A Quantitative Study in Early Chronic Obstructive Pulmonary Disease, Using a Cluster Analysis, to Establish if Prospective, Individualised, Medical Intervention Alters Projected Clinical Course

1. Background

1.1: History and Burden of COPD Chronic Obstructive Pulmonary Disease (COPD) is believed to have been first described by Theophile Bonnet in 1679 in the form of cadaveric 'voluminous lungs'(7). Despite being a major cause of disability and death in the UK(1), COPD still remains a relatively poor relation to many of the other current leading causes of death in terms of health resource allocation, patient and public understanding and the interest and motivation of health professionals to diagnose and manage the disease(8). Over the last three hundred years, COPD has been known to health professionals and the public in a variety of guises including emphysema, chronic bronchitis, smoker's cough and chronic airflow obstruction. The term, Chronic Obstructive Pulmonary Disease is believed to have been used for the first time in 1965 by William Briscoe at the 9th Aspen Emphysema Conference(7). Although the name has now been successfully unified, the negative associations, variable diagnosis rates and management strategies amongst patients with the disease continue. Sadly, a nihilistic attitude towards the value of diagnosis and treatment of the disease is still found in some clinicians, with some feeling the value of accurate and early diagnosis is small as there is no evidence for any disease course altering interventions(8). Whilst there are a lack of disease-modifying interventions other than smoking cessation, there are effective pharmacological and non-pharmacological interventions that have been shown to improve disease symptoms(4). Accurate, early diagnosis and disease education are the first steps to achieving high quality care throughout the whole patient journey up to and including palliative care.

COPD patients may be perceived as either being on a slow emphysematous downward decline or, to spiral rapidly through the cycle of recurrent exacerbations and hospital admissions to lung function decline and death (8-10). However, with the range of effective interventions now available (including pharmacological strategies, patient education, diet and exercise strategies, vaccination and targeted smoking cessation interventions) early diagnosis and ongoing proactive care should be the 'gold standard'(4).

The relatively recent evidence supporting pulmonary rehabilitation(11), lung volume reduction techniques(12), and modern developments in pharmacotherapy and preventative care have provided health care professionals with access to therapies which have proven benefits in terms of morbidity. The wealth of inhaled therapies flooding the market and the enormous cost burden of COPD to the NHS has led to more interest and research in the disease in the last decade. This research has generated an increased understanding of disease pathology, recognition of multiple disease phenotypes and the growing acknowledgement of the need to direct therapies to individuals rather than the disease population as a whole.

Increasing bed pressures in the NHS has shifted focus towards identification of those high-risk patients who are recurrent hospital attendees, and resources have been directed towards strategies to reduce hospitalisation and towards community based care. Currently, services vary enormously between hospital trusts and commissioning groups, ranging from Community Matron support, hospital admission avoidance and early discharge schemes, to full time, multidisciplinary, integrated COPD teams all of which are attempting to bridge the gap in service provision and communication between Primary and Secondary Care(4).