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  • Urban health is a growing field of research internationally. There are a number of issues that primarily affect urban areas - for examples internationalisation of metropolitan regions, ageing populations, migration and poor environmental factors. Urban areas have specific problems associated with health that are different to non-urban areas that national or regional investigations would not identify. The World Health Organisation (WHO) Healthy Cities programme “ promotes comprehensive and systematic policy and planning with a special emphasis on health inequalities and urban poverty, the needs of vulnerable groups, participatory governance and the social, economic and environmental determinants of health ” . Many urban areas have health policy determined at local level and policy makers require data at urban area level to inform these local policies. Resource allocation is usually at local level in many countries. However, national and international policy makers also require data at the urban area level not only inform evidence based policy making, but also to evaluate the impact of policies
  • … and this slide illustrates the global trajectory of urban versus rural populations.
  • … while this one illustrate the trends in urban population growth. The top red line is representing the trend for the world, the green one for the developing countries and finally the blue one for developed countries such as ourselves. We can see from this that urbanisation is on this upward trajectory mainly in the developing world so that, arguably, this is where improving urban health will have the biggest impact. This is why we are ever mindful that what we do in in this project has to be generalisable and this is one of our key objectives.
  • The vision of Manchester Urban Collaboration on Health is ‘ to perform world class research on… ’ Now, I should probably point out here, that although the words ‘ equity ’ and ‘ inequality ’ don ’ t feature in our ‘ vision ’ , they are concepts that are central to our work – after all, they ’ re inherent in our work, including our European projects Urhis 1, which had over 60 partners and Urhis 2 which spans across 44 urban areas in Europe and across the globe. But, as we are MUCH, we also conduct work on a more local level and we ’ ve been fortunate enough to secure funding from the organisations shown here on the right.
  • As urban health is such a new discipline, especially in Europe, much of MUCH ’ s work involves raising the profile of urban health and we ’ ve been doing this by establishing links with the organisations shown here. We hope to create a knowledge centre network here at the University of Manchester.


  • 1. Measures to improve COPDoutcomes in GreaterManchester: a multimodalapproachDr Arpana Verma, Annie HarrisonManchester Urban Collaboration on HealthManchester Academic Health Sciences CentreUniversity 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. GreaterManchester Index of MultipleDeprivationScore 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
  • 7. Wider determinants of health
  • 8. World Urban vs Rural Population1950-2030 Source: United Nations, Department of Economic and Social Affairs, Population Division (2006).
  • 9. World Urban Population, 1950-2005with Projections to 2020 (in billions) Source: United Nations, Department of Economic and Social Affairs, Population Division (2006).
  • 10. Manchester Urban Collaboration on Health
  • 11. 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
  • 12. Governments NGOs Charities Industry Future Urban Health Knowledge Centre Network Teaching/Training on Urban HealthTools
  • 13. The Importance of COPD
  • 14. 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.
  • 15. Healthcare Needs Assessment OfChronic Obstructive Pulmonary DiseaseServices In TraffordA. Verma1, G. Mates2, C. Franco3, L. Davies3, R. F. Heller1, B. Leahy2.1 University of Manchester2 Trafford Healthcare NHS Trust3 NHS TraffordThorax 2007
  • 16. G re percentage smoking at 17 19 21 23 25 27 29 31 Br it ai Al n lE ng la nd N or th1998 Yo r E ks as hi No t re r th an d W2000 th es e t H um Ea be r2001 st M id W la nd es tM s2002 id Ea la st nd of s En 2003 glarea an d Lo nd2004 on So ut h Wales and Scotland Ea2005 So st ut h W es t2006 W al es Sc ot la n d Smoking prevalence in Great Britain, England, English Regions,
  • 17. 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
  • 18. 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 Maeng region
  • 19. Smoking Attributable Deaths Greater Manchester140 smoking120 attributable deaths100 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
  • 20. Standardised Hospital Prevalence Greater Manchester Standardised140 Hospital Prevalence12010080604020 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
  • 21. Questionnaire completed by (n=18) Practice Nurse, 13, 72% Dont GP, 2, Both, 2, Know, 1, 11% 11% 6%
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. Education and Management n=18 Review Pneumovac Fluvac Available supportOwn illness management No What to do Yes Info on condition 0 5 10 15 20
  • 26. Using Population Impact Measures InChronic Obstructive PulmonaryDisease For Prioritisation OfResources In TraffordA. Verma1,2 I.Gemmell1 L.Davies2 R.F.Heller11 University of Manchester2 NHS TraffordJournal of Public Health Vol. 34, No. 1, pp. 83–89 doi:10.1093/pubmed/fdr026
  • 27. The Population Health Evidence Cycle
  • 28. Number Needed to Treat (NNT) and the population
  • 29. 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
  • 30. NEPP N * Pe * [Pd *] BR * RRRN = no. of people in population of interestPe = prevalence of the disease in the populationPd = Population with disease (not needed)BR = baseline risk of a cardiac event in 5 yearsRRR = relative risk reduction associated with treatment
  • 31. 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
  • 32. 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]
  • 33. 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
  • 34. N * Pe * [Pd *] BR * RRR Fluvac45000 * 0.18 * 0.0043 * 0.33 Pneumovac45000 * 0.18 * 0.0043 * 0.48
  • 35. An online tool for calculating PIMs has been developed and is available at www.phsim.man.ac.uk
  • 36. But• Trafford average LOS for COPD – 11.1 days• Cost of a bed day – £300 – Without any intervention
  • 37. 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 factorse.g. cost of programmes to improve uptake.
  • 38. 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
  • 39. 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
  • 40. Are pharmacists reducing COPD’s impactthrough smoking cessation and assessinginhaled steroid use?A. Verma1, A. Harrison1, P. Torun1, J. Vestbo1, R. Edwards2, J. Thornton11 University of Manchester, UK2 University of Otago, New ZealandRespir Med. 2012 Feb;106(2):230-4. Epub 2011 Sep 7.
  • 41. 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.
  • 42. 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
  • 43. 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).
  • 44. Table-1: Community pharmacists’ opinions on improving their knowledge further Yes No % % (95% CI) (95% CI)Need to improve knowledge on 81.1 18.9COPD 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)
  • 45. 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 12.9COPD medication dispensed (23.4 to 31.4) (10.3 to 15.9)(n=1036)Ask at least sometimes 11.0 6.0whether COPD/Asthma (8.5 to 14.2) (4.3 to 8.3)diagnosed if inhaledcorticosteroids dispensed(n=1041)Mention COPD at least 49.5 22.1sometimes as a risk from (45.1 to 53.9) (18.7 to 25.8)smoking (n=1042)
  • 46. 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
  • 47. 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