Newcastle Project Phase 2: A Report on Chronic Obstructive Pulmonary Disease (COPD) and its management in Newcastle Gateshead CCG

Introduction

Following the initial COPD project (Phase 1: An investigation into COPD and its management in 16 GP practices in Newcastle Primary Care Co-operative), Newcastle Gateshead CCG requested that investigative and supportive activity around COPD should continue, and this activity should be widened to incorporate all GP surgeries in Newcastle upon Tyne.

The overall objectives included:

  1. Initiating a series of activities aimed at improving overall COPD care in Newcastle
  2. Conducting repeat, detailed audits of COPD patient records following initiation of agreed educational interventions
  3. Developing and offering a specialist review service to all practices
  4. Drawing up a list of further actions and recommendations with regard to the outcomes of the project

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 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.

Despite the improvements made during Phase 1 of the project, there was still much work to be done and the table below indicates where improvements could still be made.

Table 1. The number and % of COPD patients where vital data was NOT being recorded

Criterion – NO RECORD OF: Number of Patients % Patients on COPD Registers
Exacerbation Frequency 1729 51%
CAT 2185 64%
Inhaler Technique Training 1580 47%
Depression Screening 2200 65%
Self Management Plan 2251 66%
Rescue Pack 2601 77%
Pneumococcal Vaccination offered 530 16%

Overview of Innovation

Key deliverables:

  1. Formal education sessions for HCPs x 4
  2. In-surgery education sessions for HCPs x 12
  3. Education days for patients x 2
  4. Introduction of a standardised COPD Annual Review template
  5. Established a Respiratory Interest Group for HCPs
  6. Established a Breathe Easy Group for patients

 Audit: Two audit cycles are to be performed, measuring six key parameters:

  1. Exacerbation frequency recording
  2. Inhaler technique training
  3. Depression screening
  4. Issue of COPD self management plans (SMPs)
  5. Issue of emergency rescue medication packs
  6. Referral for pulmonary rehabilitation

 Develop a Specialist Review Service:

Develop a service, which offers each practice the opportunity to invite patients at high risk of hospital admission to attend a specialist review and education session by an appointed respiratory specialist nurse, reviews to be conducted in the patients home where necessary.

Progress to Date

Rationale for audit parameters:

  1. Exacerbation Management – Exacerbations are not always well recorded or followed up. In order to reduce unnecessary hospital admissions it is essential to be able to identify those patients who experience frequent exacerbations. If we simply rely on counting the number of acute events recorded during consultation we risk serious underestimation. The NICE guideline recommended question How many exacerbations have you had in the previous 12 months?” was incorporated into the annual review template and nurses were encouraged to evaluate the number of exacerbation events in partnership with the patient at review.
  2. Inhaler Technique Training for Patients – Most patients believe they are able to use their inhaler device correctly, however multiple studies confirm this is not the case. One study demonstrated that 98% of patients questioned believed they were able to use their inhalers correctly; in reality only 6% used their inhaler without error.5
  3. Depression Screening – Whilst depression prevalence in the general population is estimated to be between 15-20%, in COPD patients significant symptoms of depression have been reported ranging between 10-71%.6
  4. Issue of Self-Management Plans – Self-management plays a crucial part in the management of COPD, alleviating increased pressure on healthcare systems and ensuring that fewer COPD patients are admitted to hospital.
  5. Issue of Emergency Rescue Medication Rescue packs are intended to allow patients to self-medicate with antibiotics and oral steroids in the early stages of an exacerbation.
  6. Referral to Pulmonary Rehabilitation (PR) – PR is one of the most cost effective treatments currently available to patients with COPD; its benefits are clearly stated in all evidence based COPD clinical guidelines. However the majority of primary care clinicians often miss referral opportunities.

Development of a Specialist Review Service

If we were able to reduce the number of ‘same day discharge’ hospital admissions by 50%, potential cost savings of £221,000 could be made.

A system was devised to offer each practice a Specialist COPD Review Service whereby any patient with a history of hospital admission or 3 or more exacerbations in the previous 12 months would be fully assessed by a specialist respiratory nurse and offered bespoke education on the management of their condition.

Manual review of patient records was also conducted to quantify exacerbation frequency, and subsequently identify those patients who may be most at risk of hospital admission. These searches not only quantified exacerbation frequency, but also identified potentially mis-diagnosed patients and patients who were prescribed unnecessary medication.

Impact/measures of Success

Two data extractions relating to 6412 COPD patients were obtained from 34 GP practice clinical systems; extraction 1 (baseline) relates to 1st August 2014 to 31st July 2015, and extraction 2 (intervention period) from 1st August 2015 to 31st July 2016).

Table 2. The number and % of patients where the six key parameters of care measured are being achieved.

Criterion: Patients with a record of: Baseline                Number of patients

Intervention Period

Number of patients

Overall % change
Exacerbation frequency 3371 (52.6%) 3348 (52.1%) -0.8%
Inhaler technique training 3509 (54.7%) 3115 (48.6%) -11.2%
Depression screening 2170 (33.8%) 2010 (31.3%) -7.4%
Issue of self management plan 1940 (30.3%) 2288 (35.7%) 17.9%
Issue of rescue pack 758 (11.8%) 893 (13.9%) 17.8%
Referral to pulmonary rehabilitation) 138 (2.2%) 296 (4.6%) 114.5%

Manual searches were also conducted of the records of 3266 COPD patients (out of the 6367 COPD patients in Newcastle) from 19 practices; these searches identified:

  • 495 patients (1%) are at high risk of admission, defined by experiencing 3 or more exacerbations in the previous 12 months.
  • 682 patients (8%) with no evidence of exacerbation are currently prescribed inhaled therapy, which may not be required.
  • 324 patients (3%) have potential for incorrect diagnosis using FEV1/VC ratio >70% as benchmark.

It was also identified that many patients with a diagnosis of bronchiectasis are included on the COPD register, even where there is no diagnosis of COPD. This leads to exacerbations being sub-optimally treated and repeat courses of treatment issued. In addition, there appears to be many patients who may well have unidentified bronchiectasis based on the frequency of exacerbations. Up to 5% of the COPD population has been treated for 10 or more exacerbations in the previous 12 months.

Next Steps and Plans for the Future

Areas for future work within the CCG concern poor (<50%) recording of exacerbation frequency and lack of inhaler technique training (<50%) recorded in patient records.

The final recommendation of the project is for the consideration of the development of a Community Specialist COPD Review Service. We strongly believe that unless a co-ordinated specialist COPD service is developed in primary care, the management patients who suffer from this multi-component, complex condition will not improve very significantly. The pilot carried out here showed that such a service can be delivered but that its organisation can be time-consuming and difficult. Time constraints and the current workload of primary care make it extremely difficult for clinicians to afford the time required to educate and manage these patients as effectively as they could be if a specialist service were provided.

Whilst this recommendation is being considered, the following steps are in progress:

  1. Improving the quality of diagnostic spirometry

A Specialist and quality assured diagnostic spirometry service is to be commissioned by the CCG.

  1. Over treatment with inhaled corticosteroids (ICS)

GPs are being urged to review all their patients with COPD who are prescribed inhaled steroids in light of new treatment guidelines (GOLD), which recommend avoiding commencement of ICS therapy unless patients have on-going exacerbations which cannot be controlled with long-acting bronchodilator medications.

  1. Increasing uptake of Pulmonary Rehabilitation

A series of supporting videos have been specifically created by the AHSN NENC in conjunction with the British Lung Foundation (BLF) and B.O.C. to promote the benefits of PR to patients. Five short films (2 minutes approx.) were created for use in surgeries, either on TV screens in waiting rooms or during patient consultations. One longer film (6.5 minutes) has also been created to enhance understanding of the benefits of PR amongst HCPs.

Remedy of highlighted deficiencies could result in major cost savings in excess of £4,000,000.

AHSN Support

The entire project was managed by Sue Hart and funded by the AHSN NENC.

“The value of this extensive research into the care of patients with COPD in Newcastle is without equal. By showing us what is actually happening in practices it highlights clearly the areas for improvement. The recommendations made to address these deficiencies are not only considered and evidenced based  but are  achievable and likely to succeed”.

Paul Netts, GP, Benfield Park Medical Group

Start date: Aug 2014                           End date: July 2016

Contacts

Sue Hart, COPD Project Lead, Newcastle CCG.                                               Sue.hart@ahsn-nenc.org.uk

Dr Mike Scott, GP, Newburn Surgery.                                                               mike.scott2@nhs.net

Dr Paul Netts, GP, Benfield Park Surgery.                                                        paul.netts@nhs.net

Dr Anthony De Soyza, Consultant Chest Physician, Freeman Hospital.      Anthony.de-soyza@nuth.nhs.uk

References

  1. Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England. Dept. of Health, 2010 ww.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. Souza ML et al. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumonol. 2009: 35:824-831
  6. Maurer J. et al. (2008). Anxiety and depression in COPD, current understanding, unanswered questions and research needs. Chest. 134 (4): 675-893.

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