13.62 to 0.48); minimum clinically significant difference is a change of ‐4.0), but the confidence interval was wide. Telehealthcare showed a significant reduction in the number of patients with one or more emergency department attendances over 12 months; odds ratio (OR) 0.27 (95% CI 0.11 to 0.66) in three trials with 449 participants, and the OR of having one or more admissions to hospital over 12 months was 0.46 (95% CI 0.33 to 0.65) in six trials with 604 participants. There was no significant difference in the OR for deaths over 12 months for the telehealthcare group as compared to the usual care group in three trials with 503 participants; OR 1.05 (95% CI 0.63 to 1.75). AUTHORS' CONCLUSIONS: Telehealthcare in COPD appears to have a possible impact on the quality of life of patients and the number of times patients attend the emergency department and the hospital. However, further research is needed to clarify precisely its role since the trials included telehealthcare as part of more complex packages

Telehealthcare for asthma

BACKGROUND: Healthcare systems internationally need to consider new models of care to cater for the increasing numbers of people with asthma. Telehealthcare interventions are increasingly being seen by policymakers as a potential means of delivering asthma care. We defined telehealthcare as being healthcare delivered from a distance, facilitated electronically and involving the exchange of information through the personalised interaction between a healthcare professional using their skills and judgement and the patient providing information. OBJECTIVES: To assess the effectiveness of telehealthcare interventions in people with asthma. SEARCH METHODS: We searched in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO; this was supplemented by handsearching of respiratory journals. We also searched registers of ongoing and unpublished trials. SELECTION CRITERIA: We selected completed randomised controlled trials of telehealthcare initiatives aiming to improve asthma care. DATA COLLECTION AND ANALYSIS: Two review authors independently appraised studies for inclusion and extracted data and performed meta‐analyses. We analysed dichotomous variables to produce an odds ratio (OR) and continuous variables to produce a mean difference. MAIN RESULTS: We included 21 trials in this review. The 21 included studies investigated a range of technologies aiming to support the provision of care from a distance. These included: telephone (n = 9); video‐conferencing (n = 2); Internet (n = 2); other networked communications (n = 6); text Short Messaging Service (n = 1); or a combination of text and Internet (n = 1). Meta‐analysis showed that these interventions did not result in clinically important improvements in asthma quality of life (minimum clinically important difference = 0.5): mean difference in Juniper's Asthma Quality of Life Questionnaire (AQLQ) 0.08 (95% CI 0.01 to 0.16). Telehealthcare for asthma resulted in a non‐significant increase in the odds of emergency department visits over a 12‐month period: OR 1.16 (95% CI 0.52 to 2.58). There was, however, a significant reduction in hospitalisations over a 12‐month period: OR 0.21 (95% CI 0.07 to 0.61), the effect being most marked in people with more severe asthma managed predominantly in secondary care settings. AUTHORS' CONCLUSIONS: Telehealthcare interventions are unlikely to result in clinically relevant improvements in health outcomes in those with relatively mild asthma, but they may have a role in those with more severe disease who are at high risk of hospital admission. Further trials evaluating the effectiveness and cost‐effectiveness of a range of telehealthcare interventions are needed

Protocol for a systematic review to identify and weight the indicators of risk of asthma exacerbations in children aged 5-12 years

No abstract available

Defining clinical subtypes of adult asthma using electronic health records : analysis of a large UK primary care database with external validation

Acknowledgments EMFH was supported by a Medical Research Council PhD Studentship (eHERC/Farr). This work is carried out with the support of the Asthma UK Centre for Applied Research [AUKAC-2012-01] and Health Data Research UK which receives its funding from HDR UK Ltd (HDR-5012) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation and the Wellcome Trust. The funders had no role in the study and the decision to submit this work to be considered for publication. This Project is based in part/wholly on Data from the Optimum Patient Care Research Database (opcrd.co.uk) obtained under licence from Optimum Patient Care Limited and its execution is approved by recognised experts affiliated to the Respiratory Effectiveness Group. However, the interpretation and conclusion contained in this report are those of the author/s alone. This study makes use of anonymised data held in the Secure Anonymised Information Linkage (SAIL) Databank. We would like to acknowledge all the data providers who make anonymised data available for research. SAIL is not responsible for the interpretation of these data.Peer reviewedPublisher PD

Computer decision support systems for asthma:a systematic review

BACKGROUND: Increasing use of electronic health records offers the potential to incorporate computer decision support systems (CDSSs) to prompt evidence-based actions within routine consultations.AIM: To synthesise the evidence for the use of CDSSs by professionals managing people with asthma.MATERIALS AND METHODS: We systematically searched Medline, Embase, Health Technology Assessment, Cochrane and Inspec databases (1990 to April 2012, no language restrictions) for trials, and four online repositories for unpublished studies. We also wrote to authors. Eligible studies were randomised controlled trials of CDSSs supporting professional management of asthma. Studies were appraised (Cochrane Risk of Bias Tool) and findings synthesised narratively.RESULTS: A total of 5787 articles were screened, and eight trials were found eligible, with six at high risk of bias. Overall, CDSSs for professionals were ineffective. Usage of the systems was generally low: in the only trial at low risk of bias the CDSS was not used at all. When a CDSS was used, compliance with the advice offered was also low. However, if actually used, CDSSs could result in closer guideline adherence (improve investigating, prescribing and issuing of action plans) and could improve some clinical outcomes. The study at moderate risk of bias showed increased prescribing of inhaled steroids.CONCLUSIONS: The current generation of CDSSs is unlikely to result in improvements in outcomes for patients with asthma because they are rarely used and the advice is not followed. Future decision support systems need to align better with professional workflows so that pertinent and timely advice is easily accessible within the consultation.</p