Recommendations for NHSScotland
Multidisciplinary community based respiratory care services should be offered to patients with chronic respiratory conditions where appropriate.
Health and Social Care Partnerships should offer a flexible service, that could include supported self-management interventions (such as home based pulmonary rehabilitation and advice on managing exacerbations) and hospital at home (for avoidance of hospital admissions and early supported discharge from hospital) within the context of local resources and geography.
All community respiratory care services should ensure clear, ongoing engagement with patients and their carers throughout their care. This will ensure any concerns about home based respiratory care are managed as part of the service.
To inform future service development, community respiratory teams should record service data including: respiratory conditions covered, patient numbers, services provided, hospital admission and readmission rates, and patient outcomes such as treatment success and mortality.
NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) recommendations.
1. The Council recognised the lack of evidence specific to CRTs and accepted the decision to consider evidence on components of CRTs to support this recommendation.
2. The Council noted that there was no evidence from the published literature that any component of CRT services was associated with an increase in patient harms or poorer outcomes compared with usual care.
3. The Council noted that there is currently variation in CRT service provision across Scotland and agreed that they were not recommending that all HSCPs provide the same service components.
4. The Council talked about the substantial impact that COPD and asthma have on people’s lives, specifically the effects on physical and psychological wellbeing, activities of daily life and social activities.
5. The Council discussed inequalities relating to COPD and asthma, and emphasised the importance of ensuring equity of access to CRT services across Scotland, including providing services for housebound patients and services that consider the
socioeconomic and ethnic demographics in each area.
6. The Council debated factors that could affect which patients were suitable for CRT services. It was felt that patients with severe respiratory illness or exacerbations should go directly to A&E rather than seeking care at home.
7. The Council acknowledged the risk of rapid deterioration in patients with severe asthma and the resultant difficulties in determining which patients with asthma would be suitable for CRTs.
8. The Council noted that provision of CRTs falls under the Scottish Government’s urgent and unscheduled care programme and that the Scottish Government’s COPD Best Practice Guide includes case studies from CRTs across Scotland and recommends provision of CRTs and H@H services for patients with COPD.
9. The Council discussed how people could interpret ‘community based’ interventions as being delivered in health centres, community centres or group classes rather than individual care delivered in a person’s home, as is the case with CRTs.
10. The Council noted the importance of shared decision making between healthcare professionals and patients in ensuring patients could gain the maximum benefit from supported self-management.
11. The Council acknowledged the potential for supported self-management to prevent exacerbations in the long term by supporting patients to manage their condition at home
Clinical effectiveness evidence in patients with COPD
Community respiratory teams (CRTs)
1. An observational study compared the rate of COPD emergency admissions for people aged 65 years or older, before and after the implementation of a CRT in North West Glasgow. Over a 21-month period, a small reduction of 0.85 COPD emergency admissions per 1,000 population was attributable to the introduction of the CRT service. Given the relevant population of 26,021 people with COPD, this equated to approximately 13 fewer emergency admissions per year in North West Glasgow.
Hospital at home (H@H): admission avoidance and early supported discharge
2. A systematic review of reviews found that for patients with COPD who were cared for through H@H services there was no difference in risk of hospital readmission or death compared with inpatients with COPD.
Supported self-management and home based pulmonary rehabilitation
3. A Cochrane review of 52 randomised controlled trials (RCTs, n=21,086) found that multidisciplinary programmes, that included elements of self-management support, were associated with statistically significant improvements in health related quality of
life (HRQoL), and reductions in respiratory hospital admissions and all-cause accident and emergency (A&E) attendance, among patients with COPD.
4. A systematic review and a systematic review with meta-analysis found no consistent evidence of an effect of supported self-management on quality of life, hospital admissions or A&E attendance compared with usual care in primary care patients with
COPD.
5. A meta-analysis (10 RCTs, n=1,716) within a health technology assessment (HTA) compared supported self-management within 6 weeks of hospital discharge with usual care in patients with COPD. While there were no statistically significant between-group differences in all-cause mortality or hospital admissions, there was a statistically significantly greater improvement in HRQoL in patients receiving supported self-management.
o A second meta-analysis within the HTA explored the impact of an ‘enhanced care’ self-management component. Enhanced care was associated with statistically significantly greater improvements in HRQoL after 3 months follow up and reductions in hospital admissions at 1 year follow up, compared with
usual care in patients with COPD.
6. A Cochrane review (26 RCTs, n=6,008) found that self-management (support not specified) was associated with statistically significantly greater improvements in HRQoL and reductions in respiratory hospital admissions and A&E attendance, compared with usual care in patients with COPD.
7. A systematic review of reviews and a meta-analysis (15 RCTs, n=1,800), compared home based pulmonary rehabilitation with usual care or centre based pulmonary rehabilitation for patients with COPD:
o compared with usual care, home based pulmonary rehabilitation was associated with statistically significantly greater improvements in HRQoL and exercise capacity
o comparisons of home based and centre based pulmonary rehabilitation found no statistically significant differences in HRQoL or exercise capacity.
Clinical effectiveness evidence in patients with asthma
Supported self-management
8. In a systematic review of reviews supported self-management was associated with statistically significantly greater improvements in HRQoL and reductions in hospitalisation rates, A&E attendance and unscheduled consultations, compared with usual care in patients with asthma.
9. A network meta-analysis (105 RCTs, n=27,767) comparing intensity of support in self-management interventions for patients with asthma, found that more regularly or intensely supported self-management resulted in significant reductions in healthcare use by patients with asthma compared with usual care.
Patient and social aspects
10. A qualitative study (n=89) explored the views of patients with COPD on H@H:
o perceived benefits were access to home comforts, feeling independent, a perception of a quicker recovery, improved sleep, convenience for visitors and developing one to one relationships with healthcare professionals.
o perceived barriers were fear of being alone when unwell, privacy concerns and concerns about relatives’ perceptions of home care.
11. Two systematic reviews of qualitative studies explored patient perspectives and experiences of supported self-management:
o patients with COPD, asthma or both, described the value of education, psychological support, person centred care, a collaborative support relationship, trust, continuity of carer and easily accessible support.
o patients with COPD described feeling empowered through acquiring knowledge and felt that psychological wellbeing, engaging with peers and increasing physical activity after supported self-management, were important.
12. In a qualitative study (n=24) patients with COPD wanted more information about community pulmonary rehabilitation and described barriers to access, such as location and timing of classes. There were concerns about the safety of taking exercise and feeling inferior in a group setting.
13. A patient organisation submission from Asthma + Lung UK described how:
o people with lung conditions need digitals tools, access to information and advice to support self-management from the point of diagnosis.
o there is increased strain on healthcare services because of the COVID-19 pandemic, which has impacted on self-management of respiratory conditions.
Cost effectiveness of CRTs for patients with COPD in Scotland
14. Evidence on the cost effectiveness of CRTs in Scotland is sparse. Based on patient level EQ-5D-5L data from the Glasgow pilot CRT service, admission avoidance H@H, supported self-management and early supported discharge are associated with
improvements in patients’ average utility scores on discharge from the service. While there is no direct comparative evidence, and uncertainties remain around the per patient cost estimates for CRTs, based on findings from the literature and high level cost
estimates by SHTG:
o supported self-management may be more expensive but more effective than usual care
o it is likely that, compared with inpatient care, early supported discharge and admission avoidance H@H provide similar benefits in terms of HRQoL, mortality and hospital readmission rates, and are cost saving.
What were we asked to look at
SHTG was asked by the respiratory lead for the Scottish Government’s Interface Care Programme to assess the evidence on Multidisciplinary community based respiratory care services for patients with chronic respiratory conditions. SHTG was asked to include any evidence on a service design that is delivered in some areas of Scotland, known as community respiratory teams.
Why is this important
International comparisons of chronic respiratory disease prevalence have found that Scotland and the United Kingdom (UK) have some of the highest rates of chronic obstructive pulmonary disease (COPD) and asthma in the developed world. Scotland has a higher prevalence of COPD than other nations in the UK.
Chronic respiratory conditions, such as COPD and asthma, are associated with considerable morbidity, mortality and healthcare use in Scotland. For example, in Scotland COPD accounts for an estimated 122,000 emergency bed days per year, with an average inpatient stay lasting 4–8 days and costing around £3,000. Overall emergency or unscheduled hospital admissions in the UK have increased over the last 30 years. Unscheduled episodes of care are costly and can be detrimental to patient health, particularly among older people. Community and social care programmes, such as community respiratory teams, have been developed to try to improve health outcomes and avoid unscheduled hospital admissions among patients with chronic respiratory conditions.
