Lessons for primary care from National COPD Audit

Two new reports from the National COPD Audit Programme¹ offer new insight into the clinical effectiveness of COPD care in general practice and highlight many areas for improvement.

Time to Take a Breath,² published in October 2016, provides a snapshot of the way that COPD is being managed in primary care in Wales. The National COPD audit has been running since 2013, with reports already published on the organisation of care in secondary care and pulmonary rehabilitation, and this is the first report based on primary care data.

The original aim of the primary care audit was to collect data from practices in both England and Wales relating to the routine care of people with COPD, which went beyond that provided by publicly available data sources. However, due to limitations on data extraction from practices in England it was not possible to carry out the audit in England. Instead a report called National COPD audit programme COPD in England – finding the measure of success3 was published in November 2016 based on publicly available data from 2014–15. Its aim is to provide a picture of the care of patients with COPD in the general practice setting in England. This report reiterates pertinent findings and learning from the primary care audit for Wales.

Both these reports contain a wealth of material that is directly relevant to practice nurses who care for COPD patients. They provide an opportunity for nurses to review their findings and reflect on what they could do to improve care in their own practice or locality.

NATIONAL COPD PRIMARY CARE AUDIT 2014-15: NATIONAL REPORT (WALES)

Time to Take a Breath combines Quality Outcomes Framework (QOF) data with data extracted from 280 general practices in Wales to look at the quality of diagnosis, treatment, and recording of care for over 48,000 patients with COPD in the primary care setting.

The findings reveal that there are clear inconsistencies in the electronic coding, diagnosis and management of COPD and that many patients may not be receiving care in line with evidence-based guidelines. For example, approximately one quarter of people who had an appropriate test (spirometry) to confirm their diagnosis had a result that was inconsistent with COPD. This means that in these people the spirometry results recorded did not show an obstructive pattern. These individuals should have undergone further tests to confirm the cause of their symptoms, rather than receive treatment for COPD inappropriately. The report also emphasises the need to record an accurate diagnosis of COPD using post-bronchodilator spirometry, and the importance of performing a chest X-ray at the time of diagnosis.

It also highlights the underuse of higher value interventions such as treating tobacco dependency and pulmonary rehabilitation, which can improve the quality of life of patients, while also drawing attention to the variation in prescribing rates for inhaled medications.

Time to Take a Breath has highlighted the areas of everyday care where primary are can make a difference. Much of it is the day-to-day care, be it diagnosis, thorough and appropriate annual review or management of exacerbation, and while there are pockets of outstanding care, patients are subject to too much variability. We all need to look at how the care we offer compares locally and nationally and aspire to be the best. There is much to be learned in both comparing ourselves with others and in looking at how those whose outcomes exceed ours work differently to achieve better results. We can often learn much about our own practice by audit as opposed to just data collection at practice level.

KEY FINDINGS

Poor standard of diagnosis or inconsistent coding?

• Only 20% of people on the COPD registers had an electronic record of the post bronchodilator FEV1/FVC ratio, which is necessary for diagnosing COPD.
• Only 63% of patients on the COPD register had a record of an X-ray around the time of diagnosis, which NICE recommends for all COPD diagnoses to exclude co-morbidities.

There is considerable variation in data accuracy and coding across practices, particularly for diagnosis. In people who had a record of post-bronchodilator spirometry, only 27% had a value that was consistent with a diagnosis of COPD. Therefore, overall, the data extraction from Wales provided confidence in the quality of COPD diagnosis in only 14% of people on the COPD register. This was in sharp contrast to the QOF data in Wales, which shows practices recorded confidence in diagnosis in over 90% of cases. Dr Noel Baxter, PCRS-UK Chair and a member of the National COPD Primary Care Audit 2014–15 workstream group, commented: ‘Low recording rates could reflect lower standards of care, but may also reflect confusion about appropriate coding. It was hard to tease out exactly what the issue was for some questions.’ In conclusion, at best 42% of the COPD registered population and at worst 86% will require diagnostic re-evaluation to confirm COPD.

Under-use of high value interventions means patients are missing out on optimal care

Many highly effective treatments supported by good evidence are available to manage COPD. Many of these are being used, but there is also evidence that effective interventions are being under-used.

• In COPD patients recorded as being current smokers, almost 75% had been referred to a stop smoking service. However, only 11% of current smokers had received any pharmacotherapy to help them quit.
• Two thirds of patients with a Medical Research Council (MRC) dyspnoea score making them eligible for pulmonary rehabilitation had never been referred to pulmonary rehabilitation
• It is likely that the number of people on oxygen treatment is under-recorded – only 0.4% of people on COPD registers had a record of receiving oxygen.

The report comments that there is undoubtedly a need for greater clarification about what should be recorded during a routine COPD review and how this should be recorded.

Discrepancies between coding in notes and QOF results means people with more serious disease may not be getting the care they need

• The number of COPD patients with an MRC dyspnoea score recorded in the audit year was 58.2%. A breathlessness score is important for planning care and for detecting worsening of COPD.
• In only 11% of patients with COPD was an exacerbation coded in 2013-14, which is almost certainly an under-recording. There was wide variation between Health Boards with the lowest recording 7% vs nearly 14% for the highest.
• Over 15% of COPD patients on COPD registers were exception-reported in QOF
• Considerable discrepancies emerged between the high level of achievement of regular reviews reported for QOF, while the individual components of review were not coded in records.

The report says there is undoubtedly a need for greater clarification about what should be monitored during a routine COPD review and how this should be recorded.

RECOMMENDATIONS

A diagnosis of COPD should be made accurately and early enough to ensure that treatment is most effective. If the diagnosis is incorrect any subsequent treatment will be of no value.

• Practice nurses should be alert to breathlessness, cough and frequent chest infections as potential early signs of disease and investigate with spirometry
• Patients with a risk factor and symptoms should be assessed by competent clinicians with appropriate training
• People at risk of COPD are at increased risk of lung cancer and chest X-ray is an essential part of the breathlessness assessment and COPD diagnosis

People with COPD should be offered high value interventions including flu vaccination, help to overcome tobacco dependency and pulmonary rehabilitation.

• Tobacco dependency treatment is safe and highly effective but underused. Health professionals should be trained to assess dependency and offer appropriate intervention
• Anyone with an MRC breathlessness score 3 or more should be offered pulmonary rehabilitation and have timely and easy access to a service
• Practice nurses should ensure they are up to date on the inhaler devices available, able to support patients with optimal technique and ensure people are offered appropriate bronchodilator and inhaled corticosteroid medication, taking into account long term safety of high dose inhaled steroids.

Ensuring people with more serious disease are being identified for optimal therapy. A personalised approach is essential.

• Long-term oxygen therapy is a life prolonging intervention for people with COPD who have hypoxia. When low oxygen saturation is detected, patients should be referred to a suitable assessment and review service. The use of oxygen should be recorded in patient notes to ensure timely review for assessment of safety and effectiveness.
• People having frequent exacerbations of COPD need to be identified as they are at higher risk of an accelerated decline in their condition and may require specialist review. Recording the ‘number of exacerbations in the last year’ allows this group to be better identified by practices and prioritised.

There should be better coding and recording of COPD consultation, prescribing and referrals

• Make sure that people with COPD ‘know their numbers’ i.e. understand why their spirometry test is consistent with COPD and are supported to manage their own condition.
• Much of the variation seen in the data suggests variance in electronic coding. In order to standardise data entry, and promote a systematic approach to care, the report recommends developing a template to guide systematic recording of key information.

What practice nurses can do

• Review the findings and recommendations for improving COPD care in this report and share with colleagues
• Ask yourself – how consistent is your own coding?
• Ask yourself – how could you improve the recording of information so that your patients have access to the diagnosis and interventions that they need?
• Take this report and discuss it with key people in your CCG/Local Health Board e.g. those involved in services for people with long tern conditions or with a focus on quality
• Discuss with your local network or respiratory group and agree some local action

NATIONAL COPD AUDIT 2014-15: PRIMARY CARE REPORT FOR ENGLAND

This report combines publically available data from 2014-15 for England with pertinent audit data extracted from Welsh general practices.

The data presented in this report echo findings from the Welsh primary care audit that the accuracy of COPD diagnosis needs to improve and that some of the most clinically and cost-effective treatments for COPD are being under-used. It calls for the introduction of regional or national templates for COPD review with standardised coding.

The report recommends

• A diagnosis of COPD should be made accurately and early. If the diagnosis is incorrect, any subsequent treatment will be ineffective.
• People with a confirmed COPD diagnosis should be offered treatment for tobacco dependency, targeted pharmacological treatment, and pulmonary rehabilitation that will improve their outcomes.
• People with more severe disease should be identified and prioritised for optimal therapy including referral for specialist review. A personalised approach is essential.
• Clinicians should improve coding and recording of COPD diagnosis, treatment and referrals.

The report says it aims to support primary care clinicians who are currently working under considerable pressure to deliver the standard of care for people with COPD. Its message for practice nurses is that they can greatly improve the care of their patients by ensuring that they receive effective treatments: targeted pharmacological treatments to prevent exacerbations, improve quality of life and relieve breathlessness and treatment for tobacco dependency, and pulmonary rehabilitation.

What practice nurses can do

• Read the report and consider how you could improve the quality of care provided to your own COPD patients by examining and reviewing current practices in one of the recommendation areas above – diagnosis, high value interventions, identification and prioritisation of patients with more severe COPD, and consistent coding

See also Advanced Practice – The GOLD 2017 guideline on COPD: implications for practice

REFERENCES

1. National COPD Audit Programme https://www.rcplondon.ac.uk/projects/national-copd-audit-programme

2. Time to take a breath. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: National primary care audit (Wales) 2014–2015. National Clinical Audit report. October 2016. https://www.rcplondon.ac.uk/projects/outputs/primary-care-time-take-breath

3. National COPD audit programme. COPD in England – finding the measure of success. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Primary care report for England 2014–15. November 2016. https://www.rcplondon.ac.uk/projects/outputs/primary-care-copd-england-finding-measure-success