Breathlessness and parity of esteem


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Breathlessness and parity of esteem: what matters to whom? - Dr Louise Restrick, London Respiratory Network Lead, Integrated Consultant Respiratory Physician, Whittington Health and Islington CCG

Presentation from the Breathlessness Symposium held in London on 1 July 2014

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Breathlessness and parity of esteem

  1. 1. Breathlessness and Parity What matters and to whom? Dr Louise Restrick London Respiratory Network Lead Integrated Consultant Respiratory Physician Whittington Health and Islington CCG
  2. 2. Unmet respiratory needs in ‘hard to reach groups’: which groups? • People with learning disabilities • People living with mental illness inc alcohol and drug dependence • Homeless • Prisoners
  3. 3. Unmet respiratory needs in ‘hard to reach groups’: what needs?  Die young  Diseases caused by smoking tobacco (& cannabis?)  Tobacco (and cannabis) dependence common  Respiratory and cardio-vascular diseases  Diseases where breathlessness common symptom  Breathlessness less recognised?  Undiagnosed and late diagnosis of diseases Asthma COPD Lung Cancer
  4. 4. Does asthma matter in ‘hard to reach’ groups? Mental illness contributed to risk of death and its perception in 32 (16%) deaths Substance misuse contributed in 12 (6%) deaths
  5. 5. Addressing asthma needs with people who have learning disabilities 45% died before seeking or being provided with medical care* Relationships Patient, family, ward team, learning disabilities advocate, respiratory nurse specialist & respiratory consultant, quit smoking advisor, GP Time Enabling and supporting self-care Quit Smoking as treatment Care Planning Conference Responsibility and Advocacy > 1 in 5 adults who died were current smokers* NRAD Report 2014*
  6. 6. Smoking, respiratory deaths, breathlessness and ... parity 1 in 3 respiratory deaths due to smoking Smoking causes lung cancer and COPD and makes asthma worse Symptom in common Breathlessness
  7. 7. Londoners dying from smoking 7 ‘1 in 5 deaths due to smoking’
  8. 8. Looking at maps eg London smoking, deprivation, mental health … smoking
  9. 9. Does smoking matter for people with mental illnesses? 2011 ‘Increased smoking is responsible for most of the excess mortality of people with severe mental health problems … *not including mental health settings, prisons, homeless or temporary housing …. Adults with mental health problems …. smoke 42%* of all tobacco in England.’ 2011 Smoking responsible for much higher proportion of respiratory deaths in people with mental illnesses
  10. 10. Does respiratory disease matter in ‘hard to reach’ groups? ‘People with mental health problems … die on average 16-25 years sooner than the general population. … have higher rates of respiratory, cardiovascular & infectious disease...’ 2011 Smoking also responsible for prematurity of respiratory deaths in people with mental illnesses
  11. 11. Risk of COPD in mental illness % Adults 21% smokers 9% heavy smokers Inpatients with serious mental illness People living with mental illnesses O’Brien et al 2002, Farrell et al 2001 (>20 cigarettes/day) 50% of smokers heavy smokers 30% of smokers heavy smokers High prevalence of severe tobacco dependence Very high smoking prevalence Same pattern as people living with COPD
  12. 12. Outcomes for people with mental illness and COPD ? Population 5 year COPD mortality Schizophrenia 28% Bipolar disease 19% Age adjusted population 12% Five year mortality for respiratory disease much higher in people with mental illness At least 1 in 4 deaths in people with mental illnesses due to respiratory disease Hippisley-Cox J et al . Health outcomes for patients with serious mental health problems: 2nd report to the DRC 2006 Joukamaa et al British Journal of Psychiatry 2006:188;122-127, Jones D et al Psychiatric Services 2004;55:1250-1257
  13. 13. Comparative outcomes for people with mental illness and COPD ?
  14. 14. Does breathlessness matter in ‘hard to reach populations’? *Tessier et al Eur Journal of Epidemiol 2001;17:223-229 Frostal et l J Intern Med 2006;259:520-29 Inetti et al J Am Geriatr Soc 2011;59:1618-1627 Breathlessness predicts increased risk of death for populations esp older people*
  15. 15. Does breathlessness matter in ‘hard to reach populations’? ‘Do you experience shortness of breath?’ Risk adjusted probability of death from cardiac causes 17,991 patients referred for myocardial-perfusion stress test Abidov et al NEJM 2005;353:1889-98 Patients with breathlessness … >2 x risk of dying if have CAD and 4 x risk without known CAD
  16. 16. Does breathlessness matter in ‘hard to reach populations’? 5 year mortality rates of patients with COPD According to FEV1 and MRC score MRC breathlessness stronger predictor of death than FEV1 in COPDBanzett & O’Donnell Eur Respir J 2104:43;1547-1550 Data from Nishimura et al Chest 2002:121;1434-1440
  17. 17. Where do we have access to and time with hard to reach groups? In-patient wards in Acute Trusts eg Respiratory Wards In-patient wards in Mental Health Trusts Prisons
  18. 18. Do we use this time to best value? What are the right things? Are we doing the right things? Are we doing things in the right way ...1st time! Are we doing them during hospital admission Do we measure what we do? Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
  19. 19. Who do we look after on an Inner City Respiratory Ward? • Worsening/‘exacerbation’ of long term condition • Multi-morbidity • Medication +++ • Mix of physical & mental illnesses including • Drug and alcohol dependence • Difficult home/social situations including • Alone, homeless and from prison • Learning Disabilities • Tobacco (and cannabis) dependent • High risk of premature mortality ‘hard to reach’ groups
  20. 20. Do we use our time to best value on a Respiratory Ward? Enhanced Recovery in Medicine what do we mean and what are we trying to do?
  21. 21. Enhanced Respiratory Recovery • ‘Get better’ as effectively as possible  What matters to patients …. BREATHLESSNESS  Right diagnoses & right treatment  Every inpatient day counts - green days not red days • Plan ahead with patients, families and teams  Safe transitions in & out of hospitals & between wards & teams  Live better with illnesses at home as people  Prevent the next admission Consultant Liaison Psychiatrist Social workers mental health & physical health teams
  22. 22. Enhanced Recovery to address needs of homeless with respiratory disease • Get better  Late presentation  Poor underlying health  Combination of physical & mental health needs  Tobacco and alcohol dependence • What matters to patient ‘Roof over my head’ • Plan ahead with patient, social worker, alcohol liaison, smoking cessation advisor  Safe transition to ?address ?GP  Communication?
  23. 23. Enhanced Recovery: Pulmonary Rehabilitation 2 4 ‘Breathe Better, Feel Good, Do More’
  24. 24. Do we use time to best value in prison?
  25. 25. Do we use time to best value on Mental Health Trust Wards? 1.5% risk of death within a year of inpatient care 75% of deaths natural causes: ie cardiac and respiratory SMR for respiratory disease high (4.7) & increasing Hoang U, Stewart R, Goldacre M BMJ 2011;343:d5362 270 000 people with schizophrenia &100 000 with bipolar disease England HES data
  26. 26. Do we diagnose COPD in people with mental illness? ? • ‘Spirometry done less often in people with mental illness • Less likely to have diagnosis based on spirometry ….’
  27. 27. Similarities & differences between Mental Health Rehabilitation Wards & Acute Trust Wards Patients with extended periods of enduring mental illness to relearn skills and receive treatment for psychiatric symptoms, so that they can live independently or with support in the community MDT- psychologists, psychiatrists, occ therapists, physios & mental health nurses Inpatients for an average of > 2 years Young - mean age ~ 50 years > 80% tobacco smokers* 20% smoking status not recorded 20% known smokers not offered quit smoking interventions < 10% known COPD and/or asthma Self-reported breathlessness less than observed breathlessness? Admission opportunity to ... Treat tobacco (and cannabis) dependence Make diagnosis and treat respiratory disease Participate in pulmonary rehabilitation? Personal communication, Hughes, Jeanneret, Johansson, Sherring, psychiatry trainees , C& I Mental Health Trust, London*
  28. 28. What else could we do differently? Include breathlessness in physical health assessments in mental illness? 2011 ‘Do you get short of breath?’
  29. 29. Work together on breathlessness and … respiratory failure 2011
  30. 30. Work together on stopping smoking as treatment Respiratory Physician Quit Smoking Advisor Mental Health Key Worker Respiratory Nurse Specialist * With particular focus on groups with high smoking prevalence People living with mental illness People with alcohol and drug dependence Homeless Prisoners * * *
  31. 31. Breathlessness & Parity • We know very little about breathlessness in ‘hard to reach’ groups • Under-recognised? By patients? By Health professionals? • Tobacco smoking much higher relative contribution to disease and death in ‘hard to reach’ groups • Pack-years smoker may be easier prompt for case-finding than breathlessness in this group … until we know more • Quit smoking as treatment key intervention in breathlessness pathway for ‘hard to reach’ groups • ‘In-patient’ stays opportunity to add value – Enhanced Recovery • Need pathways commissioned for value - more input for ‘same’ outcome but value high if reduces premature mortality