Official Statistics

Interactive Health Atlas of Lung conditions in England (INHALE): June 2022 update

Published 7 June 2022

Applies to England

1. New in this update

This update includes new data for 9 indicators in the Inhale profile:

• percentage of COPD (Chronic Obstructive Pulmonary Disease) deaths that occur in hospital

• percentage of COPD deaths that occur in care homes

• percentage of COPD deaths that occur at home

• median length of stay (days) of emergency admissions to hospital for COPD

• median length of stay (days) of emergency admissions to hospital for pneumonia

• median length of stay (days) of emergency admissions to hospital for asthma in adults (aged 19 years and over)

• median length of stay (days) of emergency admissions to hospital for asthma (aged under 19 years)

• the percentage of zero and one day emergency admissions to hospital for pneumonia

• the percentage of zero and one day emergency admissions to hospital for bronchiolitis in children aged under 2 years

Data should be interpreted in the context of the potential impact of COVID-19 on hospital admissions and mortality and alongside the other indicators in the Inhale tool.

The COPD mortality indicators are based on the underlying cause of death. In 2020, the total number of COPD deaths significantly decreased from by 3,545 from 2019. In 2020 there were 3,855 fewer COPD deaths in hospital, than in 2019. Conversely the number of COPD deaths in 2020 in homes increased by 415 compared to 2019. In 2020 there were 100 fewer COPD deaths in care homes than the previous year.

The indicators, including all previous years, have been recalculated for the new 2021 Clinical Commissioning Group (CCG) configurations. The mortality data have been adjusted to also take into account the changes in cause of death coding software and ICD-10 coding. Values therefore may not match those previously published.

Due to the potential impact of coronavirus (COVID-19) on mortality data, indicators are now being presented in views for both 3-year up to 2017 to 2019 and 1-year up to 2020 where numbers allow.

2. Main findings

This update shows:

• 52.5% of COPD deaths occurred in hospital in 2020. This has significantly dropped by 7.3 percentage points from 59.8% in 2019

• 13.7% of COPD deaths occurred in a care home in 2020. This has significantly increased by 1.4 percentage points from 12.3% in 2019

• 30.7% of COPD deaths occurred at home in 2020. This has significantly increased by 5.5 percentage points from 25.2% in 2019

• median length of stay values for England have remained consistent for financial years ending 2013 to 2021 for COPD, adult asthma, and child asthma. In the financial year ending 2021 median length stays for COPD were 3 days, adult asthma were 2 days, and child asthma were 1 day

• 5 days is the median length of stay in hospital for people admitted with a primary cause of pneumonia in England in the financial year ending 2021. This has been the same for the previous 6 years

3. Summary

3.1 Percentage of COPD deaths that occur in care homes, hospital, and at home (all ages)

Patients with advanced respiratory diseases have a very high symptom burden near the end of life, with a particularly high prevalence of breathlessness, fatigue, anxiety and depression. For all patients with advanced respiratory disease, good quality palliative care should be initiated early and address the holistic needs of patients and their families. There is considerable evidence that despite their higher symptom burden, and the recommendations in national and international guidelines, patients with COPD have much poorer access to palliative care. ^{[footnote 1]}

In England in 2020 there were significant changes in the place of death for COPD, when compared to 2019. There were significant reductions in COPD deaths in hospitals, and significant increases in COPD deaths in care homes and at home.

It should be noted that when calculating percentages by CCG, not all CCGs showed the same trends.

Data for the percentage of COPD deaths in ‘hospices’ and ‘other places’ have not been captured here due to small numbers but are included in the denominator.

Figure 1: Percentage of COPD deaths in England by place of death, for care homes, hospitals, and at home

The biggest change was observed in hospital COPD deaths. The percentage of COPD deaths in hospital significantly dropped by 7.3 percentage points in 2020 (52.5% (51.0 - 53.1)) compared to 2019 (59.8% (59.2 - 60.4)).

Prior to 2020, there was a gradual downward trend in the percentage of COPD deaths in hospital over time.

In 2020, there was a difference of 33.3 percentage points between the CCGs with the highest and lowest percentage of COPD deaths in hospital (66.7% (57.2 - 75.0) in NHS South East Staffordshire and Seisdon Peninsula CCG and 33.3% (24.5 - 43.6) in NHS West Suffolk CCG).

Figure 2: Box plots of percentage of COPD deaths that occur in hospital, by CCG

The percentage of COPD deaths in care homes significantly increased by 1.4 percentage points in 2020 (13.7% (13.3 - 14.2)) compared to 2019 (12.3% (11.9 - 12.7)).

From 2006 up to 2015 there was a slight upward trend in percentage of COPD deaths in care homes, followed by a small decline to 2019.

In 2020, there was a difference of 19.1 percentage points between the CCGs with the highest and lowest percentage of COPD deaths in care homes (25% (16.8 - 35.5) in NHS South and Formby CCG and 5.9% (2.5 - 13.0) in NHS Oldham CCG).

Figure 3: Box plots of percentage of COPD deaths that occur in care homes, by CCG

The percentage of COPD deaths at home significantly increased by 5.5 percentage points in 2020 (30.7% (30.2 - 31.3)) compared to 2019 (25.2% (24.7 - 25.7)).

Prior to 2020 there was a gradual upward trend in the percentage of COPD deaths at home over time.

In 2020, there was a difference of 28.7 percentage points between the CCGs with the highest and lowest percentage of COPD deaths at home (44.4% (34.6 - 54.7) in NHS West Suffolk CCG and 15.8% (9.8 - 24.4) in NHS Greater Preston CCG).

Figure 4: Box plots of percentage of COPD deaths that occur at home, by CCG

3.2 Median length of stay (days) of emergency admissions to hospital for COPD (all ages)

COPD is characterised by a progressive decline in lung function and in health status, accompanied by repeated acute exacerbations. Admissions to hospital are major adverse outcomes for people with COPD and place considerable demands on NHS resources. Length of stay can depend on many factors, and patients with COPD often have other co-morbidities, which can lead to a longer stay in hospital. Patients are likely to have an extended hospital stay if they delay treatment for exacerbations, do not respond to treatment, or have requirements such as oxygen therapy or social circumstances which delay discharge. ^{[footnote 1]}

This indicator has been updated and previous data refreshed to present data from the financial year ending 2014 to the financial year ending 2021 for persons of all ages, using the 2021 CCG configurations. This indicator is based on the length of stay for persons admitted to hospital in an emergency for which COPD was the primary diagnosis.

The England median value has remained the same at 3 days for the financial years ending 2014 through to that ending 2021.

In the financial year ending 2014, the highest CCG value for the median length of stay of emergency admissions to hospital for COPD was 6 days. In the financial year ending 2021, the highest median value was 4 days.

3.3 Median length of stay (days) of emergency admissions to hospital for pneumonia (all ages)

Community acquired pneumonia, despite being avoidable, is a leading cause of admission to hospital. Length of hospital stay is associated with the severity of illness on admission to hospital. ^{[footnote 1]}

This indicator has been updated and previous data refreshed to present data from the financial year ending 2014 to the financial year ending 2021 for persons of all ages, using the 2021 CCG configurations. This indicator is based on the length of stay for persons admitted to hospital in an emergency for which pneumonia was the primary diagnosis.

The median length of stay of emergency admissions to hospital for pneumonia England value was 6 days in the financial years ending 2014 and 2015, decreasing to 5 days for the financial years ending 2016 through to that ending 2021. The highest CCG median value in the financial years ending 2014 was 8 days. In the financial year ending 2021 the highest CCG median value was 7 days.

3.4 Median length of stay (days) of emergency admissions to hospital for asthma in adults (aged 19 years and over)

Most of the care for people with asthma is provided in primary care. The national guidelines (NICE) for the management of asthma state that people with asthma should not need emergency treatment if appropriate routine care is given. The degree of variation observed in length of stay in hospital may be related to disease severity. ^{[footnote 1]}

This indicator has been updated and previous data refreshed to present data from the financial year ending 2014 to the financial year ending 2021 for persons aged 19 years and over, using the 2021 CCG configurations. This indicator is based on the length of stay of adult emergency admissions for which asthma was the primary diagnosis.

The England median value remained steadily at 2 days for all included time periods, from the financial year ending 2014 to that ending 2021. The highest median CCG value in the financial year ending 2014 was 5 days while the lowest was 1 day. In the financial year ending 2021 the highest CCG median value was 4 days, and the lowest was 0 days. The most common CCG median value in each available financial year is 2 days, however, there has been a steady increase over time in the number of CCGs with a median value of 1 day for all available financial years.

3.5 Median length of stay (days) of emergency admissions to hospital for asthma (aged under 19 years)

Asthma is the most common long-term medical condition in childhood. Many children with asthma have poor control, often a consequence of poor medication compliance or poor inhaler technique. Environmental factors, such as exposure to second-hand smoke, air pollution and housing quality, also impact on control. ^{[footnote 1]}

This indicator has been updated and previous data refreshed to present data from the financial year ending 2014 to the financial year ending 2021 for persons aged under 19 years, using the 2021 CCG configurations. This indicator is based on emergency admissions for which asthma was the primary diagnosis.

The median value for England remained consistently at 1 day for the length of stay of emergency admissions to hospital for asthma in children aged under 19 years from the financial year ending 2014 to the financial year ending 2021. The majority of CCGs had a median value of 1 day for all financial years for which data are available.

3.6 The percentage of zero and one day emergency admissions to hospital for pneumonia (all ages)

Length of hospital stay for pneumonia is associated with the severity of illness on admission to hospital. Admissions with a shorter length of stay may represent those patients who are suitable for Same Day Emergency Care (SDEC), (also known as ambulatory emergency care), where emergency treatment is carried out on the same day without need for admission to a hospital bed. The NHS long term plan argues for increasing the use of SDECs to reduce avoidable emergency admissions. ^{[footnote 1]}

This indicator has been updated and previous data refreshed to present data from the financial year ending 2014 to the financial year ending 2021 for all persons using the 2021 CCG configurations. This indicator is presented as a percentage and is based on emergency admissions for which pneumonia was the primary diagnosis.

The percentage value of zero and one day emergency admissions to hospital for pneumonia for England rose from 15.9% in the financial year ending 2014 to 19.1% in the financial year ending 2020. The value decreased to 17.6% in the most recent financial year ending 2021. In the same year, two-thirds of all CCGs experienced a decrease in the percentage of emergency admissions that were zero and one day stays. Every CCG also experienced a decrease in the total number of zero and one days stays as well as the total number of stays of any length for emergency admissions to hospital for pneumonia from the financial year ending 2020 to the financial year ending 2021.

Figure 5: Map of percentage of zero and one day emergency admissions to hospital for pneumonia, all ages, compared to England value, by CCG

3.7 The percentage of zero and one day emergency admissions to hospital for bronchiolitis, in children aged under 2 years

Bronchiolitis is a viral respiratory infection of the lower airways, predominantly affecting infants under the age of 1 year but occasionally infants up to the age of 2 years. The majority of children with bronchiolitis do not require admission to hospital. Duration of admission is partly a function of patient factors such as disease severity. It will also reflect local differences in healthcare such as the management and assessment of children with bronchiolitis in the emergency department, thresholds for admission and discharge from hospital, and the quality of primary, community and social care support available to families during the infant’s recovery period. Length of stay should not be assessed in isolation; areas should also assess local admission rates and readmissions alongside this indicator. ^{[footnote 1]}

This indicator has been updated and previous data refreshed to present data from the financial year ending 2014 to the financial year ending 2021 for persons aged under 2 years, using the 2021 CCG configurations. This indicator is presented as a percentage and is based on emergency admissions for which bronchiolitis was the primary diagnosis. Previously, this data has been shown as a three-year aggregate by CCG due to small numbers, however recent changes in CCGs have meant that more CCGs have enough cases to avoid small number disclosure issues in single years. This has enabled CCG values to be shown for single years.

Figure 6: Trend chart of percentage of zero and one day emergency admissions to hospital for bronchiolitis in children aged under 2 years for England

The percentage of zero and one day stays for emergency admissions of bronchiolitis in children under age 2 for England has been generally increasing from 60.8% in the financial year ending 2014 to 68.3% in the financial year ending 2021.

Every CCG experienced a decrease in the number of emergency admissions of bronchiolitis in children under age 2 for zero and one day stays as well as stays of all duration in the financial year ending 2021 when compared to the previous financial year.

4. Background and further information

The Inhale respiratory disease profile provides an invaluable resource relating to one of the leading causes of death in England. The profile contains data for CCGs, lower tier local authorities and upper tier local authorities. These emergency hospital admissions and mortality indicators will support the work of health and wellbeing boards presenting local key statistics and highlighting questions to ask locally about current action to prevent respiratory disease.

Further details about the profile methodology are available within the definitions section of the online version of the Inhale profile.

Responsible statistician, product lead: Liz Rolfe, Julia Verne

For queries relating to this document, please contact: healthcare.variation@phe.gov.uk

1. Office for Health Improvement and Disparities. Inhale - INteractive Health Atlas of Lung conditions in England. 2022 (cited 19 May 2022) ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷