It is estimated that nearly 11,400 citizens in Nottingham, have COPD, 49% of who were recorded as having COPD on the QOF register in 2013/14. This data suggests that there are more than 5,800 citizens in Nottingham with COPD who have not been diagnosed. As figure 2 illustrates there is considerable variation in undetected COPD by practice.
Figure 2: Undetected COPD by ward, 2013/14. Undetected COPD by practice; QoF Register 2013/14; HSCIC (Health and Social Care Information Centre) IMD LSOA 2011(Adjusted IMD 2010 scores for 2011 LSOAs), Public Health England; APHO
The most common cause of COPD is smoking tobacco. The most deprived areas of Nottingham have a smoking rate more than double the most affluent; 38% in the most deprived quintile, compared to 16% in the most affluent (Nottingham Citizens Survey, 2010-2014 pooled).
GP practices keep registers of citizens with COPD and also keep registers of citizens who smoke. The COPD register is known to under detect cases of COPD but it is possible to estimate the number of cases that would be expected at practice level and so it is possible to look at the correlation of smoking status against COPD (detected and undetected). As figure 3 illustrates there is a clear relationship at practice level.
As practice list sizes are relatively small, practices’ smoking prevalence was divided into 5 quintiles to enable analysis. In this analysis the correlation between smoking and COPD prevalence is very strong (R2=99%).
A fall of 1% in smoking prevalence might be expected to reduce the number of citizens with COPD in Nottingham by around 400 persons.
Figure 3: Relationship between smoking prevalence and COPD prevalence. Source: Smoking Prevalence QoF 13/14, Estimated COPD Prevalence PHE 2011 model applied to 13/14 list size
The actual prevalence of COPD in citizens from BME communities Nottingham is not known as ethnicity is poorly recorded in QOF, the source of the prevalence data. However, national sources suggest that some black and minority ethnic (BME) communities, such as Bangladeshi and Black Caribbean communities, are likely to have higher rates of COPD associated with higher smoking prevalence in these communities (British Lung Foundation 2015).
Local analysis of smoking by ethnicity, from the Nottingham Citizen Survey, shows that citizens of mixed heritage, White (not British) and White British have the highest smoking prevalence, with the latter two groups having a smoking prevalence statistically higher than the city average. (Smoking JSNA chapter 2015). As smokers are much more likely to develop COPD it is reasonable to assume that COPD prevalence will be higher in these groups. In addition, citizens from black and minority ethnic (BME) groups are more likely to live in deprived areas where incidence of COPD is also higher.
National and international evidence suggest that citizens from Lesbian, Gay, Bisexual and Trans (LGB&T) communities are more likely to smoke than their ‘straight’ counterparts thus it is reasonable to assume that there are higher rates of COPD in these communities (LGBT Foundation 2013). As few services routinely ask clients their sexual orientation it is not possible to state with any confidence whether there is a higher incidence of COPD in Nottingham’s LGB&T communities.
Analysis of smoking by sexual orientation in Nottingham, taken from the Nottingham Citizen’s Survey, suggests that smoking prevalence is significantly higher among gay and lesbian groups than the city average. As smokers are much more likely to develop COPD it is reasonable to assume that COPD prevalence will be higher in Nottingham’s LGB&T community.
Smoking rates are significantly higher in those with poor mental wellbeing and mental health problems thus they are more likely to develop COPD. Local data (unpublished figures Nottinghamshire Healthcare Trust) suggests that 80% of inpatients and 57% of those with enduring mental illness smoke. Specific pathways and treatment models are in development for this group.
Around 130 citizens in Nottingham die due to COPD each year. In 2014, deaths in Nottingham due to COPD accounted for 6% of deaths overall, 39% of who were citizens aged under 75 years. Men contribute to more than half (56%) of the deaths from COPD in Nottingham.
In 2011-2013, the mortality rate from COPD in Nottingham, 67.6 deaths per 100,000 people, was statistically significantly higher than the England rate of 51.8 per 100,000. As figure 4 shows the mortality rate for males and females are also both statistically significantly higher than the England rate.
Figure 4 Mortality rate for COPD (all ages), 2011-2013 pooled, Nottingham and similar cities. Source: Health and Social Care Information Centre. © Crown Copyright. Compendium of Population Health Indicators (indicators.ic.nhs.uk or nww.indicators.ic.nhs.uk)
In terms of the proportion of citizens dying of COPD, Nottingham compares reasonably well with its cities with similar deprivation scores and levels of smoking, ranking 9th out of 16 similar cities and significantly lower than Liverpool, Hull and Manchester.
Figure 5 illustrates that whilst the mortality rate for COPD in Nottingham, 2011-13, is mid‑ranked when compared to similar cities it is statistically significantly higher than the East Midlands or England average. The mortality rate under 75 years for males, females and persons is statistically significantly higher than the England average. The mortality rate for males is approximately double the England average.
Figure 5: Mortality Rate from COPD in Males and Females, under 75 years (3 years pooled 2011-2013). Source: Health and Social Care Information Centre. © Crown Copyright. Compendium of Population Health Indicators (indicators.ic.nhs.uk or nww.indicators.ic.nhs.uk)
The crude rate of admissions to hospital for COPD in Nottingham is 2.68 per 1000 of which 2.62 are emergency admissions (InHale Profiles, PHE 2015). However, as this rate is not adjusted for age, and the likelihood of hospital admission for COPD increases with age, any direct comparisons with the England rate of 2.15 per 1000 should be made with caution.
The emergency admission rate for COPD in Nottingham, the East Midlands and England is shown in figure 6.
Figure 6 Emergency admissions for COPD. InHale Profiles, Public Health England 2015, http://fingertips.phe.org.uk/inhale
There are approximately 900 admissions a year in Nottingham with a primary diagnosis of COPD at a cost of approximately £1.9 million a year. These figures do not include admissions where COPD was not the main cause of admission and thus will underestimate the full impact of COPD on hospital admissions. Citizens with COPD are more likely, than the general population, to have multiple admissions to hospital.
962 citizens had 1667 admissions for COPD between September 2013 and August 2015. Approximately 71% of citizens were admitted once, 15% twice and 6% three times during this period. The ten highest service users were admitted 160 times between them with one citizen having 26 admissions.
An integrated respiratory service (IRS) was commissioned in 2012 which aimed to improve the quality of life of those with long-term respiratory conditions such as COPD and reduce attendance at hospital, both emergency department attendance and admissions. Figure 7 shows, whilst the referrals to IRS have increased each year there appears to have been no reduction in the rate of COPD admissions since the introduction of this service.
Figure 7: COPD Admission rate, by rolling average year. DSR COPD admissions value not available for December 2013, substituted March 2013. Source: IRS data – Citycare IRS service, COPD Admissions-eHealthscope.
There is a strong association between COPD and smoking thus COPD admissions are more common in areas with high prevalence rates for smoking. As figure 8 illustrates, in Nottingham City, the top 5 wards with the highest smoking prevalence had a combined prevalence of 34% and a crude COPD admission rate of 15.5 per 1000. Conversely, the 5 wards with the lowest smoking prevalence (19%) had a crude admission rate of 9.5 per 1000.
Figure 8: COPD admission rate and smoking prevalence, pooled data 2010-2014. Ward smoking Prevalence (Citizens Survey pooled data 2010-2014, Nottingham City Council). Practice COPD Admission Rates per 1000 population; August 2014-July 2015; (eHealthscope, Nottingham City CCG Information System)
Analysis of COPD admissions by ethnicity is not possible as ethnicity is not adequately recorded in hospital admissions (HES) data.
Citizens with a diagnosis of COPD, who are on a QOF register, should have an annual review of their condition by a healthcare professional. Around 89% of citizens on GP COPD registers in 2013/14 have had a review of their disease with their GP in the past 12 months (81% if exceptions are included). However, there is marked variation between practices ranging from 38% – 100% of citizens having had such a review each year (QoF, 2013/14).
Citizens who are experiencing exacerbation of their COPD can be referred by their GP or other health professional to the Integrated Respiratory Service (IRS). 97% of the IRS referrals were aged 50 or over. As figure 9 illustrates, a comparison of the ethnicity breakdown for citizens in Nottingham over 50 years at the 2011 census and those referred to the service, between 2012 and 2014, show some differences.
IRS data suggests that less white citizens, and more citizens of mixed/multiple heritage, were referred to IRS than the Nottingham average. However, 19.8% (1,050/5,316 referrals) of citizens referred had no stated ethnicity thus any interpretation should be made with caution. The reason why more citizens of mixed/multiple heritage are referred to IRS is not clear.
Note: truncated axis.
Figure 9: Comparison of ethnicity for Nottingham City population aged 50 and over, and referrals to IRS aged 50 and over (pooled 2012-2014) for citizens in which ethnic group was stated. Source: IRS data – Citycare IRS service, Ethnicity Data – ONS Census 2011.
In 2013, 131 million days’ work were lost through sickness in the UK (Office for National Statistics 2014); 11 million in the East Midlands. Of these lost days an estimated 4%, 5.3 million days, were caused by respiratory disease including COPD; 440,000 days in the East Midlands.
Whilst local intelligence suggests that many citizens with COPD are regularly absent from work due to their condition it is not possible to accurately identify the number of days lost from work in Nottingham due to COPD as the reason for absence is often not recorded in this detail. Absence from work due to ‘respiratory conditions’ includes a broad range of illnesses in conditions including influenza, chest infections and the common cold.
Some citizens will find their COPD sufficiently debilitating that they are unable to work. Of the 14,230 Nottingham City residents aged 18-59 years receiving ESA (Employment Support Allowance) in February 2015, 1.76% (NOMIS 2015) had a respiratory disease. The proportion increases with age from 0.75% of citizens aged 18-24 years to 3.9% of citizens age 55-59 years. Figure 10 shows ESA claimants by reason and age-band.
Figure 10: Proportion of ESA claimants by reason for claim and age band (February 2015), Nottingham Source: NOMIS, Official Labour Market Statistics, 2015
 Estimate based on 2011 modelled rates and 2013 registered population 16+
 5 groups of 12 or 13 practices ranked low to high smoking prevalence
 CIPFA neighbours (Chartered Institute of Public Finance and Accountancy (CIPFA) Nearest Neighbour Model
 Based on an average over the last 5 years
 Based on 12/13 admissions data and current admissions. 900 admissions per year, approximately £2100 per admission thus £1.9M per year.