An investigation into Chronic Obstructive Pulmonary Disease (COPD) and its management in 16 GP practices in Newcastle Primary Care Co-operative (NPCC)

Newcastle Project Phase 1: An investigation into Chronic Obstructive Pulmonary Disease (COPD) and its management in 16 GP practices in Newcastle Primary Care Co-operative (NPCC).

Introduction

In April 2014, 16 GP practices in the Newcastle Primary Care Cooperative (NPCC) embarked upon a 12 month project to audit the care given to their Chronic Obstructive Pulmonary Disease (COPD) patients. In total, 3075 patients were included in the baseline assessment rising to 3393 in the final data collection.
The long-term primary goal of the project was to reduce unnecessary hospital admissions, though from the outset it was readily acknowledged that this would be difficult to demonstrate over a 12-month period where many influencing factors are out with the control of healthcare professionals.
The project uncovered many areas where improvement could be made and the CCG readily provided funding to allow the project to continue for a further 12 months (which is the subject of Case Study 2)

The Case for Change

COPD is currently the second most common cause of emergency admission to hospital and the fifth largest cause of readmission to hospital1. It also accounts for around 1 million hospital bed days per year in England alone with an estimated direct cost of around £500 million per year2. COPD causes a greater number of deaths than lung cancer and more smoking related deaths than cardiovascular disease3.

The North East of England has the highest rates of COPD mortality and the highest rates of emergency admission in the UK4 with each hospital admission costing in excess of £2,000. Prevalence is growing in the UK and is highest in the North of England & Scotland.

Overview of Innovation

The project consisted of five elements:

1. An audit of the care given to COPD patients which aimed to assess the management of patients measured against recommendations from NICE Guidance
2. A questionnaire devised to measure the knowledge and confidence of healthcare professionals (HCPs) in dealing with COPD patients which was sent via Survey Monkey to 166 HCPs
3. A series of educational interventions for HCPs
4. A repeat audit was conducted which measured progress from the baseline figures
5. A detailed, manual review of the records of all patients admitted to hospital with exacerbation of COPD in the previous 18 months

The audit aimed to assess the management of patients in primary care with COPD in line with recommendations from NICE Guidance5. Data was measured over a period of 10 months commencing in May 2014 and completing in March 2015. The following seven criteria were chosen for measurement:

1. Number of patients (NOP) with exacerbation frequency recorded within the previous 12 months
2. NOP with inhaler technique checked within the previous 12 months
3. NOP screened for anxiety and depression within the previous 12 months
4. NOP with Quality of Life (QOL) measurement COPD assessment test (CAT) within the previous 12 months
5. NOP with a self management plan (SMP) issued within the previous 12 months
6. NOP who have ever had an emergency rescue pack issued
7. NOP with no pneumococcal status recorded – ever

Progress to Date

This project is now complete

Impact

Table 1. Audit Results: Baseline, May 2014 & Post Education, March 2015.

Baseline (3075 patients) Post Education (3393 patients)
Number of Patients Percentage of Patients Number of Patients Percentage of Patients
No. of  patients with a record of exacerbation frequency 1153 37% 1164 34%
No. of  patients with a record of quality of life measurement 646 21% 1118 33%
No. of  patients with a record of inhaler technique assessment 1224 40% 1813 53%
No. of  patients with a record of depression screening 986 32% 1193 35%
No. of  patients with a record of self-management plan issued 430 14% 1142 34%
No. of  patients with a record of emergency rescue pack issued 419 14% 692 20%
No. of  patients with a record of pneumococcal vaccination (offer) 2643 86% 2863 84%

 

Table 2. Healthcare professionals knowledge & confidence questionnaire (at baseline, before interventions)

Knowledge / Confidence Statement Disagree or Strongly Disagree
I feel confident and adequately trained to ensure patients are given correct advice in relation to their COPD 22.5%
I feel confident and adequately trained to educate patients in the correct use of their inhalers 25%
I feel confident and adequately trained to educate patients in the correct use of self management plans and emergency rescue medication 29%
I understand and am confident in the implementation of the North of Tyne COPD Treatment Guideline 36%

 

Table 3. Findings from the detailed records review of 248 patients with a history of hospital admission for COPD exacerbation.

Findings Number of Patients (%)
COPD Reviews: annual, post-exacerbation or post hospital discharge:
Patients with no record of any COPD review 146 (58%)
Possible avoidable admissions:
Patients discharged on the same day of admission 116 (33%)
Patients discharged on the next day following admission 105 (25%)
Poor adherence to preventative medications:
Patients collecting 8 or less prescriptions per year 97 (39%)
Patients collecting 6 or less prescriptions per year 78 (33%)

 

Next Steps and Plans for the Future

The following conclusions were drawn from this project:

1. There is wide variation in coding and recording of COPD reviews and management
2. There is a significant lack of confidence among HCPs around the management of COPD
3. Education for HCPs makes some, but limited difference
4. 58% of hospital admissions for COPD are probably unnecessary / inappropriate

Following this initial project (Phase 1) it was agreed that investigative and supportive activity should continue, and this activity should be widened to incorporate all GP surgeries across the city. Objectives were agreed for a new programme of activity (Phase 2), which would be jointly funded by the CCG and the AHSN NENC and supported by the North East Commissioning Support Unit (NECS).

Details of the Phase 2 project are reported in: Newcastle Project Phase 2: A Report on Chronic Obstructive Pulmonary Disease (COPD) and its management Newcastle Gateshead CCG.

Support Provided by the AHSN

The entire project was managed by Sue Hart with support from Dr Mike Scott and funded by the AHSN NENC.

Phase one has demonstrated that there is a great deal of work to be done to achieve excellence in care and it gives us a springboard for a citywide effort to provide a better service.

Dr Mike Scott, GP, Newburn Surgery

Start date: May 2014 End date: March 2015

Contacts

Sue Hart, COPD Project Lead, Newcastle CCG. Sue.hart@ahsn-nenc.org.uk
Dr Mike Scott, GP, Newburn Surgery. mike.scott2@nhs.net

References

1. Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England. Dept. of Health, 2010 www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_113279.pdf.

2. HES Online Primary Diagnosis www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category

3. Commission for Healthcare Audit and Inspection. Clearing the Air: A National Study of COPD,2006

4. National Statistics. Deaths by age, sex and underlying cause. 2003 registrations:health statistics quarterly 22, Report No.: HSQ22DT2. London: Office for National Statistics,2004

5. https://www.nice.org.uk/guidance/CG101/chapter/1-Guidance#managing-stable-copd

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