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Conference Abstracts

Conference Abstracts

Academic research presentations are run in conjunction with npj Primary Care Respiratory Medicine

Abstract posters can be found in the Gallery of The International Centre, Telford.

Full details about scientific research abstract oral presentation sessions and the poster presentation session can be found on the conference programme.

Authors: Francis NA, Gillespie D, White PT, Bates J, Lowe R, Thomas-Jones E, Wootton M, Hood K, Phillips R, Melbye H, Llor C, Cals J, Naik G, Kirby N, Gal M, Riga E, Butler CC
Institution: Cardiff University
Presenter: Dr Nick Francis
Category: Research Abstract
Allocation: Oral presentation
Please see the abstract poster in the Gallery.
Session: Abstract winner
Programme day: Saturday
Session time: 29-09-2018 13:00 - 13:15
Location: PCRS 1 (Ironbridge 1)
Authors: Slater M, Gayle A, Blakey JD, Jones G, Baldwin M.
Institution: Boehringer Ingelheim
Presenter: Mariel Slater
Category: Research Abstract
Allocation: Oral presentation
Primary care prescribing habits for asthma in England 2007–15: are we following the guidelines? Mariel Slater1, Alicia Gayle2, John D. Blakey3,4, Gareth Jones3, Michael Baldwin5 1Department of Medicine, Boehringer Ingelheim Ltd, Bracknell, Berkshire, UK, 2Market Access, Boehringer Ingelheim Ltd, Bracknell, Berkshire, UK, 3Department of Respiratory Medicine, Royal Liverpool Hospital, Liverpool, UK, 4Department of Health Services Research, University of Liverpool, Liverpool, UK, 5TA Respiratory/Biosimilars, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany Introduction Guidelines recommend a stepwise approach to treatment in asthma, with the aim of avoiding high doses of inhaled and oral corticosteroids. In the UK, prescription of ICS is common, yet ∼65% of patients on ICS/LABA are not well controlled. We investigated how asthma treatment guidelines were being applied in England. Methods UNTWIST 1 linked UK Clinical Practice Research Datalink (CPRD) records with Hospital Episode Statistics (HES) from 1st Jan 2007–31st Dec 2015, to identify asthma patients aged ≥18 years who were prescribed add-on therapy to ICS/LABA. Treatment stage was assessed during the first 3 months of observation i.e. study start + 3 months. Results Of 23,293 asthma patients (mean age 50 years; 61% female) with an average follow-up of 5 years, 16% received “additional therapies” i.e. an increase in therapy from low-dose ICS/LABA, 80% “high-dose therapies” i.e. high dose ICS ± further add-ons and 4% “maintenance OCS therapy” during the 3-month assessment period. Of these patients, only 19.2% received one or more of the add-on therapies LTRA, LAMA and/or theophylline (14.8%, 0.5% and 5.1% respectively). Conclusion Add-on therapies were used relatively infrequently in adult asthma patients, which appears inconsistent with the guidelines. In England between 2007-2015 the most common approach to asthma therapy in primary care seemed to be; SABA followed by ICS, ICS/LABA and then OCS. This approach may expose patients to harm from high-dose corticosteroids. These results also highlight the major shift in practice that is required to comply with NICE asthma treatment guidance.
Session: Research presentations: Asthma prescribing and specialist referral
Programme day: Saturday
Session time: 29-09-2018 11:10 - 11:55
Location: PCRS 3 (Wenlock Suite)
Authors: Gayle A, Blakey JD, Jones G, Slater M, Baldwin M.
Institution: Boehringer Ingelheim
Presenter: Mariel Slater
Category: Research Abstract
Allocation: Oral presentation
Introduction The number of patients eligible for referral to asthma specialist care in the UK is unknown, impeding service planning. We determined how many patients met eligibility criteria in a non-interventional cohort study using latest national asthma guidelines. Methods UNTWIST 1 linked UK Clinical Practice Research Datalink (CPRD) records with Hospital Episode Statistics (HES) from 1st Jan 2007–31st Dec 2015 to identify asthma patients ≥ 18 years. Eligibility for referral by BTS/SIGN 2016 guidelines was classed by either; a) high-dose therapies i.e. high dose ICS ± further add-ons (previously classed as BTS/SIGN “step 4”), b) maintenance OCS therapy (previously classed as BTS/SIGN “step 5”), or c) “incident eligibility” during follow-up (continuous OCS >3 months OR high-dose ICS/LABA or 3 controllers AND ≥2 asthma attacks in the following year). Results Overall, of >1.15 million records of people with an asthma diagnosis aged 18-80 years old at study start (January 2007), 281,121 from England met initial study inclusion criteria (active and registered at a GP practice between 2007-2015, eligible for linkage with HES, minimum history of 12 months before index and no active COPD diagnosis or participation in a clinical trial). Of these diagnosed asthma patients (with or without treatment), 19,837 patients (7.1%) were eligible for specialist referral during follow-up; 9% of patients on additional therapies (previously described as BTS/SIGN “step 3”) and all patients on high-dose therapies (previously “step 4”) or maintenance OCS (previously “step 5”). Conclusion A significant proportion of the asthma patient population are currently eligible for referral. These data suggest that further work is required to decide whether; i) the UK should pursue a major increase in specialist capacity, or ii) the bar for referral should be substantially higher, or both. This should be a consideration for commissioning groups in both following guidance and providing resources.
Session: Research presentations: Asthma prescribing and specialist referral
Programme day: Saturday
Session time: 29-09-2018 11:10 - 11:55
Location: PCRS 3 (Wenlock Suite)
Authors: Cates CJ, Schmidt S, Ferrer M, Sayer B, Waterson S
Institution: St. George's, University of London
Presenter: Sam Waterson
Category: Research Abstract
Allocation: Oral presentation
Aim Epidemiological evidence has suggested a link between beta2-agonists and increased asthma deaths. This Cochrane systematic review aimed to assess the risk of mortality and non-fatal serious adverse events in trials which randomised patients with chronic asthma to regular salmeterol and inhaled corticosteroids in comparison to the same dose of inhaled corticosteroids. Method We analysed data from 41 studies in 27951 adults and eight studies in 8453 children that compared regular salmeterol in addition to inhaled corticosteroids, against the same dose of inhaled corticosteroids. We included parallel design controlled clinical trials on patients of any age and severity of asthma if they randomised patients to treatment with regular salmeterol and inhaled corticosteroids, and were of at least 12 weeks duration. We conducted the review according to standard procedures expected by the Cochrane Collaboration. Results No deaths were attributed to asthma in any of the studies, and there were no deaths in children. The results for all-cause mortality in adults are compatible with at best one less and at worst one more death from any cause (in comparison with one death on regular ICS alone). Non-fatal serious adverse events (admissions to hospital) were not increased beyond the play of chance in adults or children when regular salmeterol was added to inhaled corticosteroids as randomised treatment. Conclusion We remain uncertain of the safety of salmeterol and ICS with respect to the risk of dying from asthma, while the results for non-fatal serious adverse events are too imprecise to completely rule out any increased risk. Clinical decisions regarding regular use of salmeterol in combination to ICS have to take into account the balance between known symptomatic benefits of salmeterol when used in combination with an inhaled corticosteroid and the remaining degree of uncertainty associated with its potential harmful effects.
Session: Research presentations: Asthma prescribing and specialist referral
Programme day: Saturday
Session time: 29-09-2018 11:10 - 11:55
Location: PCRS 3 (Wenlock Suite)
Authors: Hamelmann E, Goldstein S, Engel M, Sigmund R, Vogelberg C
Institution: Children’s Center Bethel, Evangelisches Klinikum Bethel GmbH, Bielefeld, Germany
Presenter: Tom Fardon
Category: Research Abstract
Allocation: Oral presentation
Aim We present a pooled analysis of lung function data in adolescents and children with symptomatic severe asthma. Method Two Phase III, randomised, double-blind, placebo-controlled, parallel-group, 12-week trials in patients aged 6–11 years (VivaTinA-asthma®, NCT01634152) and 12–17 years (PensieTinA-asthma®, NCT01277523) with symptomatic severe asthma. Patients received once-daily tiotropium Respimat® (tioR) (5µg or 2.5µg) or placebo Respimat® (pboR) as add-on to high-dose inhaled corticosteroids (ICS) plus one controller or medium-dose ICS plus two controllers. Patients had a documented history of asthma (VivaTinA-asthma®, ≥6 months; PensieTinA-asthma®, ≥3 months), and were symptomatic at screening and before randomisation (Asthma Control Questionnaire mean score ≥1.5). The primary endpoints were peak forced expiratory volume in 1 second (FEV1) within 3 hours post-dose (FEV1[0–3h]) response; the secondary endpoints were trough FEV1 response; further endpoints were forced expiratory flow between 25% and 75% of the forced vital capacity (FEF[25–75%]) response; the post hoc endpoints were trough FEV1/forced vital capacity (FVC) ratio. All endpoints were measured at Week 12. Results 793 participants (VivaTinA-asthma®, N=401; PensieTinA-asthma®, N=392) were randomised across both trials; 792 were included in this pooled full analysis set. Baseline demographics and disease characteristics were balanced between treatment groups. TioR improved lung function at Week 12, with tioR 5µg showing significant improvements in peak FEV1(0–3h), trough FEV1 and FEF(25–75%) responses, and FEV1/FVC ratio versus pboR. TioR 2.5µg showed superior improvements in peak FEV1(0–3h) and FEF(25–75%) responses and FEV1/FVC ratio versus pboR, with numerical improvements in trough FEV1 response versus pboR (Table). The safety and tolerability of tioR was comparable with those of pboR. Conclusion Tiotropium Respimat® add-on therapy is an effective bronchodilator, producing clinically meaningful improvements versus placebo in lung function in patients aged 6–17 years with symptomatic severe asthma, mirroring findings in adult patients with symptomatic asthma.
Session: Research presentations: Asthma prescribing and specialist referral
Programme day: Saturday
Session time: 29-09-2018 11:10 - 11:55
Location: PCRS 3 (Wenlock Suite)
Authors: Akindele A, Daines L, Cavers D, Pinnock H, Sheikh A
Institution: Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh Usher Institute, University of Edinburgh
Presenter: Adeola Akindele
Category: Research Abstract
Allocation: Oral presentation
Aim: Misdiagnosis (over-diagnosis and under-diagnosis) of asthma is common. Under-diagnosis can lead to avoidable morbidity and mortality, while over-diagnosis results in excessive spending and exposes patients to unnecessary side-effects of treatment. This study aimed to explore the diagnostic approach and challenges faced by general practitioners (GPs) and practice nurses when making a diagnosis of asthma. Methods: A mixture of purposive and convenience sampling was used to recruit participants. GPs and nurses working in NHS Lothian, Scotland were interviewed using in-depth semi-structured qualitative interviews. Transcripts were analysed using a thematic approach. Results: 10 GPs and 5 nurses were interviewed. Participants weighed up an individual’s probability of asthma which contributed to their decision to conduct peak flow monitoring, spirometry and/or a trial of treatment. Challenges in the diagnostic assessment of asthma included time pressures, the variable nature of asthma, overlapping clinical features of asthma with other conditions such as chronic obstructive pulmonary disease in adults and viral illnesses in children. To improve diagnostic decision making, participants suggested improved educational opportunities and better diagnostic tools. The idea of a clinical prediction calculator to guide the asthma decision-making process was appealing to the nurses interviewed, however, most GPs felt that their clinical judgement would be preferable. Participants were also positive towards the idea of diagnostic hubs as they felt hubs would provide greater availability of tests. However, some raised concerns about funding and deskilling primary care practitioners. Conclusions: Clinical judgement of the probability of asthma was fundamental in the diagnostic process. Tests (including trial of treatment) to confirm or refute the working diagnosis were chosen based on probability and local availability. To improve the diagnostic pathway for asthma, standardising the clinical assessment made by individual healthcare practitioners should be supported by access to diagnostic services for additional investigation and clarification of diagnostic uncertainty.
Session: Research presentations: Case-finding and diagnosis
Programme day: Saturday
Session time: 29-09-2018 08:50 - 09:35
Location: PCRS 3 (Wenlock Suite)
Authors: Daines LJ, McLean S, Buelo A, Lewis S, Sheikh A, Pinnock H
Institution: University of Edinburgh
Presenter: Dr Luke Daines
Category: Research Abstract
Allocation: Oral presentation
Background: Misdiagnosis of asthma is common and substantial. As asthma is mostly diagnosed in non-specialist settings, a clinical prediction model to inform assessment of the probability of asthma in primary care may help improve diagnostic accuracy. We aimed to identify and describe existing clinical prediction models designed to support the diagnosis of asthma in children and adults in primary care.
 Methods: We searched Medline, Embase and CINAHL from 1/1/1990 to 23/11/17. We included any clinical prediction model designed for use in primary care or equivalent settings, to aid diagnostic decision-making of a healthcare professional during the assessment of an individual with symptoms suggesting asthma. A quantifiable probability of asthma diagnosis was the primary outcome. Two reviewers independently screened titles/abstracts and full texts for eligibility and extracted data from included papers. Results: From 13,788 records, 53 full-text articles were reviewed. Eight articles, from seven modelling studies were included. Risk of bias within studies was moderate to high. Logistic regression was the most common modelling technique. One study created a decision tree. Only three studies validated their models. Three studies used symptoms as the only variables in their model. Two studies incorporated the results of clinical tests (spirometry and fractional exhaled nitric oxide) in their final models but only one study used examination findings of a clinician. Wheeze was the most commonly used predictor. Variability of asthma symptoms was an important predictor for asthma diagnosis in all but one model. Conclusions: Relatively few clinical prediction models have been developed to aid asthma diagnosis in primary care. Most, but not all had limitations in study design. Wheeze, symptom variability and results of clinical tests were valuable in predicting asthma diagnosis. The results of this systematic review will inform the development of a clinical prediction model for asthma diagnosis in primary care.
Session: Research presentations: Case-finding and diagnosis
Programme day: Saturday
Session time: 29-09-2018 08:50 - 09:35
Location: PCRS 3 (Wenlock Suite)
Authors: Ray E , Kruk, H, Gillett K, Culliford D, Lin X, Jordan R, Thomas DM, Price D and Wilkinson T.
Institution: University Hospital Southampton NHS Trust
Presenter: Mrs Emma Ray
Category: Research Abstract
Allocation: Oral presentation
Aim: Chronic Obstructive Pulmonary Disease (COPD) accounts for a significant proportion of hospital admissions in the UK and is a leading cause of death worldwide. Missed opportunities for early diagnosis and optimisation of treatment are common in primary care. We implemented a case-finding strategy in order to identify previously undiagnosed patients with COPD who may have attended their GP practice with symptoms of the disease (ASSIST study, REC: 16/5C0629). Methods: Ever smokers, aged 40-79 years with an estimated risk score ≥22.5% were identified using a published, Read-code based case-finding algorithm (TargetCOPD score), applied to primary care records to actively case-find smokers with signs and symptoms of COPD. Eligible patients were invited to attend their GP practice for a specialist respiratory review including spirometry testing. Results: 2,213 patients across 12 GP practices in Hampshire, UK were identified. Of these, 611 were deemed ineligible by the GP, leaving 1,602 invited. 383 (23.9%) patients responded to an initial mail-out, and 288 (male 51%, mean age 63, SD=6.71) were consented into the study following further eligibility checks and accounting for non-attenders. Overall, 31% (89) demonstrated obstructed spirometry (FEV1/FVC or FEV1/VC<70) with 15.2% (44) having a fixed obstruction less than the lower limits of normal. Of those with an FEV1/FVC or FEV1/VC<70, 66% (59) had mild obstruction (FEV1 >80% predicted) and 34% (30) had moderate obstruction (FEV1 50-79% predicted). 85% (76) with obstructed spirometry also reported chronic respiratory symptoms and 63% (55) had an MRC ≥2. 66 (23%) patients were current smokers and overall the mean pack year was 24.68 (SD=20.47). Conclusions: Results demonstrate that actively case-finding patients for COPD using an electronic algorithm applied to GP records, identified patients with obstructed spirometry and symptoms of COPD. Further analysis and follow-up data will examine whether using the case-finding algorithm results in earlier identification of COPD in a cost-effective manner and an improvement in quality of life for patients.
Session: Research presentations: Case-finding and diagnosis
Programme day: Saturday
Session time: 29-09-2018 08:50 - 09:35
Location: PCRS 3 (Wenlock Suite)
Authors: Ray E. Gillett K, Kruk H, Summers R, North M, Thomas DM, and Wilkinson T
Institution: University Hospital Southampton NHS Trust
Presenter: Mrs Emma Ray
Category: Research Abstract
Allocation: Oral presentation
Aim: A late or a missed diagnosis of Chronic Obstructive Pulmonary Disease (COPD) in primary care is associated with significant health care costs and poor patient outcomes. The ASSIST study (REC: 16/5C/0629) implemented a computerised case-finding algorithm in primary care records, to identify previously undiagnosed patients at risk of having COPD. Methods: In total, 1,602 patients were invited to attend a lung health check visit at their GP practice, 288 patients (male 51%, mean age 63, SD=6.71) were enrolled, reviewed by a respiratory nurse and completed spirometry testing. Patient feedback was sought via completion of a study-specific questionnaire, analysed and a thematic review of free text was completed. Results: Results showed that a proportion of patients (161, 57.5%) were concerned to receive an invitation letter explaining they may be at risk of having a lung condition, although 147 (53.3%) were not surprised. Patients (265, 94.3%) agreed that being invited made them feel supported by their GP practice but felt worried about attending the clinic (285, 100%). Common themes to attend included (i) ‘concern for their own health’, (ii) ‘benefitting their own health’ and (iii) ‘benefit for others’. 283 (99%) patients stated that attending the clinic was a positive experience, whilst 223 (80%) agreed that it had made them think about their health. In general, patients expressed that attending the clinics (i) was a ‘positive learning opportunity’, (ii) had provided ‘reassurance’ and that (iii) ‘future clinics’ should be available to other patients. Conclusions: Although patients were concerned they may be at risk of having a lung condition, patients who attended the clinic overwhelmingly found it a very positive experience. This was due to the thorough assessment at the visit, perceived expertise of the staff conducting the clinics and advice provided, which led to patients recommending continuing the service in the NHS.
Session: Research presentations: Case-finding and diagnosis
Programme day: Saturday
Session time: 29-09-2018 08:50 - 09:35
Location: PCRS 3 (Wenlock Suite)
Authors: Ray, E. North, M. Morris, B. Field, S. Gillett, K. Kruk, H. Stafford-Watson, M.
Institution: University Hospital Southampton NHS Trust
Presenter: Mrs Emma Ray
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
Aims: Although smoking rates have declined in recent years, 35% of 15year olds admit to ever having smoked. The role of health education at school is therefore an important factor in preventing smoking uptake. For World COPD day 2018, NHS respiratory teams from across Hampshire collaborated to deliver a smoking prevention educational event aimed at year 7 students (aged 11-12 years) at a local school in Southampton City. Methods: The event included a presentation by a respiratory Doctor about the causes and effects of COPD and a question and answer session with a patient on their experience of living with the disease. Students then completed activities including viewing lung specimens through microscopes, partaking in a mini-pulmonary rehabilitation session, and used iPads to visualise the airways and understand how smoking ages the skin. After the event students were asked to complete an evaluation form with 77 forms returned. Findings: The events were positively received by the students with the majority, 84% (65), agreeing that they were less likely to smoke as a result of attending the event. Written feedback included ‘This lesson was very educational and should be taught to each pupil in England to make them understand more about cigarettes’. 87% (69) of students stated that they found the event helpful in understanding lung health and how smoking affects the lungs, whilst 55% (42) stated they felt better able to talk to a relative or carer about their smoking. Overall, 75% (58) stated that they would recommend the event to other students. Summary: In conclusion, delivery of a smoking prevention education event to a local secondary school by NHS respiratory teams has the potential to raise awareness of the known dangers of smoking and may help prevent smoking uptake in children.
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Gaduzo S, Gupta V
Institution: Cheadle Medical Practice
Presenter: Dr Stephen Gaduzo
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
Patients with breathlessness referred to cardiology or respiratory clinics are often sent on to the other specialty if the diagnosis is unclear. This can lead to delay in diagnosis, duplication of investigations and inconvenience for patients. An audit of a sample of such referrals confirmed this. With support from CCG and FT, initially under "100 day improvement" banner, we set up a joint clinic with cardiologist and respiratory physician consulting together, having access to ECG, echocardiogram, spirometry and CXR. (BREATHE - Breathlessness Rapid Evaluation, Assessment, Treatment and Health Education) The aim was to see and assess patients in 1 stop if possible. If further investigations were necessary they would be arranged and a report, results and treatment plan sent to the GP. Where possible patients were signposted to appropriate community teams, self-help organisations etc. All appointments were for new patients, follow-up was carried out in individual specialty clinics. Patients were initially recruited from out-patient waiting lists, results from the first cohort have been previously reported. (BTS winter meeting 2017 poster) This report examines the second cohort of 53 attendees, the majority of whom were referred directly to BREATHE from 1y care, using a template developed with GPs. More than half were assessed with only 1 OPD attendance. Extra investigations included full lung function, HRCT thorax, stress echo, overnight oximetry, 24hr ECG, cardiac MRI. There was a range of final primary diagnoses, and a significant number with multifactorial causes. Of significance is the relatively high number with deconditioning, anxiety, high BMI. (data to follow). Patient feedback was very positive, most commenting that although they spent a couple of hours in the clinic, a lot was done, and they liked the collaboration between consultants. The clinicians themselves comment that they have found consulting together rewarding and also an invaluable asset in terms of communication and learning between specialties. Although resource intense, this model of joint consultation and investigation offers an alternative, symptom based way of dealing with breathless patients whose diagnosis is not clear. We would like to develop the pathway and model further with more involvement of primary and community care teams.
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Daw R, Petty D
Institution: Westcliffe Medical Practice, Westcliffe Road, Shipley, Bradford, BD18 3EE
Presenter: Robert Daw
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
Context NICE recommended FeNO testing to help diagnose asthma and as an option to support management in people who are symptomatic despite using inhaled corticosteroids (ICS).1 FeNO testing has also been shown to useful in predicting response to ICS and in reducing ICS.2,3 Analysis of problem Little is known about how to use FeNO testing in “real-world” practice. We aimed to pilot FeNO testing to see if it could improve: • diagnostic accuracy of patients presenting with asthma-like symptoms • patients acceptance of an asthma diagnosis • confidence in stepping-down ICS treatment Strategy for change Asthma nurses were trained to use the FeNO testing and how to apply alongside normal clinical practice. Fours nurse in 5 surgeries were trained. 107 patients were reviewed. Measurement of improvement Data was collected on FeNO testing used to assist/confirm asthma diagnosis; patients not accepting diagnosis and determining ICS step up/down. Follow up data was collected after 3 months. Results The mean age of patients was 46 (63% female). FeNO testing was used to assist in diagnosis in 39 (36%) patients; confirming existing diagnosis 11 (10%); helping patient accept diagnosis 1 (1%); improving adherence 12 (11%); helping ICS step-down 27 (25%) and step-up 26 (24%). Use of FeNO testing increased confidence in making asthma diagnosis in 74 (69%) cases; stepping up/down ICS in 57 (53%) and increasing patient confidence in treatment changes in 39/51 cases (76%). ICS was increased in 12; reduced in 18 and used not to increase ICS in 22 patients. The net annual savings on ICS prescribing was £3,206 outweighing FeNO costs. Leasons learnt FeNo testing improves practitioner and patient confidence. Savings on ICS outweighed costs. Training is required to ensure appropriate targeting of FeNO testing. 1. https://www.nice.org.uk/guidance/dg12 2. Smith A.D, et al N.E.J.M 2005:352; 2163-2173 3. Price D.B et al Lancet Respiratory Medicine http://dx.doi.org/10.1016/S2213-2600(17)30424-1.
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Subramanian D, Greenwood S, Ali S, Bennett C, Lagnado H, Sutton L
Institution: Royal Derby Teaching Hospital NHS Foundation Trust
Presenter: Deepak Subramanian
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
The Improving Asthma Care Together (ImpACT) project implemented a novel model of care which provides an integrated responsive services for patients with asthma in Derby. Problem: Our baseline audits showed that low number of patient (20%) who were admitted to hospital had a management plan and only 20% were reviewed by their GP practice within 48 hours of discharge. Patients also found it difficult to access service and support during an exacerbation. Strategy for change: We implemented a whole-scale service intervention which included in-reach to the emergency department, a ward discharge clinic, a 7 day telephone helpline and face to face review by specialist nurse within GP Practices. Measurement of improvement: A questionnaire was devised and patients were asked to complete this approximately 6 weeks following the intervention. A 10 point scale was used to ask patient’s what their confidence levels were in self-managing their asthma (0=no confidence and 10=highly confident) and how they rated their asthma control (0=poor and 10=excellent). Effect of change: The service led to significant improvements in patient’s self-reported assessment of asthma control and confidence in managing their own asthma (see attached diagrams Paired t-test <0.001; n=107). Over 600 FeNO measurements were performed in primary care. Monthly asthma admissions between Dec-April have consistently been lower than the preceding year, despite an increase in respiratory attendances. 91% of genuine asthma admissions were followed up by our service. Lessons learned: The service led to an improvement in patient-reported asthma control and self-management. Qualitative feedback demonstrated that patients valued this service, in particular the responsiveness and knowledge of the staff. The service also led to a significant improvement in 48-hour follow-up reviews Message for others: An integrated, responsive service for asthma can be effective in improving patient’s asthma control, self-management and can lead to a reduction asthma admissions.
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Freeman D, Gerrard V, Turton J
Institution: Norfolk Community Health & Care
Presenter: Dr Daryl Freeman
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
Following on from the IMPACT project ( Improving the Management of Patient AssignedCOPD Treatment) undertaken in North Norfolk CCG, a Primary Care based Respiratory Service was designed and implemented. The need for this was based on a three fold difference between COPD admission rates across practices within the CCG. It was felt that any improvement in the variability should be focussed in Primary Care and a service was set up to be run primarily by D Freeman & V Gerrard. The service had 2 phases - a practice visit identifying the training levels of Health Care Professionals delivering the service, discussing with practice managers, admin staff and where relevant dispensers ,how their roles could be used in identifying patients who may require referral to the service, and then a mentored clinic with the Practice Respiratory Leads. The second phase was a series of practice based clinics, run by DF & VG, seeing patients referred by the Practice Respiratory Leads. The Practice Leads were encouraged to refer patients who had been admitted to an Acute Trust, who had been seen in A&E, seen by OOH, seen by the Ambulance Service or who had had 2 or more exacerbations in the previous 12 months. The Practice Respiratory Leads were encouraged to attend the clinics too as an ongoing mentoring & educational process. Each practice gave the visiting clinician access to their clinical computer system & notes were made co-temporaneously in the GP record - in order to ensure that recommendations were carried out and that the Primary Health Care Team could see not only what had been done - but why. The Primary Outcome important to the CCG was a reduction in admissions, this was demonstrated in the Practices visited on a regular basis where not only a reduction in admissions was seen but a cost saving. Sadly the CCG decided that the service should be terminated mid 2017- this was as a result of the repeated concerns of the clinicians over the lack of IT & admin support leading to a large degree of clinical concern. Had the service been set up with full support - as had been originally suggested- it would have continued. Both clinicians are very experienced & had repeatedly voiced their concerns over the way the overall support for the service had been designed and it was felt that should the process be repeated it would be imperative that the implementation should include full IT & admin support. The Norfolk & Waveney STP has a Respiratory Working Group which is looking at providing a similar project across the entire STP footprint.
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Bannerman AR.
Institution: NHS
Presenter: Amy Bannerman
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
The British Thoracic Society (BTS) recommends all patients with Chronic Obstructive Pulmonary disease (COPD) are offered Pulmonary rehabilitation (PR), however, the referral rate is lower than the number of eligible patients (National COPD Audit Programme, 2015). The aim of this Quality Improvement Project (QIP) was to increase the percentage of eligible patients within one GP surgery referred to PR by discussing and offering referrals; if referrals were declined, data was collected regarding this. 'SystmOne Clinical Reporting Tool' was used to identify patients on the COPD register with 'MRC3 or above'. Of 72 patients identified, 11 (15.3%) had been referred to PR and 61 patients (84.2%) had no documented referral. Following application of exclusion criteria, 29/61 unreferred patients were eligible for PR; of these, 15 declined and 14 accepted referrals. Reasons for declining referral included: Family circumstances, carer role, location, mobility, wanted to consider referral and moving out of area. Later interventions included staff training regarding PR and the referral process with plans to incorporate this into annual COPD reviews. Following this QIP, all eligible COPD patients within the practice had discussed and been offered a referral to PR based on their electronic documentation. However, it is unknown if these patients attended or completed PR or if any clinical benefit was seen. Data collected relied on accurate electronic documentation which could indicate some eligible patients were missed. The next stage would review if this GP referral rate was maintained and whether staff found the training beneficial regarding discussing and referring to PR. The anecdotal reasons for declining referral provided an interesting insight into other factors affecting utilisation of local PR services. References: - National COPD Audit Programme: Resources and organisation of Pulmonary Rehabilitation services in England and Wales 2015. Pulmonary Rehabilitation: Time to breathe Better. National organisational audit report November 2015
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Grimwood L, Sellers, V
Institution: BOC
Presenter: Laura Grimwood
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
Background/Introduction It was identified that a significant proportion of patients required help completing written paperwork during Pulmonary Rehabilitation (PR). This raised a concern regarding patients’ health literacy levels that may not be a localised issue. An audit was conducted across all PR services to discover the extent of the problem. Existing and emerging literature suggests that poor health literacy is both a national and worldwide concern and that it is linked to poor clinical outcomes. Specific Measure 98% of all patients will be able to understand the printed literature that is supplied as part of PR. Method Consecutive sampling of all consenting PR patients during the audit period (13th November 2017 – 2nd February 2018) using an initial assessment and discharge questionnaire that had been piloted. A blank questionnaire was returned if a patient declined to partake in the audit. Results A total of 161 patients across 9 regions and 25 venues completed the questionnaires. The Specific measure was not met. The audit found that 20% had a below functional health literacy score (METER) rising to 31% when calculated as an adjusted METER score (Rawson et al, 2010). 26% reported needing help with understanding forms, letters or medicine labels. 43% reported difficulty remembering things and 20% reported trouble following a conversation in the past few months. 6% reported English was not their first language and 3% reported learning difficulties. 36% reported having hearing difficulties and 19% reported eyesight problems that were uncorrected. Conclusion/Recommendations The findings identified a significant level of health illiteracy. Further work needs to be done regarding patient education across all health services, not just PR. The findings indicate that a significant number of patients may not be able to effectively self-manage due to health illiteracy, memory, cognition, eyesight, hearing and language barriers. This raises concerns regarding the safety, reliability and practicality of patients' self-managing their respiratory condition.
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Anderson A, Canavan M
Institution: Respiratory care Solutions
Presenter: Miss Melissa Canavan
Category: Best Practice / Service Improvement Abstract
Allocation: Poster presentation
Introduction: Leeds has one of the highest admission rates and some of the poorest outcomes for chronic obstructive Pulmonary Disease (COPD) in the country. We aimed to identify gaps in current care provision for COPD patients in primary care, who have been identified at high risk of exacerbation and hospitalisation, to inform and prioritise care against high value interventions. Methods: We virtually reviewed 200 patient records from across 11 GP practices in Leeds, auditing the use of high value interventions. The audit included patients who had two or more exacerbations in a year. Results: From 200 records, we found that there were low rates of high value interventions. 23% did not receive flu vaccine. 53.5% continued to smoke with 5.5% recorded as never smoked. 2% had completed pulmonary rehabilitation. 43% were on triple therapy. 43% had moderate disease. 20.5% with potentially the incorrect diagnosis. There are also issues with anticipatory medication on repeats. Audit findings were presented and discussed at a multidisciplinary meeting which included the clinical commissioning group, secondary care and community respiratory team in Leeds. Discussion: Similarly this audit identified that there are issues with correct diagnosis of COPD patients in primary care, same as the National COPD Audit (2017). Of those correctly diagnosed this audit identified that moderate disease patients are the group that are exacerbating more frequently with no specialist input. A focus towards this cohort of patients should be considered. It is evident that there is low uptake of high value interventions. It is up to the commissioners to use this data to inform decision making surrounding the provision of care and services within primary care if they would like to see a reduction in exacerbations and hospital admissions alongside improving outcomes for COPD patients in Leeds.
Session: Best Practice / Service Development Poster Presentation
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: (Gallery)
Authors: Hutchinson A, Barclay-Klingle N, Galvin K, Johnson MJ
Institution: University of Hull
Presenter: Dr Ann Hutchinson
Category: Research Abstract
Allocation: Oral presentation
Aim: Chronic breathlessness affects patients’ lives and their carer. We aimed to explore the experience of people living with breathlessness due to chronic conditions and those caring for/treating them with regard to coping with breathlessness, and nature of clinical interactions. Method: Electronic databases (Ovid MEDLINE, Embase, CINAHL Plus, PsycINFO) were searched (1987 to October 2017; English language), for qualitative studies exploring the experience of chronic breathlessness (patients, carers, clinicians). Two independent reviewers screened titles, abstracts and papers retrieved against inclusion criteria. Disagreements were resolved with a third reviewer. Primary qualitative data were extracted and synthesised using thematic synthesis. Results: Inclusion and synthesis of 101/2,303 international papers produced four descriptive themes: 1) widespread effects of breathlessness, 2) coping, 3) help-seeking behaviour, and 4) clinicians’ responsiveness to the symptom of breathlessness. The themes were combined to form the concept of “Breathing Space”, to show how engaged coping and appropriate help-seeking (patient) and attention to symptom (clinician) helps maximise the patient’s quality of living with breathlessness. Conclusion: Breathlessness has widespread impact on patient and carer and affects Breathing Space. The degree of Breathing Space is influenced by interaction between the patient’s coping style, their help-seeking behaviour and their clinician’s responsiveness to breathlessness itself in addition to managing the underlying disease.
Session: Research presentations: Lived experience of lung disease
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: PCRS 3 (Wenlock Suite)
Authors: Hutchinson A, Galvin K and Johnson MJ
Institution: University of Hull
Presenter: Dr Ann Hutchinson
Category: Research Abstract
Allocation: Oral presentation
Aim: Patients with chronic breathlessness due to cardiorespiratory conditions present frequently to the emergency department (ED). We aimed to understand reasons for presentation from the perspectives of the patients themselves, their carer and their clinician. Method: Patients recruited as part of a mixed methods observational study in a single tertiary hospital ED of presentation to the emergency department (ED) due to breathlessness crisis were purposively sampled. Linked semi-structured interviews with patients (n=18), their carer (n=9) and their clinician (n=8) were conducted, recorded and verbatim transcribed. Transcripts were subjected to thematic analysis. Results: Patients’ ages ranged between 32 to 84 and 56% were men. Nine carers and eight clinicians were interviewed. Two themes represented the findings: 1) The daily experience of living with chronic breathlessness; subthemes: i) widespread effects of breathlessness, ii) coping with breathlessness and iii) help-seeking in the community and its consequences and 2) Presentation to the ED; subthemes: i) patient reluctance to call for medical help and the involvement of others in the decision to present, ii) presentation because of previous help-seeking in the community and iii) presentation having sought help from their primary clinician just prior to the presentation. Conclusion: The decision to present to the ED is made within the context of the daily experience of living with breathlessness and is made in crisis, often with the involvement of others. In this sample there were four broad reasons for presentation: 1) reluctance to call for medical help and then the decision was often made by others, 2) learned experience to turn directly to the ED for breathlessness crisis, 3) if reviewed by their primary clinician, directed to present to the ED for tests/treatment/specialist advice or 4) primary clinician is unavailable.
Session: Research presentations: Lived experience of lung disease
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: PCRS 3 (Wenlock Suite)
Authors: Masters L, C de C Williams A, Cassidy E, Simpson, J
Institution: UCL
Presenter: Lisa Masters
Category: Research Abstract
Allocation: Oral presentation
Aim The aim of this study was to understand, in greater depth, the impact that COPD has on quality of life for individuals of a working-age. Method A qualitative investigation was conducted with 11 adults with COPD, aged between 52 and 63. A framework analysis approach was used to analyse the data. Results Ten themes were identified, which interact in complex and nuanced ways. The themes identified were: valuing giving back, valuing independence, conflict with the COPD, helplessness vs. agency, changed relationship to health, loss of control, self-efficacy, resilience, readiness, and empowerment vs. disempowerment from services. Conclusion The study sample reported very few concerns specific to their age group. The majority of participants did not report concerns about loss of employment, for example. However, changes to their role within the family and the need to be cared for by their children were reported as being particularly distressing aspects of living with COPD. Participants also reported complex relationships to making lifestyle changes, such as stopping smoking. Participants commonly reported a lack of ‘readiness’ for making changes, and some experienced services as disempowering when this sense of not being ready was not taken seriously. These areas need further exploration.
Session: Research presentations: Lived experience of lung disease
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: PCRS 3 (Wenlock Suite)
Authors: Murphie P, Little S, Paton R, McKinstry B, Pinnock H.
Institution: Respiratory Medicine Department - NHS Dumfries and Galloway
Presenter: Phyllis Murphie
Category: Research Abstract
Allocation: Oral presentation
Please see the abstract poster in the Gallery.
Session: Research presentations: Lived experience of lung disease
Programme day: Friday
Session time: 28-09-2018 16:00 - 16:45
Location: PCRS 3 (Wenlock Suite)
Authors: Hulin J, Brodie A, Mitchell CA
Institution: University of Sheffield
Presenter: Joe Hulin
Category: Research Abstract
Allocation: Oral presentation
Background Since the 1990s, there has been a gradual increase in the rates of opiate inhalation. This is related to growing awareness amongst opiate users and practitioners of the consequences of injecting opiates, such as blood borne virus transmission and increased risk of lethal overdose. This has led to increased concerns over the impact this could have on individual’s respiratory health. These concerns are heightened by the high rates of tobacco, cannabis and crack cocaine smoking in this group. Method A systematic review of the literature on the association between opiate misuse and respiratory health was undertaken (Prospero ID=CRD42017059953). Electronic searches of MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library databases were undertaken for all English language studies published between 1980-2017. All study designs excluding case studies were considered for inclusion. The researchers conducted independent assessment of the inclusion criteria and critical appraisal of the studies. Methodological diversity precluded meta-analyses. Results Overall, 21246 records were retrieved following the removal of duplicates. A total of 38 studies were included in the narrative synthesis. A lack of high quality data and methodological heterogeneity made it difficult to draw firm conclusions regarding the association between opiate misuse and respiratory health. The following three key themes emerged from the data: 1) increased prevalence of COPD and asthma within the opiate misuse population; 2) increased hospitalisations with acute asthma; 3) feasible screening in community substance use services. Conclusion Further research is required to determine the association between opiate misuse and respiratory illness. There is a need to control for factors such as tobacco smoking and poly-drug use in future research, in order to gain further understanding of the impact of opiate inhalation on the overall disease burden and the development and treatment outcomes of conditions such as COPD and asthma.
Session: Research presentations: Multi-morbidity in respiratory care
Programme day: Friday
Session time: 28-09-2018 14:45 - 15:30
Location: PCRS 3 (Wenlock Suite)
Authors: Gayle A, Dickinson S, Poole CD, Pang M, Quint J
Institution: Boehringer Ingelheim Ltd.
Presenter: Alicia Gayle
Category: Research Abstract
Allocation: Oral presentation
Aim: To estimate the incidence of type II diabetes mellitus (T2DM) among people with COPD and investigate whether exposure to inhaled corticosteroids (ICS) and exacerbation status is associated with developing T2DM. Methods: This descriptive cohort study used primary care data from the UK Clinical Practice Research Datalink (CPRD). People with a diagnosis of COPD, any smoking history, and registered in practice between January 2010 and December 2016 were selected. Crude incidence rates and cumulative prevalence by age, gender and social deprivation were determined. Using a nested case-control design we matched each patient with incident T2DM (cases) with five non-T2DM controls by age, gender and GP practice at T2Dm diagnostic date. Logistic regression measured the association between ICS exposure, frequent exacerbations (2 or more annually) and T2DM co-morbidity adjusting for lifestyle factors and co-morbidity. Results: We identified 220,971 COPD patients with a mean age at diagnosis of 66 years (95% CI: 65 - 66), of whom 54% were male. The cumulative prevalence of T2DM was 9.27% (9.15-9.39). The incidence of T2DM was 1.26 per 100 patient years (1.24-1.28), and was higher among men than women (1.32 vs 1.18). The adjusted odds ratio (OR) for developing T2DM was 1.47 (1.36- 1.60) among frequent exacerbators versus infrequent. All levels of ICS exposure increased the likelihood of T2DM incidence compared to those not exposed; most affected were patients receiving >800mcg budesonide equivalent daily(OR 1.73 [1.65-1.82]). Conclusion: Incidence of T2DM among COPD patients is high. Exposure to ICS and frequent COPD exacerbations are independently associated with elevated risk of developing T2DM in this population.
Session: Research presentations: Multi-morbidity in respiratory care
Programme day: Friday
Session time: 28-09-2018 14:45 - 15:30
Location: PCRS 3 (Wenlock Suite)
Authors: Mitchell C, Zuraw N, Twohig N, Delaney B, Dolan N, Hulin J, Walton E
Institution: University of Sheffield
Presenter: Caroline Mitchell
Category: Research Abstract
Allocation: Oral presentation
Aim To explore, with people with a SMI and obstructive airways disease: 1) barriers and facilitators to respiratory healthcare care; 2) the impact of the SMI on the self- management of respiratory health. Methods General practice staff undertook database searches to identify and screen eligible participants, prior to postal invitation to participate (10 general practices). Semi-structured interviews were undertaken with consenting respondents. Anonymised, transcribed interview data were organised using NVivo software. Self-conscious, iterative, thematic analysis identified emergent themes linked to coded data. This process was subject to independent verification Results Participants (6 female, 4 male) were diverse in age (45-74 years) and co-morbid Asthma (6) or COPD (4). Interviews are ongoing. Four key themes identified to date: ‘Social support’ was an enabler of healthcare, for example carers accompanying participants to appointments, neighbours ‘calling for help’ during illness. Family and friendship networks were often disrupted by life trauma and the wider psychosocial impact of mental illness. The majority of participants lived alone and reported ‘Social Isolation’. Breathing problems and financial constraints compounded anxiety associated with ‘getting out’ and sometimes excluded patients from access to healthcare. Relational continuity with local healthcare practitioners helped counteract isolation and psychological barriers to healthcare. ‘Smoking’ was embedded in daily routines and widely ritualised, ‘for stress’. Interventions such as ‘stop-smoking’ support and pulmonary rehabilitation to support 'Self-care' were poorly accessed, if at all. Smoking cessation services were not perceived to support a need to develop alternative self-management strategies to support mental health. Conclusions Interventions to reduce social isolation and optimise supportive networks and self-care could alter the restrictive housebound trajectory for those with SMI and co-morbid respiratory disease and improve access to healthcare. There is a need to co-design accessible smoking cessation treatments, with people with SMI, to address mental health concerns and provide stress management support.
Session: Research presentations: Multi-morbidity in respiratory care
Programme day: Friday
Session time: 28-09-2018 14:45 - 15:30
Location: PCRS 3 (Wenlock Suite)
Authors: aMammoliti K-M, aSohanpal R, bBarradell A, aTaylor SJC, cPinnock H aQueen Mary University of London, bUniversity Hospitals of Leicester NHS Trust, cUniversity of Edinburgh
Institution: Queen Mary University of London
Presenter: Kristie-Marie Mammoliti
Category: Research Abstract
Allocation: Oral presentation
AIM Those living with chronic obstructive pulmonary disease (COPD) have a higher risk of anxiety/depression which increases with the severity of their COPD. TANDEM is a randomised controlled trial investigating whether a cognitive behavioural approach (CBA) intervention, delivered by trained respiratory health care professionals, and preceding pulmonary rehabilitation, improves anxiety/depression outcomes and pulmonary rehabilitation attendance/completion -thereby reducing functional limitations. The aim of the study was to assess the feasibility of the TANDEM CBA intervention prior to a definitive trial. METHODS Individual face-to-face interviews were conducted with study participants following completion of intervention delivery (Intervention n=4; Control, n=3). Reasons and experience of participating, experience of receiving the intervention and suggestions for improvement were explored. Interviews were recorded, transcribed verbatim and analysed thematically. RESULTS Identified themes: (1) Negative impact of COPD and anxiety/depression (2) Willingness to be involved in TANDEM (3) Acceptability of the recruitment process (4) Acceptability of the intervention (5) Refinements in the recruitment process and intervention for the main trial. CONCLUSION The participants’ experience of the TANDEM CBA intervention were consistently reported as positive. Practical skills learnt were easily translated into everyday tasks, leading to participants feeling empowered in their ability to break the vicious cycle of anxiety/depression. In turn, inspiring overall confidence, especially in their ability to manage their condition and improvement in their physical abilities.
Session: Research presentations: Multi-morbidity in respiratory care
Programme day: Friday
Session time: 28-09-2018 14:45 - 15:30
Location: PCRS 3 (Wenlock Suite)