1. Measures to improve COPD
outcomes in Greater
Manchester: a multimodal
approach
Dr Arpana Verma, Annie Harrison
Manchester Urban Collaboration on Health
Manchester Academic Health Sciences Centre
University of Manchester, UK

2. Overview
• Setting the scene
– Urban health
– Who are we
– Rationale for studying COPD
• The three studies
• Conclusions

3. Setting the scene
• Greater Manchester
– Conurbation of 10 areas
– Population 2.6 million
– Deprivation
– Industrial past and present

4. Greater
Manchester
Index of
Multiple
Deprivation
Score 2007

5. Where is this?

6. www.gapminder.org
• Prof Hans Rosling and Google
• Free to use “fact tank”
• Credit Gapminder as the source
• www.bit.ly/acXjFJ

8. Wider determinants of health

10. World Urban vs Rural Population1950-2030
Source: United Nations, Department of Economic and Social Affairs, Population Division (2006).

11. World Urban Population, 1950-2005
with Projections to 2020 (in billions)
Source: United Nations, Department of Economic and Social Affairs, Population Division (2006).

13. Manchester Urban Collaboration on Health

14. M U C H
Vision Manchester Urban Collaboration on Health
“To perform world class research on
urban issues for the benefit of
local populations, building real world
evidence”
EU Commission
€5 million
£1.2 million

15. Governments
NGOs
Charities
Industry
Future
Urban Health
Knowledge Centre Network
Teaching/Training on
Urban Health
Tools

16. The Importance of COPD

17. COPD and Public Health Tools
• COPD is a complex disease
– public health can offer tools to help with evidence-
based decision making
• The following demonstrate the utility of the tools
commonly used in the UK as part of routine public health
practice
– The first is a needs assessment which maps local
needs, demands and service with the evidence-
based literature.
– The second is to use a population impact assessment
tool to help prioritise interventions in COPD.
– The third is how to evaluate pharmacists to providing
support for evidence-based prescribing in COPD.

18. Healthcare Needs Assessment Of
Chronic Obstructive Pulmonary Disease
Services In Trafford
A. Verma1, G. Mates2, C. Franco3, L. Davies3, R. F. Heller1, B. Leahy2.
1 University of Manchester
2 Trafford Healthcare NHS Trust
3 NHS Trafford
Thorax 2007

19. G
re
percentage smoking
at
17
19
21
23
25
27
29
31
Br
it ai
Al n
lE
ng
la
nd
N
or
th
1998
Yo
r E
ks as
hi No t
re r th
an
d W
2000
th es
e t
H
um
Ea be
r
2001
st
M
id
W la
nd
es
tM s
2002
id
Ea la
st nd
of s
En
2003
gl
area
an
d
Lo
nd
2004
on
So
ut
h
Wales and Scotland
Ea
2005 So st
ut
h
W
es
t
2006
W
al
es
Sc
ot
la
n d
Smoking prevalence in Great Britain, England, English Regions,

20. Smoking Mortality Rates for North West region compared with England
and Wales
450
400
350
300
250
200
150
100
50
0
93
94
96
98
02
95
97
99
00
01
03
04
05
06
es
al
19
19
19
19
20
19
19
19
20
20
20
20
20
20
w
d
an
d
an
gl
en
year

21. Comparative SMR figures for 2006
250
204 191
200
150 141 144
value 112 105
100 100 99
72 83
47 59
50
0
D D D D D D
les SHA MC MCD MCD MC MC MCD MC M C MCD MC
a st
n d w We ol ton Bury s ter ham dale l ford k port es ide fford i gan
d a orth e d h Sa o c
n
B
nc h O l Roc St Ta
m Tra W
la N Ma
eng
region

22. Smoking Attributable Deaths
Greater Manchester
140
smoking
120 attributable
deaths
100
80
60
40
20
0
r
m
rd
ry
le
rd
n
an
t
e
te
or
lto
id
ha
Bu
da
fo
lfo
es
ig
kp
es
Bo
af
ld
h
Sa
W
ch
oc
m
oc
Tr
O
an
Ta
St
R
M

23. Standardised Hospital Prevalence
Greater Manchester
Standardised
140 Hospital
Prevalence
120
100
80
60
40
20
0
r
rd
n
e
t
rd
e
m
an
ry
te
or
lto
al
id
ffo
ha
l fo
Bu
kp
es
ig
hd
es
Bo
Sa
W
a
ld
ch
oc
m
oc
Tr
O
an
Ta
St
R
M

24. Questionnaire completed by (n=18)
Practice
Nurse,
13, 72%
Don't GP, 2,
Both, 2,
Know, 1, 11%
11%
6%

25. Results
• 100% recorded smoking
18
status
16
• 14/18 (74%) of practices
• COPD lead 14
• Nursing resources 12
• COPD register 10
• Only 8/18 (50%) of practices 8
has COPD trained staff 6
4
2
0
01:01 Smokers Clinic 4 week follow up
How does the practice offer smoking cessation
support? N=18

26. At risk group targeted for smoking cessation and then
screened? N=18
8
7
6
5 • Only 9/18 (50%) of nurses had
4 received any training in COPD
3 • 15/18 (83.3%) were trained in
2 spirometry
1 • 10/18 (55.6%) used it
0
Not targeted or Targeted but not Targeted and 16
screened screened screened 14
12
10
8
6
4
2
0
Nurses received Nurses received Nurses who
COPD training spirometry performed
training Spirometry

27. Who has been trained for spirometry?
n=16
• 10/18 (56%) checked diagnosis with spirometry
• 17/18 (94%) had access to secondary care
• 10/18 (56%) had access to a respiratory specialist nurse
• 15/18 (83%) had an agreed management plan with the patient
• 16/18 (89%) checked inhaler technique

28. Education and Management n=18
Review
Pneumovac
Fluvac
Available support
Own illness management No
What to do Yes
Info on condition
0 5 10 15 20

29. Using Population Impact Measures In
Chronic Obstructive Pulmonary
Disease For Prioritisation Of
Resources In Trafford
A. Verma1,2 I.Gemmell1 L.Davies2 R.F.Heller1
1 University of Manchester
2 NHS Trafford
Journal of Public Health Vol. 34, No. 1, pp. 83–89 doi:10.1093/pubmed/fdr026

30. The Population Health Evidence Cycle

32. Number Needed to Treat (NNT) and the population

33. Going from the patient to the population
• Population Impact Numbers have been designed to take into
account the impact of an intervention on the population as a whole
• Number of Events Prevented in your Population (NEPP)
“the number of events prevented by the intervention in your population”
• Size (and characteristics) of your population
• Frequency of the condition in your population
• Baseline risk of death in next year (or whatever other outcome measure you want to use)
• Relative Risk Reduction (from the literature)
• Best practice treatment levels (from guidelines)
• Current treatment levels in your population

34. NEPP
N * Pe * [Pd *] BR * RRR
N = no. of people in population of interest
Pe = prevalence of the disease in the population
Pd = Population with disease (not needed)
BR = baseline risk of a cardiac event in 5 years
RRR = relative risk reduction associated with treatment

35. Aims
In line with the new BTS/NICE guidelines in COPD, we
examined the number of admissions prevented in the
Trafford population aged over 65 years by increasing
the uptake of influenza and pneumococcal
vaccination

36. Data
• Population size and incidence
– Office of National Statistics
– Trafford PCTs data
• Relative risk reduction from meta-analyses data
– 0.33 for fluvac [Kelly et al 2004]
– 0.48 for pneumovac [Nichols 1999]

37. Results
• The current level of immunisation in
• >65-year olds for fluvac and pneumovac
– 72% and aim to increase this to 90%
• The population size for Trafford
– Total = 225,000
– Aged >65 = 45,000
– Pe = 90% - 72% = 18% or 0.18
– BR is 4.3 hospitalisations/1000 or 0.0043

38. N * Pe * [Pd *] BR * RRR
Fluvac
45000 * 0.18 * 0.0043 * 0.33
Pneumovac
45000 * 0.18 * 0.0043 * 0.48

39. An online tool for calculating PIMs has
been developed and is available at
www.phsim.man.ac.uk

42. But
• Trafford average LOS for COPD
– 11.1 days
• Cost of a bed day
– £300
– Without any intervention

43. Fluvac Pneumococcal
(95%CI) (95% CI)
Pe 0.18 0.18
BR 0.0043 0.0043
RRR 0.33 0.48
(0.27-0.38) (0.16-0.62)
NEPP 11.5 16.7
(9.3 to 13.8) (8.3-24.7)
Potential Cost £38,000 £56,000
saving*
*The potential cost savings need to be considered in light of other factors
e.g. cost of programmes to improve uptake.

44. Therefore
• If we were to increase the vaccine uptake from 72% to
90% in our >65 year population
• we would prevent 11.5 and 16.7
admissions/year at a cost saving
of £38,000 and £56,000/year
• Different populations with differing demographics, immunisation rates and baseline
risk will have differing results which will influence policy making decisions

45. Conclusion
The utility of PIMs is to help prioritise and
implement national guidelines based on recent
evidence and local data by comparing the
different cost savings afforded by reducing the
number of admission prevented

46. Are pharmacists reducing COPD’s impact
through smoking cessation and assessing
inhaled steroid use?
A. Verma1, A. Harrison1, P. Torun1, J. Vestbo1, R. Edwards2, J. Thornton1
1 University of Manchester, UK
2 University of Otago, New Zealand
Respir Med. 2012 Feb;106(2):230-4. Epub 2011 Sep 7.

47. UK Recommendations
• NICE/BTS COPD 2004 guidelines recommend
• COPD patients who smoke should be encouraged to stop at
every opportunity
• Inhaled corticosteroid should be used only among patients with
moderate to severe COPD
• Pharmacists should identify smokers and provide smoking
cessation advice.
• Methods
• A self-completion questionnaire was sent to 2080 community
pharmacists from the 2005 pharmacist census database.

48. Results
• Of the 1051 (50.5%) respondants
• 37.1% mentioned COPD as a risk from
smoking most or every time
• 54.5% sometimes or rarely
• 19.6% routinely asked about smoking status
when dispensing COPD medication

49. Results
• Pharmacists with more than 20 years experience
were more likely to have read the Guideline
compared to pharmacists with 10 years or less (OR:
1.54; 95% CI: 1.13 to 2.10)
• Pharmacists who had read the NICE Guideline
(46.8%) were around twice as likely to mention
COPD as a risk of smoking, ask about COPD if
inhaled corticosteroids were dispensed and ask
about smoking routinely if COPD medication was
dispensed. (p<0.005).

50. Table-1: Community pharmacists’ opinions on
improving their knowledge further
Yes No
% %
(95% CI) (95% CI)
Need to improve knowledge on 81.1 18.9
COPD management (78.6 to 83.4) (16.6 to 21.4)
Training would be beneficial 91.5 8.5
(89.7 to 93.1) (6.9 to 10.3)

51. Table-2: Relationship between reading the COPD Guideline and
compliance with the recommendations among community pharmacists
Read NICE COPD Guideline
Yes No
% %
(95% CI) (95% CI)
Ask about smoking routinely if 27.2 12.9
COPD medication dispensed (23.4 to 31.4) (10.3 to 15.9)
(n=1036)
Ask at least sometimes 11.0 6.0
whether COPD/Asthma (8.5 to 14.2) (4.3 to 8.3)
diagnosed if inhaled
corticosteroids dispensed
(n=1041)
Mention COPD at least 49.5 22.1
sometimes as a risk from (45.1 to 53.9) (18.7 to 25.8)
smoking (n=1042)

52. Conclusions
• NICE guidelines encourage some community
pharmacists to carry out smoking cessation and
educational interventions
– We recommend further dissemination to
encourage other pharmacists of their role

53. Conclusions for the multi-modal approach
• Resources are limited and reducing in many
aspects of healthcare
• A multi-modal approach for COPD is essential
• Baseline activity and needs/demands
• Prioritisation of interventions
• Evaluation of interventions