Practical decision support in respiratory patient care

Two new digital support tools aim to support general practice nurses to reach evidence- and guideline-based decisions when reviewing patients with asthma or COPD – without undermining their clinical judgement

The COVID-19 pandemic has disrupted many of the routine processes and mechanisms in primary care, with individual practices and practitioners having to quickly implement significant changes to how they provide care for their patients. This has been particularly true in the adoption of digital technology for – among other things – patient case-finding, triage, remote consultations and the use of video and email for patient support. Clearly, as restrictions ease, there will be time to reflect on which changes have worked and which haven’t. Many patients will undoubtedly welcome and benefit from a return to face-to-face consultations and reviews, particularly the more vulnerable members of society who have struggled to access care during the pandemic.¹ However, coronavirus restrictions accelerated the UK population’s shift to online,² and it is likely that some patients – and indeed some healthcare professionals – may have grown more comfortable with a sense of self-care and independence and prefer to continue with video or telephone consultations when it is appropriate.

In the short to medium-term it will be interesting to what extent these new ways of working will be a catalyst for change and whether technology’s potential for service transformation and redesign will be embraced as the NHS and wider society adjusts to a ‘new normal’. Importantly, many of these new care models and technologies have been driven locally – rather than top-down – with practice nurses and primary care colleagues at the forefront: collaborating, sourcing and adopting workable solutions to local challenges. Moving forward, support for ‘digitally excluded’ patients will be critical. However, what is beyond doubt is that ‘digitally enabled care’, a key driver in the NHS Long Term Plan,³ has already progressed to a point which was unimaginable in Spring 2020.

The potential of digital applications in healthcare delivery has long been a part of our work at Keele University. Based at Keele University’s School of Pharmacy and Bioengineering, the Centre for Medicines Optimisation has provided medicines optimisation solutions to the NHS for over 20 years. Using the Centre’s expertise and experience as a foundation, we have developed and delivered a number of digital applications designed to support and encourage implementation of best practice at the point-of-care.

In the middle of 2020, we launched an Asthma & COPD Audit & Review Toolkit free to all UK healthcare professionals. With key recommendations from the National Review of Asthma Deaths4 and National COPD Audit Programme5 at its core, the toolkit ‘interrogates’ the clinical coding in patient records using a series of search reports and alerts. In turn, this facilitates the identification of asthma and COPD patients considered to be at risk of unplanned admissions and/or displaying signs of poor disease control. Prior to its launch, the toolkit was tested for accuracy and utility across a number of practices in the West Midlands with the support of colleagues in our local Midlands Practice Pharmacy Network. At a time when healthcare professionals were, and still are, under considerable pressure, the intention is to help practitioners prioritise those asthma and COPD patients who would most benefit from a review – remotely or otherwise – without contributing unduly to practice workload. In addition to highlighting patients who haven’t had a review in the last 12 months, the toolkit enables patients to be further prioritised; for example, by the number of short-acting reliever inhalers they have received or by the number of exacerbations.

By chance, the advent of the pandemic also coincided with the initial development work for a new digital application: a clinical decision support tool (CDST) for patients with COPD. Early in the pandemic great efforts were made to protect patients who were thought to be at increased risk of severe illness, particularly those with respiratory conditions such as COPD. While current evidence indicates that patients with COPD do not seem to be at greatly increased risk of infection with COVID-19, it is possible that this more closely reflects the effectiveness of protective strategies such as social distancing and shielding.⁶ As a result, a significant proportion of COPD patients haven’t been able to visit practices over the last year, with many parts of the country now experiencing a bottle neck in the number of outstanding patient reviews.

Clinical decision support has been defined as the ‘provision of assessments or prompts specific to the patient and selected from a knowledge base on the basis of individual patient data’. Importantly, the CDST does not replace a healthcare professional's clinical judgement, often a criticism of digital healthcare technology. Rather, the aim is to distil or untangle the evidence and guidelines with the hope of making it more accessible to practitioners and easier for them to tailor best practice to the needs of the individual patient.

In this case, the ‘knowledge base’ was the NICE guideline Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115, last updated July 2019)⁷ and, in particular the NICE visual summary covering non-pharmacological management and use of inhaled therapies.⁸ During the spring and summer of 2020, key elements of the NICE guideline and each of its prescribing recommendations were re-purposed into a series of algorithms and decision trees, and ultimately into the computer code which populated the software application. Although the pandemic hindered progress, a number of practitioners kindly found the time to test prototype versions of the CDST to ensure its accuracy and utility.

From the user’s perspective, the CDST will check that the patient has a confirmed COPD diagnosis, that they have been offered appropriate interventions such as pulmonary rehabilitation and vaccinations and that they have a personalised self-management plan. After confirming the patient’s current treatment with inhaled therapies, symptom control and where appropriate, if they have any asthmatic features, the tool provides individualised prescribing recommendations based on the NICE guideline.

Recommendations include initiation, switching or the addition of inhaled therapies. Each recommendation is supported by a reason, management considerations, common treatment side-effects and appropriate references. Importantly, the tool is intended to ‘support’ rather than ‘replace’ clinical decision-making and practitioners should always use their own clinical judgement when considering and/or acting upon the tool’s prompts, alerts, notes and recommendations. Ultimately the decision remains with the practitioner. However, by using the tool, the hope is that when decisions are made, they are done so with the knowledge of national guidance.

The COPD CDST was launched in April of this year. It is available as a free-to-use, software application that can be run in all major web browsers (e.g. Google Chrome, Internet Explorer) and practice nurses can access it via their computer or touch screen tablet device.

While we endeavour to make all of our digital applications as user-friendly as possible, we don’t claim them to be a panacea or assume them to be an intuitive proposition for all practitioners. However, if the pandemic has taught us anything, it is that many people working in primary care are not only resilient and resourceful, but also receptive to new ways of working and the potential that digital offers.

ACKNOWLEDGEMENT

The development and delivery of the Asthma & COPD Audit & Review Toolkit and the COPD Decision Support Tool was sponsored by GlaxoSmithKline. GlaxoSmithKline was involved in scoping for both Tools and has reviewed them for compliance with the ABPI Code.

Thanks to the Midlands Practice Pharmacy Network (www.mppn.org.uk/) for their advice and support in developing and testing the Toolkit and CDST.