A Winter’s Tale
The impact of respiratory disease on the winter crisis
With alarmingly high numbers of unnecessary deaths, overwhelmed services, and demanding patients, it’s safe to say ‘winter’ and ‘crisis’ are two words that are likely to turn any healthcare professional cold. Occupancy levels within the National Health Service (NHS) are increasing, particularly in winter.1 Furthermore, occupancy levels are frequently getting to dangerous levels within some trusts.2 Doctors and hospitals are struggling to accommodate sudden and unpredictable increases in admissions,3 all the while funding isn’t keeping pace with this increasing demand.4
Increasing emergency hospital admissions and lack of beds can potentially lead to unsafe wait times, with patients being found in the back of ambulances or the hospital corridors. It comes as no surprise that the growth in emergency admissions is substantially higher than the number of patients arriving at major A&E departments.3
The winter crisis – is it time for a new paradigm in risk management?
Hospital admissions for respiratory diseases have risen at three times the rate of all hospital admissions generally.5 Most respiratory admissions are non-elective and during winter these double in number.5 The winter months also lead to almost 80% more respiratory admissions compared with the warmer spring months,2 meaning respiratory diseases are not something to be overlooked.
Non-tuberculous mycobacterium (NTM) are a group of bacteria, capable of causing lower respiratory tract infections (LRTIs).6 Patients with an underlying respiratory disease will be more susceptible to infections caused by NTM. The prevalence of LRTIs in respiratory disease patients in the colder winter season is considerably higher than those of summer.7 Viruses were detected in 92% of stable bronchiectasis patients during the 2018 winter period, whilst viruses were detected in only 33% of patients during the summer period.7
The increase in viral infections that circulate in cold and damp conditions is thought to be the link to the strong seasonal patterns of hospitalisation in patients with Chronic Obstructive Pulmonary Disorder (COPD).2 Respiratory viruses are known to precipitate exacerbations, especially in COPD and Cystic Fibrosis (CF) patients.7 With an increase in respiratory viruses it is clear to see why COPD exacerbations are consistently 50% more likely in winter, often leading to hospitalisation.2 Comorbid NTM increases the risk of hospitalisations in the COPD population.8
Patients with NTM often do not receive the appropriate treatment options, with around half of patients in primary care not receiving guideline-based therapy, and around 14% of patients not receiving treatment at all.9 However, a delay in commencing therapy for NTM pulmonary disease (NTM-PD) can lead to severe consequences and disease progression. Over an average of 6 years, 97.5% of untreated nodular bronchiectatic Mycobacterium avium complex (MAC) pulmonary disease patients experienced radiographic disease progression, after receiving no early interventional treatment due to minimum symptoms.10 Whilst this study only investigated 40 patients, it does demonstrate the potential unmet need for patients living with NTM-PD.
With an increase in the prevalence of LRTIs during the cold winter,7 11 alongside the reluctance to initiate treatment for patients showing symptoms for pulmonary diseases,10 it is clear to see why respiratory conditions were the underlying cause for 36.4% of all excess winter deaths in 2016-2017.2
So what now?
Respiratory viruses are more prevalent in the winter months, causing more exacerbations in patients with underlying respiratory conditions.2 Alongside this, not all patients are receiving appropriate treatment for pulmonary diseases.9 10 This could be adding extra pressures to the NHS during an already busy time. By taking action and improving primary services, as well as ensuring the whole health care sector recognises the seasonality in respiratory disease admissions, the burden on the NHS during the winter could be reduced.2