Long Term Conditions
Long-term conditions have an impact on the health of the nation and the costs of health care that in some cases lasts from cradle to grave. They may only affect particular social or ethnic groups, or they may result from generalised risks for which national preventative strategies have been devised. With Chronic Obstructive Pulmonary Disease (COPD), the commonest respiratory disease caused by smoking, we are undertaking practice level systematic analysis of service delivery for COPD using local and national data, and exploring the impact of the disease in its advanced stages.
Chronic Obstructive Pulmonary Disease (COPD) Research
There are three themes to the COPD research programme at the Division of Health and Social Care Research:
- Service delivery for COPD across primary and secondary care
- Needs and services in advanced COPD
- Epidemiology of COPD
Thirty thousand people die from COPD each year in the UK, almost as many as die from lung cancer. As deaths from COPD reach a plateau in the UK they continue to rise across the world with COPD projected to be the fourth cause of death worldwide in 2020. COPD is currently the second commonest cause of death in China. Services for people with COPD are highly variable with inaccurate diagnosis, underdiagnosis, poor targeting of services, and widespread under-provision of smoking cessation services and pulmonary rehabilitation, the two most important interventions in COPD. COPD is the second commonest cause of emergency admission in the UK and the cost implications of the disease and its treatment are enormous. Combined inhaled fluticasone and salmeterol, the most widely prescribed drug for COPD, is currently the most costly preparation prescribed in the NHS. Our research is concerned firstly with optimal delivery of services for patients with COPD. In this respect we are particularly interested in pulmonary rehabilitation, the role of socio-economic deprivation, the costs and impact of drugs and services for COPD, and the palliation of symptoms and provision of end of life care services in advanced disease. Our second concern is to understand the needs and experiences of patients. To that end we are studying the experiences of patients who are referred for pulmonary rehabilitation, the impact of breathlessness in advanced disease, and the impact of pulmonary rehabilitation on sleep.
We have received grants from Guy’s and St Thomas’Charity, Dunhill Medical Trust, and NIHR.
- To improve the delivery of services for people with COPD across primary and secondary care
- To define the healthcare needs of COPD sufferers with advanced disease
- To define the prevalence of intractable breathlessness and end of life care needs in COPD
- To explore the epidemiology of COPD prevalence and prescribing in a primary care setting
- To explore the predictors and pattern of admissions due to COPD from a primary care perspective
Current Research Programme
Service delivery for COPD across primary and secondary care
Evaluation of a system-wide service innovation across primary and secondary care
Relationship between prescribing of respiratory drugs and admissions for COPD and asthma between 2006 and 2011
We have recently (2008-2011) evaluated a system-wide integrated service for COPD in south London in a service innovation project funded by the Guy’s and St Thomas Charity for £1 million. The evaluation has been completed and papers have been submitted with others in preparation.
The aim was to improve the whole patient journey across the health and social care spectrum by shifting care from hospital to the community and funding the development of community based services by savings in COPD admissions. The main outcome measures were changes in admissions due to COPD and length of stay in hospital, rates of contact with clinicians across the whole pathway of care, rates of referral to pulmonary rehabilitation, attendance at community-based intermediate care clinics, attendance at community-based pulmonary rehabilitation, and prescribing of respiratory medication in primary care.
Principal Investigator: Patrick White
Hannah Thornton, Craig Davidson, Noel Baxter, Jack Barker, Lauren Hogg.
Funder: Guy’s and St Thomas Charity
The impact of pulmonary rehabilitation on sleep quality in patients with Chronic Obstructive Pulmonary Disease
This research has examined the relationship between practice prescribing of respiratory medication and practice admissions for COPD in 800 practices selected at random in England. We have allowed for the variation in practice characteristics in terms of prescribing, demography, training status and QoF performance. The correlation between spending on bronchodilator and on ICS/LABA inhalers per patient recorded with COPD and admissions per patient estimated to have asthma and patients estimated to have COPD will be analysed. The influence of practice characteristics on these relationships has been assessed. Comparison has been made between level of spending on inhalers per patient with recorded COPD diagnosis and the rate of admissions per patient with COPD.
Clinical Academic Fellow: Timothy Harries (NIHR In-Practice Fellow 2011-13)
Co-investigators: Paul Seed
Supervisor: Patrick White
Prevalence and predictors of intractable breathlessness in advanced COPD following optimisation of treatment in primary care
Chronic Obstructive Pulmonary Disease (COPD) is a common disease in the UK and has been associated with poor sleep quality. There has been little research on non-pharmacological methods to improve sleep quality. Pulmonary Rehabilitation (PR) has already been shown to reduce hospital admissions and improve quality of life in patients with COPD, however the effect of PR on sleep quality is unknown. This research has been designed to investigate the effect of a course of pulmonary rehabilitation on the sleep quality of patients with COPD, in collaboration with the PR service in South East London. In addition to routinely collected data, consenting patients who enrol on the PR course and meet the study criteria have been asked to complete the self assessed Pittsburgh Sleep Quality Index, which is a validated measure of sleep quality. A group of patients on the waiting list for PR are acting as controls. As a secondary outcome measure, the results from the sleep questionnaire will be correlated with changes in anxiety and depression scores and quality of life scores. It is hypothesised that PR improves sleep quality in patients with COPD.
MSc Student: Dr Lucy McDonnell (MRC funded)
Supervisor: Dr Patrick White
People with advanced COPD have been neglected with respect to both research and service development. In a large retrospective survey we have shown that those who died from COPD had considerable unmet needs in terms of symptoms, information, and access to services in the year before their death. We have recently completed a prospective cross-sectional survey of palliative care needs in 145 patients with advanced COPD in primary care. Eighty per-cent of primary care teams approached participated and 61% of patients identified with advanced COPD responded. 82 (57%) patients were identified with very severe breathlessness. Whilst pain, low mood and anxiety were significant contributory factors, almost all interviewees (92%) identified breathlessness as their most important problem. Symptoms and dependency needs were dominated by breathlessness. More than 30% of subjects were on sub-optimal treatment. The need for palliation of breathlessness in severe COPD is therefore likely to be substantial. In this study we have identified patients in primary care with advanced COPD, optimised their COPD treatment, and made a detailed assessment of their breathlessness and its impact. We have verified the resulting prevalence of patients with advanced COPD in whom palliation of breathlessness remains a clinical priority despite optimal treatment. This is an essential first step in a programme with the long term aim of implementing and evaluating a breathlessness palliation service for these highly vulnerable patients.
Principal investigator: Dr Patrick White
Co-investigators: Ms Cathy Shipman, Professor Irene Higginson, Professor John Moxham, Professor Scott Murray, Dr Hilary Pinnock, Dr Sara Booth, Mr Paul Seed.
Funder: Dunhill Medical Trust (2009-2011)
HSR Epidemiological Studies
Quality of primary care management of Chronic Obstructive Pulmonary Disease (COPD) in South London: Prescribing and prevalence rates
COPD hospital admissions in south London: associations with the characteristics and quality of general practices, prescribing and population
We carried out a survey of COPD care in 41 practices in south London, examining the electronic and paper records of 3537 COPD patients in a population of 310,775 people. We assessed diagnosis and treatment against international guidelines and will report on rates of diagnosis, levels of appropriate treatment, overtreatment, and undertreatment, and the risks and costs of overtreatment with inhaled corticosteroids. A paper is currently under review for publication reporting this research.
Principal Investigator: Patrick White
Helen Booth, Hannah Thornton, Hilary Pinnock, Sophia Georgopoulou.
Funder: Dunhill Medical Trust
Socio-economic deprivation and illness perception in the medical care of patients with chronic obstructive pulmonary disease
The aim of this study was to determine the rates of hospital admissions and readmissions for chronic obstructive pulmonary disease (COPD) over a 4 year period between April 2006 and March 2010 in the south London boroughs of Lambeth, Southwark, Wandsworth and Lewisham, and to seek associations between COPD hospital admissions and the characteristics of local general practices, their prescribing of respiratory drugs, and the socio-economic deprivation of admitted COPD patients.
Principal investigator: Patrick White
Co-investigators: Gita Thakur, Hannah Thornton, Timothy Harries, Paul Seed.
The aim of this study, which is the subject of work towards a PhD by Sophia Georgopoulou, is to investigate the role of socio-economic deprivation and illness perception in the access to services and quality of life of patients with COPD. The variables of particular interest are socio-economic deprivation, social capital, illness perceptions and self-efficacy. It is hypothesized that socio-economic status and illness perceptions as well as self-efficacy are associated and linked to patients’ healthcare utilisation and disease outcome. Education, income and occupation are assumed to have an impact on the way people make sense of and perceive their illness. This, in turn, would be expected to influence patients’ healthcare seeking (e.g. referral and participation in smoking cessation programmes, hospital admissions and prescribed medications) and their health outcomes (e.g. disease severity, mental health).
PhD student: Sophia Georgopoulou
Supervisors: Dr Patrick White, Dr Alison Wright, and Professor John Weinman.
People & Contact Us
Dr Patrick White, Senior Lecturer in General Practice and Primary Care
Division of Health and Social Care Research,
Faculty of Life Sciences & Medicine,
King’s College London,
9th Floor Capital House,
42 Weston Street
London SE1 3QD
Tel 020 7848 8679
Fax 020 7848 6620
Dr Tim Harries, NIHR in-practice Research Fellow
Dr Lucy McDonnell, MRC Alice Cory Early Research Training Fellow
Ms Sophia Georgopoulou, PhD Student
Mr Paul Seed, Senior Lecturer in Medical Statistics
Collaborations with other Divisions and Institutions
King’s College London King’s Health Partners, Division of Asthma, Allergy and Lung Biology.
Corrigan C, Pillai P, Sun Y, Gould H, Barker J, White P. The effect of a humanised monoclonal anti-IgE antibody (omalizumab) on disease control and bronchial mucosal inflammation in non-atopic (“intrinsic”) asthma. Funders - Guy’s and St Thomas’ Charity and Novartis UK, (£240,000) 2011-2013.
University of Cambridge
Barclay S, Higginson I, McCrone P, Cohn S, Shipman C, Graffy J, White P. NIHR Research for Patient Benefit (RfPB) Programme: PB-PG-0909-20323 – CAPE study. Community cAre Pathways at the End of life: mapping the pathways to improve care. Apr 2011- Sep 2013. £249,748
University of Edinburgh
Pinnock H, Kendall M, Murray S, Worth A, Levack P, MacNee W, Sheikh A, White P, Rabinovich R, Drost E, Stewart J. Supporting older people with very severe chronic obstructive pulmonary disease (COPD) at the end of life: developing, piloting and refining a practical intervention. Dunhill Medical Trust. January 2012-December 2014. £21,0272.
University of Cambridge
Farquhar M, Barclay S, Ewing G, Grande G, Ashelford L, Ling T, Burge P, White P, Mahadeva R,Booth S, Palmer C, Howson S.End of life care in advanced Chronic Obstructive Pulmonary Disease (COPD): identifying, understanding and meeting the changing care and support needs of patients and their carers. Marie Curie Cancer Care Research Programme (admin Cancer Research UK). Apr 2012 – Mar 2015. £298,905.