Impressions 28 - relative value of COPD interventions

Finally, our guide to value is here We reckon it's one of the first attempts to evaluate the relative value of different interventions for a long term condition like COPD, when applied to a population.   It's been a year-long journey, working with the London School of Economics and Political Science School of Management.  We've learnt about evaluating health economics data, we've challenged each other about our assumptions; been disappointed by gaps in the data and worked hard to think what we did about them.  It's been a real team process, and just shows how much time, effort, expertise and experience is needed to do this sort of work.  We hope we've saved you from repeating it all, but on the other hand, would encourage you to learn about the decision conferencing process, which has been extremely illuminating. 


It's taken the Value Pyramid, that the London Respiratory Team designed from our work on More for Less, and now features in the NHS Companion Document and developed it furher to show the implications for populations who are undiagnosed, diagnosed with mild-moderate disease, and diagnosed with severe disease.


Its conclusions are that we can improve the outcomes for the diagnosed and undiagnosed population by rebalancing  the current spend on COPD care towards stop smoking as a treatment and also pulmonary rehabilitation programmes, and reducing overuse of some inhaled medicines.


In effect, it echoes Geoffrey Rose "Mass diseases and mass exposures require mass remedies"

The news release we've issued is as follows:


Commissioners and clinicians can improve the value extracted from the respiratory programme budget by rebalancing investment in stop smoking services and pulmonary rehabilitation programmes, and reducing overuse of some inhaled medicines.

The study by IMPRESS analysed which interventions offer most value for a population with chronic obstructive pulmonary disease (COPD).

It applied an analysis developed by researchers at the London School of Economics and Political Science (LSE) supported by the Health Foundation to assess the benefit of different types of intervention. In 2010/11 the NHS in England spent more than £4 billion a year on respiratory illness, £720 million of it on COPD, so what are the best interventions to provide for that investment if we want to reduce mortality from COPD and reduce the burden of breathlessness and other associated problems?


A key finding was that clinical interventions to help those people with COPD who smoke to stop (about 35%) improve their outcomes at a relatively low cost and therefore, given the number of people who smoke, offer value not just to the individuals but also to the population. This is true both for those diagnosed with COPD who smoke and those with COPD who smoke but are as yet undiagnosed (estimated to be as many as 6000 in a population of 300,000). Yet stop smoking services are not routinely offered in hospitals or in other places where there are likely to be substantial numbers of people who smoke.


The study Relative Value also found that there is “substantial overtreatment” of inhaled medicines for patients with mild to moderate disease and that in some cases this could create health problems. In particular, it warns of the risks of prescribing “triple therapy” -multiple inhaled treatments – both because of the risk of causing harm and because of unnecessarily high costs.


It also found that programmes of pulmonary rehabilitation – combining exercise, education and self-management – were particularly cost-effective ways of improving patient outcomes but are under-supplied in many parts of the country.


IMPRESS was set up as a partnership between the British Thoracic Society and the Primary Care Respiratory Society-UK to stimulate improvement and integration of respiratory services. It involves doctors, nurses, allied health professionals, managers and lay people with experience in general practice, community and hospital care.


Steve Holmes, GP, joint author and co-chair of IMPRESS said: “Large amounts of public money are spent in respiratory care but it’s not always used wisely. Healthcare professionals have an ethical responsibility to avoid waste, which means doing what’s best for a patient’s health and avoiding treatments which don’t improve things or which actually make them worse.


“This report applies health economics to our decision-making to produce the evidence for what provides value and what does not. It’s the most comprehensive study conducted of the value of differing treatments for COPD patients and it may contain some surprises for clinicians.


Mike Ward, joint author of the report, Co-chair of IMPRESS and hospital physician in the Midlands, added “For example we’ve tended to see stop smoking interventions as not our business – as something carried out by public health programmes. We should be arguing for greater investment in specialist stop smoking services for our patients and also for education programmes for us all to have the skills to help people quit.“


The study modelled a population of 300,000 including about 12,000 at risk of COPD of varying degrees of severity. A technique called decision conferencing was then used to assess the effectiveness of different types of treatment and the number of people who could benefit. This enabled the researchers to compare the value of different treatment scenarios in terms of both cost and their use to patients.


The Executive Summary and  full report, IMPRESS Guide to the relative value of COPD interventions:a population-based approach to improving outcomes for people with chronic obstructive pulmonary disease based on the cost of delivering those outcomes, is available at IMPRESS publications.  Each appendix is also available as a separate pdf in case you want to share specific aspects with colleagues, such as QALY data. 

25 July 2012




Additional resources for clinicians, commissioners, managers

17 September 2012, BMJ Editorial on this work:

Muir Gray.  Optimising the value of interventions for populations. BMJ 2012;345:e6192

Health Service Journal Resources section 2012 here


Powerpoint slides




#7 Sian Williams 2012-10-22 10:16
In response to comment 4. Your view is very interesting but does not fit in with the majority of both scientific reviews and those of people with COPD who are asked about responses to their drugs and rehabilitation. We recognise that there is a range of individual opinion both between specialist physiotherapist s, doctors, nurses and patients. We try to provide advice and evidence that fits the majority of people's needs and with those whose work is to look into the scientific evidence. We recognise that some individuals can have experiences different to the vast majority. Specifically we recognise a very small body of literature and number of people with conditions that cause COPD for example alpha one antitripsin. These very rare causes of COPD to an extent fall outside the advice for the majority of people - though some experts suggest the advice is very similar. We would suggest therefore that this debate has been covered now in the comments section.
#6 Sian Williams 2012-10-22 10:11
In response to comment 6. We follow NICE guidance and have used information from that. The evidence also shows that not all patients are receiving care that follows this guidance.
#5 Kay Atherton 2012-10-19 19:20
May I ask why you have a comment facility in response to the above if you do not post the comments for others to see? I am referring to my previous comment which I see you have inadequately responded too. What "value" does your suggested decrease in essential medications have to those patients who gasp for breath?
#4 Sian Williams 2012-10-19 18:43
Caroline and Kay - thank you for taking the time to read and to comment

We have not specifically  looked at alpha-1 antitripsin deficiency, nor do we actively exclude it; the vast majority of our guidance to commissioners and clinicians would apply.  For example:

We  promote earlier diagnosis of COPD, and the new DH guide to case-finding is an important contribution to this.

We promote care planning, and individualised patient-centred care.

We promote interventions that are often underused by clinicians such as stop smoking, pulmonary rehabilitation and training patients in inhaler technique. 

We also promote joined up, integrated care for patient benefit.

If you have any good peer-reviewed examples of services for people with alpha-1 antitripsin deficiency, we could consider adding them to our good practice examples.  We could also add links to good resources for clinicians and commissioners, which is our audience.
#3 Kay Atherton 2012-10-19 18:29
I don't see how advising doctors not to use triple therapy inhalers is going to help matters. Yes they do cause other symptoms but at least we can breath better with them. Removing them and causing further respiratory decline will only decrease O2 and/or the exchange of gasses due to inflammation of the lungs. That in turn will effect other major organs or even toxify the brain probably causing severe neurological problems. Yes rehabilitation may help those in early stages but those in severe stages especially with other ailments cannot cope with the additional requirements needed to support their muscles and lungs. My Respiratory Physio told me any score above 3 on the breathless scale while doing light exercise has a negetive effect and causes more harm. Please tell me how can you be actively promoting copd while excluding alpha-1 - a genetic form of copd? Far more contributive factors exist besides smoking, vehicular emissions/some work related toxins are just as bad if not worse!
#2 Caroline Gillissen 2012-10-09 10:40
I would be interested to know why genetic COPD, namely alpha-1 antitrypsin deficiency (alpha-1), isn't included in your report?
#1 Sian Williams 2012-09-24 08:35
See Sir Muir Gray's very positive Editorial in the BMJ 17 September 2012 BMJ 2012;345:e6192