Commissioning guides
Published 01 October 2011

Services for people with chronic obstructive pulmonary disease

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg43

3 Assessing service levels for people with COPD

3.1 Benchmarks for a standard population

A population benchmark is offered for commissioners to consider when planning services for people with COPD in each of the following areas:

  • pulmonary rehabilitation

  • assisted discharge schemes

  • supportive and palliative care.

Each of the areas and the assumptions used to arrive at the benchmark will be explored.

Available data suggest that the indicative benchmark rate for the number of people with diagnosed COPD is 1.6%, or 1600 per 100,000 population, of those aged 18 years or older per year[7].

However, commissioners should take into account local socioeconomic and demographic factors such as age and the number of people who smoke, which can affect local rates, and recognise that COPD is under-diagnosed in the population.

For the purpose of this commissioning guide, the adult population has been defined as people aged 18 years or older. This is because of the availability of population data at general practice level within certain age bands, and its use within the commissioning and benchmarking tool. Approximately 80% of the population in England is aged 18 years or older.

For a standard population of 100,000, around 80% of the population would be aged 18 years or older. Around 1.6% of this population, or around 1280 people, would be diagnosed with COPD.

For an average practice with a list size of 10,000, around 80% of the population would be aged 18 years or over. Around 1.6% of this population, or around 128 people, would be diagnosed with COPD.

The Healthcare Commission report 'Clearing the air'[8] stated that there are 900,000 people diagnosed with COPD in the UK, and an estimated 2 million people with undiagnosed COPD. If the number of people with undiagnosed COPD is taken into account, the above figures could be increased by approximately a factor of two.

This service is likely to fall under the programme budgeting category 211A (problems of the respiratory system – obstructive airways disease).

Use the commissioning and benchmarking tool for services for people with COPD to determine the level of service that might be needed locally and to calculate the cost of commissioning the service using the indicative benchmark and/or your own local data.

3.2 Assumptions used in estimating a population benchmark

The assumptions used in estimating a population benchmark for COPD are based on the following sources of information:

  • epidemiological data on the prevalence and incidence of COPD

  • activity data to establish hospital activity

  • current practice where there is an existing example of a COPD care scheme

  • published research on COPD

  • expert clinical opinion of the topic-specific advisory group, based on experience in clinical practice and literature review.

The areas of care that will be examined in the population benchmark can be found in the following sections:

  • pulmonary rehabilitation – section 3.3

  • assisted discharge schemes – section 3.4

  • supportive – section 3.5.

3.3 Benchmark for establishing a new pulmonary rehabilitation service

Experience of current practice suggests that the benchmark population rate for uptake of pulmonary rehabilitation when establishing a new service would be 0.41%, or 410 per 100,000 population aged 18 years or older, per year.

However, when planning services, commissioners should take into account local socioeconomic and demographic factors such as age and the number of people who smoke, and recognise that COPD is under-diagnosed in the population.

For a standard population of 100,000, around 80% of the population is aged 18 years or older. The average number of people expected to receive pulmonary rehabilitation annually is likely to be around 330.

For an average practice with a list size of 10,000, around 80% of the population is aged 18 years or older. The average number of people expected to receive pulmonary rehabilitation annually is likely to be around 33.

This service is likely to fall under the programme budgeting category 211A (problems of the respiratory system – obstructive airways disease).

Activity data for establishing a new pulmonary rehabilitation service

When commissioning a new pulmonary rehabilitation service, it is appropriate to use the population prevalence of COPD to determine the levels of service needed. Commissioners may have to plan services over a number of years to cover unmet needs and prioritise initial demand against capacity. This is because there will be a significant number of people with COPD who are eligible for, but who have not previously received, pulmonary rehabilitation.

Quality and outcomes framework (QOF) data for 2009/10[9] indicate that the national prevalence of diagnosed COPD is 1.6%. The clinical opinion of the topic advisory group is that the proportion of people with diagnosed COPD at Medical Research Council grade 3 or above is approximately 38%. Therefore, around 38% of people with diagnosed COPD would be eligible for pulmonary rehabilitation.

Conclusion for establishing a new pulmonary rehabilitation service

When establishing new pulmonary rehabilitation services consider commissioning services for 0.41% of the adult population aged 18 years or older (410 per 100,000). This is based on:

  • 1.6% prevalence of diagnosed COPD, of which

    • 38% are eligible for pulmonary rehabilitation, of which

      • there is an uptake of 67%.

Benchmark for an existing pulmonary rehabilitation service

Experience of current practice suggests that the benchmark population rate for uptake of pulmonary rehabilitation for an existing pulmonary rehabilitation service would be 0.026%, or 26 per 100,000 aged 18 or older, per year. However, when planning services commissioners should take into account local socioeconomic and demographic factors such as age and the number of people who smoke, and recognise that COPD is under-diagnosed in the population.

For a standard population of 100,000, around 80% of the population is aged 18 years or older. The average number of newly diagnosed people expected to receive pulmonary rehabilitation annually is likely to be around 20.

A proportion of the prevalent population would also need pulmonary rehabilitation services.

Activity data for an existing pulmonary rehabilitation service

Where pulmonary rehabilitation services are already established, local incidence and referral rates would be the most appropriate data on which to base commissioning intentions.

Data from the IMS Disease Analyzer, which collects anonymised data from a sample of GP practice systems, shows that new diagnoses of COPD are around 0.1% of the patient population. Of these 38% had Medical Research Council grade 3 or above.

Conclusion for an existing pulmonary rehabilitation service

Clinical experience of existing pulmonary rehabilitation services suggests that the uptake rate in the population eligible for pulmonary rehabilitation is approximately 67%.

For an existing pulmonary rehabilitation service consider commissioning for 0.026% of the population aged 18 years or older (26 per 100,000 adults). This is based on:

  • 0.1% incidence of new cases of COPD annually, of which

    • 38% are eligible for pulmonary rehabilitation, and of which

      • there is an uptake of 67%.

3.4 Benchmark for assisted discharge schemes

Existing data suggest that the benchmark population rate for eligibility for an assisted-discharge scheme is 0.086%, or 86 per 100,000 people aged 18 years or older, per year. This is based on a mean non-elective admission rate of 258 per 100,000 population for exacerbations of COPD and a 33% uptake rate for assisted discharge.

For a standard population of 100,000, around 80% of the population is aged 18 years or older. The average number of COPD patients admitted with an exacerbation and expected to need assisted discharge is likely to be around 69 per year.

For an average practice with a list size of 10,000, around 80% of the population is aged 18 years or older; the average number of COPD patients admitted with an exacerbation and expected to need assisted discharge is likely to be around 7 per year.

However, commissioners should take into account the local socioeconomic and demographic factors that may impact on rates of admission, such as age and the number of people who smoke. They should also recognise that COPD is under-diagnosed in the population.

Hospital episode statistic data on assisted discharge

Data from the Hospital Episode Statistics (HES) database (2009/10)[10] indicate the mean rate of admissions for a COPD exacerbation is 258 per 100,000 population aged 18 years or older.

Published models exist that aim to estimate the number of readmissions for COPD[11]. Successful pulmonary rehabilitation, assisted discharge schemes and supportive and palliative care schemes are likely to reduce non-elective admissions and re-admissions for exacerbations of COPD.

This is examined further in the COPD commissioning and benchmarking tool.

Current practice assisted discharge schemes

Published research[12] suggests that between 25 and 35% of patients are eligible for assisted discharge. Research relating to the UK national COPD audit of assisted discharge schemes indicates that 30% of people who are admitted to hospital with an exacerbation of COPD can be safely managed in an assisted-discharge scheme[13].

Expert clinical opinion suggests that approximately one in three (33%) people admitted for a COPD exacerbation may benefit from assisted discharge.

Conclusions on assisted discharge schemes

From the information above, we can conclude that:

  • the mean non-elective admission rate for COPD exacerbations is 258 per 100,000 population aged 18 years or older, of which

  • 33% of patients would be eligible for assisted discharge, based on views of the topic-specific advisory group, experience from current practice and information from recent research.

This gives a benchmarking estimate for a population rate for eligibility for an assisted discharge scheme as 0.086, or 86 per 100,000 aged 18 years or older, per year.

3.5 Supportive and palliative care for patients with COPD

Available data suggest that the indicative benchmark rate for the number of deaths from COPD is 0.054%, or 54 per 100,000 population aged 18 years or older, per year.

For a standard population of 100,000 the average number of people aged 18 or over is approximately 80% of the population. Of these, the number of people who will die from COPD is 44 per year.

For an average practice with a list size of 10,000, the average number of people aged 18 or over is approximately 80% of the population. Of these, the number who will die from COPD would be 4 per year.

Epidemiological data

The Office for National Statistics (ONS)[14] publishes figures for death registrations by cause in England and Wales. In 2009 more than 23,500 deaths were primarily attributable to COPD (ICD-10 codes J40–J44). This equates to 0.054% of the population of England and Wales aged 18 or older.

Current practice

Because of the limited provision of supportive and palliative care for people with COPD, many patients with COPD will not have access to supportive and palliative care services at the end of their life.

According to the national 2008 COPD audit[15], 44% of primary care organisations have formal arrangements for patients with COPD to receive palliative care.

The 2010 article 'Current and planned palliative care service provision for chronic obstructive pulmonary disease patients in 239 UK hospital units: comparison with the gold standards framework'[16] reported that only 49% of the 239 units that admitted COPD patients had a formal referral pathway for palliative care. Furthermore, only 13% had a policy of initiating end-of-life care discussions with appropriate patients.

Conclusions

Based on the epidemiological data and other information outlined above, there is limited provision of or access to palliative care at the end of life for patients with COPD. This is based on the following assumptions:

  • that 0.054% of the population of England and Wales have deaths attributable to COPD

  • applied to the adult population of England, there are approximately 22,000 deaths attributable to COPD annually

  • fewer than half of acute trusts (49%) and primary care organisations (44%) have formal provision for palliative care for patients with COPD.

3.6 Overall conclusions for benchmark for services for people with COPD

Based on the epidemiological data and other information outlined above:

  • when establishing new pulmonary rehabilitation services, consider commissioning services for 0.41% of the general adult population (410 per 100,000 adults)

  • for an existing pulmonary rehabilitation service consider commissioning for 0.026% of the general adult population (26 per 100,000 adults)

  • eligibility for an assisted discharge scheme is 0.086% (86 per 100,000 adults)

  • the annual number of deaths attributable to COPD is 0.054% (54 per 100,000 adults).

The population benchmark for the number of people with diagnosed COPD is 1.6%. It has been estimated that there are twice as many undiagnosed people with COPD.

Commissioners should use their local needs assessment to determine optimum levels for local service provision. Commissioners should note that the benchmark rates do not represent NICE's view of desirable, or maximum or minimum, service levels.

Commissioners should use this benchmark and local data to facilitate local discussion on optimum service levels. There is considerable variation in the prevalence and identification of COPD. This is influenced by the social, economic and demographic profile of the local population. Therefore commissioners are encouraged to consider local assumptions.

Use the COPD commissioning and benchmarking tool to determine the level of service that might be needed locally and to calculate the cost of commissioning the service.



[7] Quality and out comes frame work (2010) 2009/2010 QOF data. Leeds: The NHS Information Centre for health and social care.

[8] Healthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease. London: Commission for Healthcare Audit and Inspection

[9] Quality and outcomes frame work (2010) 2009/2010 QOF data. Leeds: The NHS Information Centre for health and social care

[10] The NHS Information Centre (2010) Hospital episode statistics. Leeds; The NHS Information Centre for health and social care.

[11] Buxton KL, Stone RA, Buckingham R et al (2010). Current and planned palliative care service provision for chronic obstructive pulmonary disease patients in 239 UK hospital units: comparison with the gold standards framework Palliative Medicine 24: 480–5 (first published March 26, 2010)

[12] Demir E, Chaussalet T, Xie H (2006) A method for determining an emergency readmission time window for better patient management London: University of Westminster;

Cotton MM, Bucknall CE, Dagg KD et al. (2000) Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial. Thorax 55: 902–6;

Shepperd S, Harwood D, Jenkinson C et al (1998) Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes. British Medical Journal 316: 1786–91;

Skwarska E, Cohenb G, Skwarskia KM et al. (2000) Randomised controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. Thorax 55: 907–12;

Ram FSF, Wedzicha JA, Wright J et al. (2004). Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ 329: 315; British Thoracic Society guideline development group (2007) Intermediate care – Hospital-at-Home in chronic obstructive pulmonary disease. Thorax 62: 200–10

[13] National COPD Audit 2008 (2009) Clinical audit of COPD exacerbations admitted to acute NHS units across the UK. London: Royal College of Physicians

[14] Office for National Statistics (2009) Statistical Bulletin: Death registrations by cause in England and Wales. Office for National Statistics

[15] National COPD Audit 2008 (2009) Clinical audit of COPD exacerbations admitted to acute NHS units across the UK. London: Royal College of Physicians

[16] National COPD Audit 2008 (2009) Clinical audit of COPD exacerbations admitted to acute NHS units across the UK. London: Royal College of Physicians