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LRN's COPD Value Pyramid

Widely used for its impactful message about the comparative value of interventions for COPD that rebalances the value accorded to flu vaccination, stop smoking as a treatment, pulmonary rehabilitation, inhaled medicines and telemedicine using cost per quality adjusted life year (QALY). Find the original and key references here.

Thorax cover 28 October 2014 

http://thorax.bmj.com/content/69/11/973/F1.large.jpg  and http://thorax.bmj.com/content/69/11.cover-expansion

DOWNLOAD the LRN slide you can use (please acknowledge London Respiratory Network).


References (as listed in the NHS Companion Guide to the DH Outcomes Strategy)

1.Hak  E et al.  Is immunising all patients with chronic lung disease in the community against influenza cost effective? Evidence from a general practice based clinical prospective cohort study in Utrecht, The Netherlands.J Epidemiol Community Health. 1998 Feb;52(2):120-5  £50 saving for over 65
2.Hoogendoorn M et al. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD.Thorax.  65(8):711-8, 2010 Aug.
3. Griffiths TL et al.  Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme.  Thorax 2001;56:779-784 £0-1000 per QALY
4.Neyt M et al. Tiotropium in the treatment of COPD. Health technology Assessment KCE reports 108C  £7,456  per QALY
5.Oba Y Cost effectiveness of long acting bronchodilators for COPD. Mayo Clinic Proc 2007;82:575-582 £5,396 per QALY
6.Mayers I et al. LABA plus Corticosteroids vs LABA alone for COPD. CADTH Issue 83 March 2007. £130,000  per QALY and NICE COPD management of COPD in adults in primary and secondary care 2010  £131,000  per QALY

7. Henderson C et al. Cost effectiveness of telehealth for patents with long term conditons (Whole Systems Demonstrator telehealth questonnaire study): nested economic evalualon in a pragmatic, cluster randomised controlled trial. BMJ 2013;346:f2065 Accessed June 2013 from http://www.bmj.com/content/346/bmj.f2065 .  Note  from the London Respiratory Team Final Report 2013: 

"In our last 6 months, we concluded that we should further update the pyramid to include the latest data on telehealth, for which there is currently insufficient evidence of value in COPD to justfy its inclusion in services. We fear that premature directives to use this technology will distort investment priorities and cause commissioners to forsake known cost-­‐effective services that require additonal investment such as flu vaccination (for patents at risk and staff), stop smoking and pulmonary rehabilitation.

“The incremental cost per QALY of telehealth when added to usual care was £92 000. With this amount, the probability of cost effectiveness was low (11% at willingness to pay threshold of £30 000; >50% only if the threshold exceeded about £90 000). In sensitivity analyses, telehealth costs remained slightly (non-­‐significantly) higher than usual care costs, even a􀅌er assuming that equipment prices fell by 80% or telehealth services operated at maximum capacity. However, the most optimistic scenario (combining reduced equipment prices with maximum operating capacity) eliminated this group difference (cost effectiveness ratio £12 000 per QALY)."


Some of the links to other citations




Outcomes Strategy for COPD and asthmaNHS Companion Guide. DH.




National primary care COPD audit - Wales
The thinking behind this work has been taken forward into this audit, Primary care: Time to take a breath, the first comprehensive primary care snapshot audit for a UK nation.

Taking account of severity and cost
Note a more detailed evaluation of COPD intervention value that segments the population into undiagnosed, diagnosed with mild-moderate COPD, and diagnosed with severe COPD, and also takes account of the cost today of each intervention was undertaken by the IMPRESS team: Executive Summary and  Full report: IMPRESS Guide on Relative Value of interventions for COPD.

The IMPRESS work and website has now ended, but the documents are loaded on the NHS Networks website  and Respiratory Futures  for more information on the inhaled medicines references and specific topics eg IMPRESS Guide to Pulmonary Rehabilitation go there.