Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the UK and Europe, after cancer and ischaemic heart disease, and the only common cause of death that is increasing in prevalence.
There are approximately 1.5 million GP consultations per year related to COPD, which is about four times higher than consultations for angina. These consultation rates along with prescribing costs mean that the disease places a heavy burden on primary care, which could be reduced if care were more formally structured.
The British Thoracic Society (BTS) COPD guidelines (1997)1 were produced following widespread acceptance of the asthma guidelines as the general standard for asthma care.
For years there had been controversy and confusion about the diagnosis and management of COPD.
With the expansion of practice-based asthma clinics through the 1990s came increasing awareness that many of the older patients with a significant smoking history were not being appropriately managed by following the asthma guidelines. These patients, who had little or no variability in symptoms, were not catered for in the stepwise approach recommended.
Patients with COPD often assumed that they were asthmatic because they were attending asthma clinics, yet could become disheartened at ever low peak flows that would not increase however much therapy was stepped up.
The diagnosis of asthma or COPD was commonly attached to such patients as a result of a history, examination, chest X-ray, or peak flow readings. Many patients had obvious elements of both diseases, but which diagnosis was correct with this mixed pattern?
Advantages of a structured approach
The BTS COPD guidelines offered a structured approach to the diagnosis and management of this complex condition. Its recommendations to establish the diagnosis correctly using spirometry meant that, with the appropriate tools and training, practices could differentiate their respiratory patients, and hence manage them more effectively under the appropriate guidelines.
It also meant that disease registers for asthma and COPD could gradually become more accurate and audit more appropriately focused. For example, an audit of bronchodilator use in asthma patients can demonstrate levels of asthma control but would demonstrate very little in COPD.
Spreading best practice
Wyre PCG highlighted COPD as a priority for local health improvement in April 1999. Our practice, the Crescent Surgery in Cleveleys, had demonstrated that by adopting a structured approach based on the BTS COPD guidelines, patient outcomes could be improved.
The practice has been awarded Beacon status for COPD management, so the PCG's Health Improvement Programme was seen as a way of spreading best practice.
The COPD management in our Beacon practice was based on a three-step approach to diagnosis and protocols for management based on the BTS guidelines, so the PCG adopted this approach to influence COPD management across its 20 practices.
Getting the diagnosis right
The BTS COPD Guidelines (1997) recommend three options for the provision of spirometry in primary care:
- To provide open access to the lung function department at each district general hospital for general practice. This is an impractical option in many cases.
- To provide spirometry in individual practices. This certainly makes the tests more accessible and allows opportunistic testing at health assessments, such as new patient registrations. The cost of the equipment, its maintenance and the training of GPs and nurses in the use and interpretation of spirometry must, however, be taken into consideration.
- To provide a mobile community spirometry service. Although this model has significant cost implications for primary care organisations, it does ensure accessibility and consistent testing with well maintained equipment.
In Wyre PCG the third option has been chosen. Spirometry assessment is offered to patients identified in individual practices, by a visiting respiratory technician following a three-step assessment process.
The mobile spirometry service is fully funded by the PCG and all the equipment, including spirometer, nebuliser and pulse oximeter, is transported to practices for their allocated clinics.
Each practice runs regular spirometry clinics where potential COPD patients are offered:
- An initial appointment where diagnosis is established through spirometry and bronchodilator reversibility testing. Any patient with normal spirometry or asthmatic reversibility demonstrated is referred back to the practice-based asthma clinics.
Patients who demonstrate irreversible airflow obstruction are categorised as mild, moderate or severe COPD in line with the BTS COPD guidelines. These patients are offered a steroid trial. If patients are already on inhaled steroids then a reverse steroid trial may be initiated.
- At a second appointment, steroid response is established. An inhaled anticholinergic trial may then be initiated.
- A third appointment is offered, where appropriate, to assess subjective benefit to anticholinergics using the oxygen cost score,2 and undertake pulse oximetry.
The respiratory technician is a trained smoking cessation advisor and discusses smoking cessation at each appointment if appropriate, then refers the patient on to our local smoking cessation service for support if he/she is interested in quitting.
Practice-based computer templates have been developed for clinical systems used in Wyre and these are completed for each patient by the respiratory technician.
The templates provide information to assist with clinical follow-up, and data to enable audit. Such data include: spirometry results, reversibility to bronchodilators and steroids, smoking status and functional ability using oxygen cost score.
Follow-up assessment by practice nurse
Following spirometry assessment, COPD patients are referred back to their GP or appropriately trained practice nurse for clinical assessment. It is then the GP's decision, based on the assessment, to decide whether further action, e.g. referral to a chest consultant, is necessary.
All GPs in this scheme receive funding from the PCG to:
- Maintain an up-to-date COPD register
- Undertake annual audit of COPD
- Undertake annual follow-up of COPD patients identified
- Have systems in place for identifying potential COPD patients to refer for assessment.
The PCG is also committed to improving skills and knowledge about COPD locally. As with asthma care, appropriately trained nurses are well placed to offer ongoing care to COPD patients.
Practice nurses have been supported through asthma and COPD diploma courses and other health professionals, e.g. district nurses, health visitors and physiotherapists have undertaken COPD study days provided by the National Asthma and Respiratory Training Centre.
Results after the first year of the programme
The COPD programme has now been running in Wyre PCG since December 1999. More than 700 patients were assessed in the first 12 months and we are able to demonstrate that these patients now have an accurate diagnosis and are being managed in the way recommended by the BTS COPD guidelines.
All the patients seen were identified by practices as 'potential COPD', i.e. over 40, on respiratory medication and no definite diagnosis of asthma. Following assessment:
- 12% were diagnosed mild COPD
- 28% were diagnosed moderate COPD
- 17% were diagnosed severe COPD
- 25% were diagnosed asthma
- 13% had normal spirometry
The remaining 5% had a non-obstructive pattern of spirometry.
As COPD is a progressively declining disease, evaluation of the process of a health improvement programme can be as important as outcome evaluation. The priorities of our programme are:
- Accurate disease registers (asthma and COPD)
- Smoking cessation advice to all smokers with potential COPD
- Steroid responsiveness determined in COPD patients
- Treatment optimised in line with current evidence/best practice
- More appropriate referral to secondary care.
If the COPD patients assessed so far, 30% were still smoking and all of these have been offered smoking cessation advice. By the end of their three-step assessment, half of these had decided to try to stop smoking with some help, e.g. nicotine replacement therapy. Many have been referred on to the local smoking cessation service for support.
Of the patients assessed so far:
- 46% have required steroid trials. The types of steroid trials and results were:
- oral steroid trials 11% (of these 58% were positive)
- inhaled steroid trials 51% (of these 28% were positive)
- reverse steroid trials 38% (of these 26% were positive).
Changes to the protocol
Evaluation of the first 12 months of the programme, along with consideration of current evidence, has led to several changes in our protocol:
- We are now offering inhaled steroid trials as first line. Previously, practices could opt for either oral or inhaled steroid trials as first line in their patients; however, we have found that many patients are reluctant to comply with oral steroids when well. Furthermore, it could be argued that 2-week oral steroid trials do not predict long-term response to inhaled steroids, and patients should be tried on the type of medication they are to remain on if the trial is positive.
- In patients with severe COPD, exacerbation rates along with assessment of functional ability and quality of life are now considered in the decision whether to prescribe long-term, high-dose inhaled steroids.3
- Long-acting beta2-agonist trials are now included in the protocol. Trials of anticholinergic drugs are assessed by subjective benefit and patients are now also offered a trial of long-acting beta2-agonist, with continued prescribing dependent on subjective benefit.
- As spirometry is not needed to assess the benefit of either anticholinergics or long-acting beta2-agonists, trials of these drugs are to be undertaken by the practice nurses in their respiratory clinic rather than the spirometry service.
- We plan to introduce a quality of life assessment tool into the programme.
In collaboration with our local secondary care providers we have also developed an integrated care pathway to follow the patient journey from identification as a potential COPD sufferer, through the full assessment process, to possible respiratory consultant referral and back to primary care.
Our current protocol for COPD management in Wyre PCG is shown in Figure 1 (below). We plan to review the protocol annually and update it in the light of local evaluation and current evidence.
|Figure 1: Current protocol for COPD management in Wyre PCG|
Although the model of COPD management adopted by Wyre PCG is a community-wide approach using a mobile spirometry service and practice nurses with appropriate training, the programme could be adapted to fit any primary care organisation from a small, single-handed practice to a large trust.
The key elements are:
- Accurate diagnosis
- A structured approach
- Follow-up by appropriately trained health professionals.
For an information pack on Wyre PCG's COPD Health Improvement Programme, please contact Kay Holt, Respiratory Coordinator, at Wyre PCG, Furness Drive, Poulton-le-Fylde, Lancashire FY6 8JT, or email kay.holt@ exch.bvh-tr.nwest.nhs.uk or visit our website at www.wyrepcg.org.uk
- British Thoracic Society. COPD management guidelines. Thorax 1997 (Suppl): S1-S28.
- Durnin JGVA, Passmore R. Energy, Work and Leisure. London: Heinemann, 1967.
- Burge PS, Calverley PW, Jones PW, Spencer S, Anderson JA, Maslen TK. Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease: the ISOLDE trial. Br Med J 2000; 320: 1297-302.