Breathlessness and Parity

What matters and to whom?

Dr Louise RestrickLondon Respiratory Network LeadIntegrated Consultant Respiratory

PhysicianWhittington Health

and Islington CCG

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

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

AsthmaCOPD

Lung Cancer

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

Addressing asthma needs with people who have learning disabilities

45% died before seeking or being provided with medical care*

RelationshipsPatient, family, ward team, learning

disabilities advocate, respiratory nurse specialist & respiratory consultant, quit

smoking advisor, GP

TimeEnabling and supporting self-care

Quit Smoking as treatmentCare Planning Conference

Responsibility and Advocacy

> 1 in 5 adults who died were current smokers*

NRAD Report 2014*

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 commonBreathlessness

Londoners dying from smoking

7

‘1 in 5 deaths due to smoking’

Respiratory Disease

Cancer

Cardiovascular disease

Mental illness

Looking at maps eg Londonsmoking, deprivation, mental health … smoking

Does smoking matter for people with mental illnesses?

2011‘Increased smoking is responsible formost of the excess mortality of peoplewith 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

Does respiratory disease matter in ‘hard to reach’ groups?

‘People with mental health problems … die on average 16-25 years soonerthan 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

Risk of COPD in mental illness

%

Adults21% smokers

9% heavy smokers

Inpatientswith serious

mental illness

People livingwith 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

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

Comparative outcomes for people with mental illness and COPD

?

Does breathlessness matter in ‘hard to reach populations’?

*Tessier et al Eur Journal of Epidemiol 2001;17:223-229Frostal 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*

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

Does breathlessness matter in ‘hard to reach populations’?

5 year mortality rates of patients with COPDAccording to FEV1 and MRC score

MRC breathlessness stronger predictor of death than FEV1 in COPD

Banzett & O’Donnell Eur Respir J 2104:43;1547-1550Data from Nishimura et al Chest 2002:121;1434-1440

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

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

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

Do we use our time to best value on a Respiratory Ward?

Enhanced Recovery in Medicinewhat do we mean and what are we trying to do?

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

Enhanced Recovery to address needs of homeless with respiratory disease

• Get better Late presentationPoor underlying healthCombination of physical & mental health needsTobacco and alcohol dependence

• What matters to patient‘Roof over my head’

• Plan ahead with patient, social worker, alcohol liaison, smoking cessation advisorSafe transition to ?address ?GPCommunication?

Enhanced Recovery:Pulmonary Rehabilitation

24

‘Breathe Better, Feel Good, Do More’

Do we use time to best value in prison?

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:d5362270 000 people with schizophrenia &100 000 with bipolar disease

England HES data

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 ….’

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 recorded20% known smokers not offered quit smoking interventions

< 10% known COPD and/or asthmaSelf-reported breathlessness less than observed breathlessness?

Admission opportunity to ...Treat tobacco (and cannabis) dependence

Make diagnosis and treat respiratory diseaseParticipate in pulmonary rehabilitation?

Personal communication,Hughes, Jeanneret, Johansson, Sherring, psychiatry trainees , C& I Mental Health Trust, London*

Enhanced Recovery...

NB not easy

What else could we do differently?Include breathlessness in physical health assessments in

mental illness?

2011

‘Do you get shortof breath?’

Work together on breathlessnessand … respiratory failure

2011

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 dependenceHomelessPrisoners

*

*

*

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