Title: NHS priorities in the management of chronic respiratory disease
Funder: Department of Health and Social Care

Abstract: NHS priorities in the management of chronic respiratory disease Background: This programme of work focusses on strengthening the evidence-base for interventions to improve the health of people with chronic obstructive pulmonary disease (COPD) through the production and publication of Cochrane Reviews. We will also update two key asthma reviews. The systematic reviews will be produced by Cochrane Airways in collaboration with national and international author teams and will be published on the Cochrane Library. Lung diseases are responsible for 115,000 deaths in the UK each year, and represent some of the most burdensome long-term conditions, not only for individuals and carers but also for the NHS. COPD is a progressive condition affecting primarily the lungs leading to increasing breathlessness, reduced quality of life and intermittent flare-ups (exacerbations). It is a major cause of death and disability and a considerable cost to the NHS, affecting over one million people in the UK alone. COPD accounts for approximately 1 million inpatient days and £1 billion in direct healthcare spend. There is also a considerable burden on the public, with around 24 million working days lost annually due to this often debilitating condition. Respiratory disease is an active research area and new, often expensive, treatments become available while others go out of date. There is an urgent need to provide health care providers, policy makers, patients and carers with the most up to date and comprehensive synthesised evidence available to allow them to make evidence-informed decisions. In planning this programme of work we have we have consulted guideline producers, clinicians and patients and have scoped the relevant topics to prioritise titles which will address the most important issues currently facing the NHS. Theme and scope: Our programme focusses on three key areas; systematic review of these topics have strong potential to bring about changes in practice: 1. Effective treatment and prevention of COPD exacerbations and hospital admissions: Around 50% of patients with moderate-to-severe COPD have at least one exacerbation per year and around 22% have more than two exacerbations per year. Increasing exacerbation frequency is associated with accelerated decline in lung function, impaired physical activity and quality of life, and early death. COPD exacerbations are responsible for approximately 100,000 hospital admissions and 1 million bed days in the UK annually. The National COPD Audit programme reported a large increase in re-admissions for COPD since 2008. Inadequate treatment is common and may delay or prevent recovery. Hospitalisation impairs physical function, which can accelerate physical decline and increase dependence. Effective treatment and prevention of exacerbations and related hospitalisations are therefore key goals. 2. Improving self-management, quality of life and care pathways: This area of the programme was developed in conjunction with our COPD patient advisory group and focusses on measures that they felt to be important, including those with potential to increase activity and independence and improve coordination of healthcare. 3. Safe and effective prescribing: The NHS spends around £1 billion annually on respiratory inhalers. In the last few years there has been rapid proliferation of inhaled drugs and devices. Clinicians advise us that this has made it very difficult to select the most appropriate medicine for their patients. In this climate of uncertainty, our proposed new network meta-analysis (NMA) will be important to direct effective clinical practice. Updates of our existing long-acting beta-agonist (LABA) safety overviews will ensure clinicians and guideline producers have the most up-to-date information about safe use of this class of inhaled drug in asthma. Project outline: During this three year programme grant we will complete 15 reviews (eight new reviews; three review updates; two overview updates; one NMA; and one prognostic review). We will actively disseminate these reviews via guideline bodies and clinical networks to optimise their impact on patient care in the NHS. We will recruit an experienced full time systematic reviewer to lead the reviews from the editorial base. We will seek external methodological support for the NMA, prognostic review and any review that requires the inclusion of non-randomised studies. We will set up a Steering Group which will include health care providers, researchers and a patient representative to monitor progress and provide advice. We will collaborate with local clinicians, the National Institute of Health and Care Excellence (NICE), the National COPD Audit programme, the NIHR Complex Review Support Unit and Cochrane Pain, Palliative and Supportive Care Group. Planned reviews: 1. Effective treatment and prevention of COPD exacerbations and hospital admissions: •Long term antibiotics: use is increasing to prevent COPD exacerbations and is a concern due to limited evidence and antibiotic resistance •Vitamin D supplementation: our recent high impact review shows vitamin D can reduce asthma exacerbations; this may also apply in COPD •Targeted management: exacerbation management by ‘phenotype’ (e.g. by measurement of procalcitonin, CRP, blood eosinophils) •Long term non-invasive ventilation: may reduce night-time hypoventilation, hypercapnia, and hospitalisation. New trials have recently been published •Prognostic indicators: symptom control and place of care are essential priorities towards the end of life and are poorly addressed in COPD •Interventions to improve adherence to therapy: adherence to treatment is suboptimal in many people with COPD •Pharmacotherapy in people with frequent exacerbations: stratification of treatment according to exacerbation status is increasingly important 2. Improving self-management, quality of life and care pathways: •Interventions to increase physical activity and exercise capacity: patients prioritise being able to do more •Telehealth for COPD: a developing field, but with potential harms as well as benefits •Strategies/care pathways for multimorbidity: common in people with COPD, burdening individuals and costly for the NHS •Use of weather forecasting/air pollution monitoring for self-management: a priority for patients to whom we spoke 3. Safe and effective prescribing: •Long acting inhaled therapies for COPD: we will update our existing NMA of inhaled therapies for COPD to reflect the rapid expansion of new drugs •The safety of LABAs in asthma: an ongoing controversy and is a patient priority. Three large new trials mandated by the Food and Drug Administration will be incorporated into existing evidence Dissemination and knowledge translation: The output of our programme will be a series of high-quality systematic reviews. These will synthesise the best available evidence to determine which therapies are most effective and which are ineffective or may cause harm. A key feature of our programme is the engagement of patients, clinicians and guideline developers, which creates a direct pathway for our output to be embedded in clinically - and cost effective services. NICE is currently updating its guidelines for COPD management and we have agreed a timeline to ensure that our long term antibiotic reviews are considered in the process. NICE guidelines are widely adopted into the NHS, so this is an effective way for our programme to make an early contribution to clinical practice. Grant co-applicants contribute to clinician networks, such as the British Thoracic Society, National COPD audit programme and national respiratory specialty interest group. These networks will be used to disseminate programme outputs to respiratory specialists and encourage uptake into clinical practice. Patient networks will approached (e.g. British Lung Foundation) to disseminate information to patients and participants from a local COPD patient advisory group will form a Patient Steering Group.

Lay abstract: Treatments for people with long term breathing problems Why is this important? Lung diseases are a common problem in the UK and cause 115,000 deaths every year. Chronic obstructive pulmonary disease (COPD), sometimes known as ‘emphysema’ or ‘chronic bronchitis’ is one of these diseases. It is a long term condition, often caused by smoking, which leads to shortness of breath, difficulty with daily activities and in some cases early death. People with COPD may have flare-ups (sometimes known as ‘exacerbations’), which can be serious and may result in them needing to be admitted to hospital. Around half of people with COPD will have at least one flare-up every year and more than one in five will have two or more flare-ups. Flare-ups are particularly worrying as they are linked to more rapid disease progression and difficulty in daily life for patients. Exacerbations are also very costly to the health service. There is a lot of research happening to help people with COPD and other breathing conditions. New inhalers, tablets, injections and technologies are being tested all the time. It is really important that this new evidence is brought together in a way that is most helpful to health care providers, policy makers, patients and their friends and families. What are we going to do? Over the next three years we plan to produce 15 ‘systematic reviews’ that attempt to answer important questions about the treatment of COPD and other breathing conditions. A systematic review is a type of research that looks for all the studies about a particular question and brings them together in one document. If possible, the results of the different studies are combined to make a more powerful result. The studies are also assessed according to how well the research was carried out and how much confidence we have in the results. The work will be carried out by Cochrane Airways, working with authors from the UK and around the world. We will employ an experienced full time systematic reviewer to lead the reviews. We will set up a Steering Group which will include health care providers, researchers and a patient representative to monitor progress and provide advice. We will work with a local COPD patient group, doctors, nurses and physiotherapists, the National Institute of Health and Care Excellence (NICE), the National COPD Audit programme, the NIHR Complex Review Support Unit and Cochrane Pain, Palliative and Supportive Care Group. With the help of health care providers, patients and guidelines writers, we identified three main areas to look at. Within each of these main areas, we have developed more specific questions we will try to answer: 1. Preventing flare-ups and hospital admissions •Do long term antibiotics help prevent flare-ups? Are they safe? •Do vitamin D supplements help prevent flare-ups? •Can special tests when a person is having a flare-up help decide what treatment they need? •Does long term breathing support at home help prevent flare-ups and hospital admissions? •How can we tell when a person with COPD may be nearing the end of life, so they can be offered the most appropriate treatments? •How can we help people with COPD take their medication regularly and as prescribed? •What long term treatments are most helpful for people with COPD who have lots of flare-ups? 2. Helping people to manage their own condition, improve their quality of life and improve co-ordination of healthcare •What can be done to help people with COPD be more active in their daily lives? •Can new “telehealth” technologies (e.g. phone apps) help people with COPD to manage their condition better? •How can healthcare services be better organised to help people who have COPD and other medical conditions? •Can specialised weather forecasts or air pollution reports help people with COPD to manage their condition better? 3. Helping health care providers to prescribe the best and safest inhalers for patients •What are the best inhalers or combination of inhalers for people with COPD? •Asthma: in recent years there have been concerns raised about the safety of a particular type of inhaled drug for people with asthma (“long acting beta-agonists”). Three large new studies have been published about this and we will combine the results with existing evidence How will we ensure the right people hear about it? A key part of our work is to make sure the findings of our reviews reach the right people. We have links with local health care providers and patients as well and national medical organisations and guideline writers and we will send them summaries of our reviews. We will use social media and other networks to share our findings even more widely. We will present the work at conferences for health care providers who look after people with breathing conditions. We will work closely with Cochrane’s communications team to produce press-releases, blogs and editorials if we have particularly important findings.

Research activity codes: 6.1 PHARMACEUTICALS;6.3 MEDICAL DEVICES;7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: RESPIRATORY