Impact case study database

COPD is a leading cause of disability, healthcare utilisation and mortality in old age. An estimated 3,000,000 people in Britain (BLF, 2012) and 210,000,000 worldwide (World Health Organisation) are living with the disease. 65,000,000 people have moderate to severe COPD (GOLD 2019). With no known ‘cure’, it was long felt that little could be done to help patients. However, since the 1990s, new research and treatment options have led to a focus on managing the disease, reducing exacerbations and optimising lung health. Highlighting gaps in provision and opportunities to improve care, Yohannes’ research is a critical part of the evidence base for guidelines and practices that have improved the quality of life of COPD patients.

The debilitating symptoms of COPD can lead to social isolation and the development of depression and anxiety. The conditions may also co-exist. Although they worsen a patient’s quality of life and ability to cope, they are often overlooked due to the overlap with symptoms of the disease. The first ever NICE guideline on the management of COPD in adults in primary and secondary care (CG12, 2004) began to address this by including guidance on identifying and managing anxiety and depression. Yohannes’ studies (2000-2002) on mortality predictors, depression and anxiety, anti-depressant therapy and the MRADL and BASDEC scales were central to the evidence base for this section. They constituted five of the 16 studies cited (in addition to two of his earlier studies), informing the consensus statements. NICE retained guidance, based on his research, in subsequent iterations (CG101 2010, NG115 2018), which inform patient care across England and Wales to the present day. The Chair of the Guideline Development Group stressed that these earlier recommendations remain: “ just as important and relevant now as they did when the original guideline was produced”. Underscoring this, the 2014 surveillance review of the guideline cited Willgoss and Yohannes’ systematic review of anxiety disorders in patients with COPD (2013) as evidence that its existing recommendations were still valid. NICE also drew on Yohannes *et al.*’s longitudinal follow-up study (2017) on the association of depressive symptoms with rates of acute exacerbations in patients with COPD in a major evidence review focused on predicting and preventing exacerbations (2018). [A]

Internationally, Yohannes’ findings on COPD mortality rates and the multifactorial causes of depression and anxiety informed the recommendations made on the management of stable COPD, and prevention and maintenance therapy in all versions of the annual Global Obstructive Lung Disease (GOLD) guidelines from 2017-2020. His research on the benefits of walking aids is also used as evidence in a section on PR therapy in all earlier GOLD guidelines from 2013-2016. Launched in 1997, in collaboration with the National Heart, Lung and Blood Institute; National Institutes of Health, USA; and the World Health Organization, GOLD aims to: “ Recommend effective COPD management and prevention strategies for use in all countries”. [B]

At strategic-level, Yohannes’ research on depression and COPD informed the UK’s Chief Medical Officer’s annual report (2013) ‘Public Mental Health Priorities: Investing in the Evidence.’ It was used to evidence depression levels amongst COPD patients and demonstrate that people with COPD, who also have co-existing depression and anxiety, have higher functional disability, greater loss of productivity and greater health resource use. The advocacy volume led to 14 recommendations, including that all Health and Wellbeing Boards should have a focus on mental health in the Joint Service Needs Assessment (JSNAs), and ensure mental health needs receive ‘parity of esteem’ or equal priority with physical healthcare. [C]

In 2017, the Scottish Government launched its COPD Best Practice guidance in response to national data that showed COPD was the most common cause of presentation to Emergency Departments (ED) with a respiratory emergency, and that figures were rising. The guidance profiled three case studies, including one on Integrated Care in NHS Lothian. This used Yohannes and Willgoss’ research on anxiety to highlight how the relationship between hyperventilation and symptoms can lead to unnecessary 999 calls, and evidenced the prevalence of anxiety and depression in people with COPD. It describes the recognition of this ‘ significant unmet need’ as one of the drivers to the programme and one that was critical to its success. The psychological interventions that NHS Lothian delivered as a result led to ‘ a clinically significant improvement’ in patients’ quality of life. The support also contributed to a 7% reduction in stays of 48 hours or less and a reduction in respiratory bed days that exceeded its target by over 500% (April 2013-September 2015). The national COPD working group drew on the case studies and associated evidence to design a series of best practice recommendations, including ‘ Access to psychological therapies and assessment of psychological distress to reduce anxiety and improve mood and coping skills’ and ‘ dedicated psychology input.’ The project also informed the development of an Anticipatory Care Plan (ACP) that included psychological needs alongside others and shaped a programme to support nationwide implementation. [D]

Public Health England (PHE) cited Yohannes’ COPD research in its ‘State of Respiratory Health in Yorkshire and the Humber’ (2019). Again, his findings on COPD and depression in elderly outpatients with COPD supported a claim that, “ anxiety is a significant predictor for hospital admissions as symptoms continue to be unrecognised and untreated in COPD patients”. His findings on palliative care in patients with COPD were also used to demonstrate that “ people with advanced stage disease are much less likely to access palliative care compared to people with cancer”, and address the factors influencing poor quality end-of-life care for this group. PHE invited health and social care commissioners; providers and professionals in the region, where COPD was also responsible for 13.6% of all deaths in 2017, to “ use the resource to review best practice, identify key areas of current delivery and address areas for improvement”. [E]

Growing attention to non-medical support for COPD patients has led to a focus on the benefits of PR services. The British Thoracic Society (BTS) used Yohannes’ findings on the marked variation in PR services across the UK to demonstrate the need for the first evidence-based national Guideline for Pulmonary Rehabilitation (2013). The guideline provided the rationale for its Quality Standards (2014) and formed the basis of the Royal College of Physicians’ Accreditation scheme (2018), which aims to drive further quality improvement in PR. The Joint BTS/Association of Chartered Physiotherapists (ACPRC) Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient (2009) also cite Yohannes and Connolly’s research on early mobilization with walking aids following hospital admission (2003). It is the sole piece of evidence used to support its recommendation that practitioners: “ Assess the effectiveness of a gutter rollator frame in the acute setting, for patients with COPD severely disabled by breathlessness, especially the elderly”. The research found that using those frames greatly facilitated ambulation – a benefit the guideline extends to patients to the present day. [F]

Further informing practice, in 2013, Yohannes was one of 163 national experts who took part in a Delphi process led by the European Respiratory Society (ERS)’s Respiratory Physiotherapy Harmonised Education in Respiratory Medicine for European Specialists (HERMES) task force. This shaped the development of a consensus-based international syllabus in respiratory physiotherapy (adult and paediatric tracks) to “ serve as a blueprint for organisations that engage in the development of postgraduate education in respiratory physiotherapy” and, in 2019, a curriculum. The American Respiratory Society (ARS)/ERS cite five of Yohannes’ papers on PR and COPD (2000-2011) in the current joint statement on Key Concepts and Advances in Pulmonary Rehabilitation (2013), which “ represents the consensus of 46 international experts in the field of pulmonary rehabilitation. His research informed the expert’s case that “ recognition of comorbidities is essential because treating them can have a beneficial effect on COPD and vice versa, and early intervention may actually influence the course and prognosis of the disease”. [G]

As both MRADL and AIR are sensitive to change following PR, health professionals can use them to evaluate the effectiveness of interventions. The ARS/ERS statement confirms that MRADL is “ commonly employed” for this purpose. It is also one of three tools the current NICE guideline on the management of COPD in adult states: “ can be used to formally assess patients’ need for occupational therapy”. MRADL has been used in clinical PR research in UK hospitals, translated for use in hospitals in China, which has the world’s highest prevalence of COPD, and validated for use in Hong Kong. Additionally, health professionals in New Zealand have highlighted its potential in determining which patients may benefit from a palliative approach to care. AIR has been used in clinical interventions in the USA and Canada, and translated and validated for use in China and Brazil. Willgoss has also transferred methodological approaches from the development of AIR to his role as Head of Head of Clinical Outcome Assessments (Europe) at pharmaceutical company, Roche, informing outcome measures his team uses to assess concepts relevant to patients. [H]

Yohannes and Goldbart’s research into LTOT for people with COPD helped NHS Wirral to improve service delivery in line with patient needs. Despite the challenges posed by Covid-19, the Trust has retained and enhanced some of the services that the study showed were valued. These include specialist home oxygen and community-based PR. The report Yohannes and Goldbart produced also recommended better communication between the Hospital Admissions Prevention Service (APS) and the Community teams, plus the introduction of a 24-hour service. NHS Wirral implemented these changes in 2012, fully integrating the APS into a 24-hour integrated Community Nursing Service, which is still in place today. Their conclusions about the importance of education from specialist nurses or physiotherapists also informed recommendations on the follow-up of LTOT patients in the BTS guidance on home oxygen use (2015). [I]

The WHO Expert Committee on Selection and Use of Essential Medicines (2019) cited Yohannes, Willgoss and Vestbo’s findings on tiotropium as evidence of its efficacy in reducing COPD exacerbations. Concluding that it was also safe and cost-effective, it recommended the inclusion of tiotropium with a square box to the core list of the Essential Medical List (EML) for use in the treatment of COPD. It was one of twelve medicines added to the core EML list, which includes “ the most efficacious, safe and cost–effective medicines for priority conditions” for “ minimum medicine needs for a basic health-care system”. More than 150 countries use the list to compile essential medicines lists that meet their own priorities. The list captures “ the medicines that need to be available in a functioning health system at all times, in appropriate dosage forms, of assured quality, and at prices individuals and the community can afford”. [J]