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Chronic obstructive pulmonary disease is predicted to be the world’s third leading cause of death by 2020. Early diagnosis is crucial and pharmacy is ideally placed to identify sufferers

“Chronic obstructive pulmonary disease (COPD) is extremely common and causes a lot of misery to a lot of patients, but if managed well, it can make an enormous difference to patients’ lives,” says Dr Nick Hopkinson, medical advisor to the British Lung Foundation. One of the most important factors in managing this common lung problem is early diagnosis, before the lung damage becomes too advanced. Yet a recent study of 39,000 people with COPD found that 85 per cent could have been diagnosed earlier.

Dr Hopkinson believes pharmacy could make the difference: “These patients make contact with pharmacists quite often, which gives opportunities to ask about symptoms.”

Projects running through pharmacy support this. The Community Pharmacy Future (CPF), a joint initiative between Boots, Lloyds, the Co-op and Rowlands, has just been awarded the British Medical Journal’s Respiratory Team of the Year Award for its work in identifying possible COPD sufferers and in helping those with COPD improve the management of their condition.

Jonathan Buisson, healthcare policy manager at Alliance Boots, speaking for the CPF team, says pharmacy counter staff were essential to the scheme’s success. “They were the first port of call for these patients,” he says.

A growing problem

Patients may not know or talk of COPD, but they are usually aware of emphysema or chronic bronchitis. These conditions are actually COPD, which is the overall term for a group of severe and incurable lung diseases. Although COPD is a progressive condition, for many people it does not get worse, though this does depend on effective treatment, says Dr Hopkinson. An estimated three million people in the UK have COPD, but only 900,000 are diagnosed. It is the fifth most common cause of death in England and Wales and is unfortunately predicted to rise to third place by 2020.

COPD has an enormous impact on both sufferers and society. The bulk of the £817 million NHS expenditure on COPD goes on hospital care, with sufferers often admitted after an exacerbation of their condition. This happens to around 20 per cent of COPD sufferers each year, accounting for over a million bed-days per year in England alone. The rest of the time, sufferers struggle with everyday tasks. One survey found that over three quarters had difficulty climbing the stairs, problems gardening or sleeping, while over 65 per cent had difficulties walking outside or doing housework.

Simple symptoms

COPD is, however, a condition that can be prevented. For 90 per cent of people, the cause is smoking, including passive smoking. Other causes include pollutants from dust, fumes and vapours (particularly at work) and solid fuels used indoors for cooking and heating. Most sufferers are not diagnosed until they are in their 50s. While the number of men affected has stabilised, it is increasing in women, with three times as many women as men diagnosed with COPD.

The symptoms of COPD are simple , but because these are common in smokers, sufferers may delay seeing their GP until the condition has advanced. Dr Hopkinson says: “People attribute their cough to a smoker’s cough and their breathlessness to ageing. Yet chest infections are a sign of respiratory disease related to past or present smoking.”

 

Identifying patients

The simplicity of COPD symptoms means it is easy for pharmacy staff to get involved in identifying possible sufferers. A number of projects have run through community pharmacy with this in mind.

The CPF team implemented one such initiative in 34 pharmacies in the Wirral. Two services were provided: one to identify high-risk patients with no known COPD and another to help known sufferers improve their management. Pharmacy staff were trained on the services they would offer, with clinical information on COPD and extensive training on counselling skills. Pharmacy customers who were identified for COPD screening included those who were:

• Known to be smokers or who had asked about smoking cessation
• Using cough or cold medicines on a regular basis
• Taking antibiotics regularly for chest infections

Customers were taken through a risk questionnaire, and microspirometry (a simplified lung assessment test) was done in the pharmacy. If they had either a high risk score or a low test result, they were referred to their GP with a letter explaining why. “Quite a big pool of patients are undiagnosed,” says Jonathan. “We found that more than half of those chosen by pharmacy assistants for our case finding service were potentially at high risk of COPD.”

Of 238 patients screened by 21 pharmacies, almost 57 per cent had high risk factors, and one-third were current smokers.

Pharmacy staff can still help identify COPD sufferers without being part of a project. North East London Local Pharmaceutical Committee (LPC) secretary Hemant Patel advises: “Be alert to customers who make repeat purchases of cough medicines. People come back for the same medicines over and over again and usually at large doses.”

Pharmacy can also play a critical role in targeting the hard to reach COPD sufferer, believes Dr Hopkinson. “People, such as those with mental health issues, also smoke, so when they come in to collect their prescription, this can be a way to catch them.”

Being alert to regular cough medicine purchases can put patients on the first step to managing their condition

 

Helping sufferers

Optimising the care of existing COPD sufferers is another vital pharmacy role. “We know that people often don’t use their inhalers properly,” says Dr Hopkinson. “We spend an enormous amount of money on inhalers and it would be good if people used them correctly.”

Targeting people with COPD and providing the skills they need to self-care appropriately will be a key aim of a new Self Care Pharmacy scheme being run through the North East London LPC. Pharmacy assistant involvement is essential. “Pharmacy counter staff play a huge role. They speak the language their customers speak,” says Hemant. “Pharmacists tend to make it very technical, but counter staff can communicate with patients in simple everyday language about their lung function and COPD so that patients understand.”

In the CPF project, patients with COPD were given additional support, beginning with an initial work up to identify issues with inhaler technique and devices, medicines adherence, GP and A&E visits and their quality of life. Where necessary, they were given support to obtain a “rescue pack” of steroids and antibiotics to manage exacerbations. Jonathan comments: “With this service, we saw increased adherence to medicines, they used fewer NHS resources and patients felt their condition was better managed.”

The single biggest difference pharmacy can make to existing COPD sufferers is to encourage them to stop smoking as it can slow down worsening lung function. The Royal Pharmaceutical Society advises that smokers with COPD should be advised to quit, regardless of age, and offered the full range of smoking cessation support. Jonathan agrees: “Smoking cessation is the key intervention and that’s something pharmacy assistants can do without a diagnosis.”

Encouraging patients to get vaccinated against flu is also important, as is signposting to other sources of advice and support, adds Dr Hopkinson. Taking an active approach can make a difference; rates for flu vaccination in the CPF project in the Wirral were 97 per cent for those on the COPD Support Service, versus 75 per cent as the local average.

The simplicity of COPD symptoms means it is easy for pharmacy staff to get involved in identifying possible sufferers

Make a difference The benefits of pharmacy involvement in COPD can be seen from patient feedback on the Community Pharmacy Future project. “I understand the importance of taking the medications on time and as prescribed and the things that go together or do not go together, which I didn’t know before,” says one patient. Another commented that it had allowed them to prove to themselves that COPD was not “as life-stopping or debilitating as I had allowed it to be”.

Being alert to regular cough medicine purchases and asking about smoking cessation can put your patients on the first step to managing their condition and making an enormous difference to their lives. To find out more about the Community Pharmacy Future click here.

 

 

Signposting

• British Lung Foundation 
• Smokefree 
• QUIT