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. 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. 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. 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. 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. 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. 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
8. Looking at maps eg London
smoking, deprivation, mental health …
smoking
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. 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. 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. 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
www.rcpsych.ac.uk/pdf/No%20Health%20-%20%20the%20evidence_%20revised%20May%2010.pdf
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. 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. 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. 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. 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. 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. 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. 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. 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?
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. 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. 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. What else could we do differently?
Include breathlessness in physical health
assessments in mental illness?
2011
‘Do you get short
of breath?’
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. 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