written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
- COPD is a clinical area of considerable unmet need and impacts greatly on patients, the NHS, and the economy
- The updated NICE guideline highlights the need to determine pharmacological therapy based on both disease severity and airway obstruction
- Smoking cessation is the main intervention for patients with COPD; pulmonary rehabilitation is reserved for all symptomatic patients. These interventions should be the main treatment for patients to slow both progression of disease and improve symptoms; however access to these therapies has been patchy and pushing commissioners to enable this is a priority
- There is a need to review prescriptions that are 'wasting' NHS resources to reallocate them towards smoking cessation and pulmonary rehabilitation
- Case finding of undiagnosed patients with COPD both to increase detection and signpost to appropriate therapy is paramount
- Healthcare professionals need to determine when to implement end-of-life care plans for COPD.
COPD=chronic obstructive pulmonary disease;
|NICE Clinical Guideline 101 on Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) has been awarded the NHS Evidence Accreditation Mark.
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.
Chronic obstructive pulmonary disease (COPD) is well recognised as a multisystem condition. It is currently the fourth leading cause of death from chronic disease worldwide1 and is predicted to be the third leading cause of death, behind ischaemic heart disease and cerebrovascular disease by 2030.2 Chronic obstructive pulmonary disease affects over 3 million people in England alone3 and accounts for 27,500 deaths annually; this equates to three people dying every hour.4,5 This preventable disease has a significant health and economic impact—nearly £500 million is spent annually in the NHS on direct costs as a result of COPD.6
NICE Clinical Guideline (CG) 101 on the Management of chronic obstructive pulmonary disease in adults in primary and secondary care, 7 which was published in 2010, was a partial update of the original guidance published in 2004 (CG12).8 It covers diagnosis, spirometry, assessment of disease severity, and management.7
This article explores the impact of the NICE guideline for COPD on primary care, its limitations, areas of deficiency, and the potential for future development.
It is recommended that a diagnosis of COPD is made on the basis of the presence of characteristic symptoms and signs and demonstration of airflow obstruction using spirometry.7 Assessment of the severity of airway obstruction is based on predicted forced expiratory volume in 1 second (FEV1); this will also help to guide pharmacological inhaler therapy (see Figure 1). The reclassification of disease severity (based on predicted FEV1) is a significant change from the previous version of the guideline, and was made so that the NICE advice was in line with other international guidelines on COPD.9,10 Disease severity should be assessed using the Medical Research Council (MRC) dyspnoea score.11
Both the NICE guideline and the Primary Care Respiratory Society UK have highlighted smoking cessation and pulmonary rehabilitation as key interventions for people with COPD (see Figure 2).7,12 Pulmonary rehabilitation is a personalised multidisciplinary approach that not only assists patients with their mobility, breathing, and confidence, but also helps them gain more of an understanding of their disease as well as independence from their breathlessness. Statistically significant and clinically meaningful improvements in exercise capacity and quality of life have been demonstrated in a meta-analysis of pulmonary rehabilitation.13 Pulmonary rehabilitation should be offered to all individuals with symptomatic COPD (i.e. functionally breathless, MRC dyspnoea score ?3).7
Since publication of the updated NICE guideline on COPD, newer pharmacological interventions (both inhalers and oral phosphodiesterase-4 [PDE4] inhibitors) have been licensed, with further products in development. The exact impact of these drugs on disease trajectory and FEV1 has yet to be fully determined by NICE within a guideline or technology appraisal.
|Figure 1: Use of inhaled therapies for chronic obstructive pulmonary disease7|
Priorities for implementation
Improving detection of COPD
The true prevalence of COPD has been estimated to be anywhere between 3% and 10% of the population.14–17 Achievement data from the quality and outcomes framework (QOF) 2010/11 put prevalence at 1.6% in England;18 although well short of expected prevalence, this is an actual increase from 1.5% in 2008.19
Although the QOF achievement data for COPD show that UK general practice performs well,18 it can be argued that the QOF has limited value in determining level of care. This is evidenced by the plethora of undiagnosed patients (as shown above) as well as the unquestionable rise in hospital admissions for COPD across England.20
More work needs to be done to identify patients who have COPD but remain undiagnosed. Earlier treatment of these individuals could prevent hospitalisation as well as reduce exacerbations, which would maintain lung function and reduce the economic burden of the disease. It would be useful if a future update of the NICE guideline recommended that healthcare professionals attempt to actively identify patients with COPD by inviting people 'at risk' to undergo spirometry. The results would need to be interpreted in line with symptoms, and the mainstay of treatment would be non-pharmacological (i.e. smoking cessation and pulmonary rehabilitation) therapy. At-risk patients might include smokers aged above 35 years who have been prescribed an inhaler and have no diagnosis of asthma or COPD ever recorded. This identification process could be performed easily by running a practice computer search, generating a list, and inviting patients to attend the practice.
Currently, the QOF contract only pays a limited amount of extra money for recording COPD prevalence and the amount of training and time required to perform screening spirometry may inhibit this process. Implementation of the updated NICE recommendations may be difficult as it relies on quality spirometry performed within primary or secondary care. The former can be challenged in terms of maintaining quality and the latter in terms of cost. Additionally, the handheld spirometry machines used in primary care often do not allow for easy calculation of % predicted FEV1, which would make adhering to the NICE recommendations for pharmacological management of COPD difficult.
A key aspect of the updated NICE guideline on COPD was the promotion of smoking cessation therapy, which improves patient outcomes at low cost. However, evidence from the Improving and Integrating Respiratory Services (IMPRESS) relative value paper has found that these cessation services are not offered routinely in all hospitals and access in primary care can be patchy.21 In addition, pulmonary rehabilitation has been undersupplied in many parts of the UK.22 The provision of services for these interventions may be prohibited by the start-up costs and the need to ensure that patients are using them. Sufficient numbers of trained healthcare professionals are needed to run the clinics, which ideally will be housed within the community.
The IMPRESS paper also found that there is 'substantial over treatment' with inhaled medicines in patients with mild to moderate COPD.21,22 It warns of the risks of prescribing 'triple therapy'—multiple inhaled treatments—both in terms of the risk of causing harm and because of unnecessarily high costs. The promotion of drugs and interpretation of the COPD guideline7 has led to overprescribing. It has been argued that the resources wasted on inappropriate and overprescribing (including oxygen therapy) would be better spent on other services such as pulmonary rehabilitation.21 It can be difficult for the busy GP and practice nurse to keep abreast of all these changes and implement the latest guidelines, so input from community respiratory teams would be helpful. Our local NHS trust is discharging patients admitted for a COPD exacerbation with a package of inhaler/medicine review, oxygen assessment, smoking cessation, and pulmonary rehabilitation if appropriate.
Although end-of-life care for people with COPD is discussed in the NICE guideline, there is insufficient detail on the mechanisms by which this should be triggered. Although basic parameters are mentioned, end-stage patients often have a variable prognosis. Further research is needed to determine what objective measures could be used reliably to predict when individuals should be placed on an end-of-life register, and more specifically, when it is appropriate to discuss the withdrawal of hospital-based interventions with patients and their relatives.
|Figure 2: The PCRS UK patient-centred approach to COPD management in primary care12|
PCRS=Primary Care Respiratory Society; COPD=chronic obstructive pulmonary disease; BMI=body mass index; MRC=Medical Research Council; FEV1=forced expiratory volume in 1 second
Reprinted with permission from Primary Care Respiratory Society UK. Diagnosis and management of COPD in primary care. Dr Kevin Gruffydd-Jones. Available at: www.pcrs-uk.org/resources/copd_guidelinebooklet_final.pdf. This image is the copyright of PCRS-UK and Dr Kevin Gruffydd-Jones. 2010.
Chronic obstructive pulmonary disease is a systemic disease that has a high impact on mortality and morbidity, as well as financially on the NHS. The updated NICE guideline on COPD7 covers diagnosis, spirometry, assessment of disease severity, and management. Although there was a significant change in classification of disease severity (predicted FEV1), which should be used to guide pharmacological therapy, it has been argued that an unintended consequence has been the over prescribing of inhaled medicine. An increased focus on smoking cessation and pulmonary rehabilitation as well as appropriate prescribing of oxygen should be a key objective for any clinician involved in COPD. In primary care, case finding undiagnosed patients and offering them non-pharmacological treatment (as discussed above) would help reduce the burden of COPD both on the NHS and more importantly on the patient.
|NICE implementation tools|
NICE has developed the following tools to support implementation of Clinical Guideline 101 (CG101) on Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). The tools are now available to download from the NICE website: www.nice.org.uk/CG101
NICE support for commissioners
Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.
A costing template helps services in estimating the local cost of implementing guidelines and public health guidance. This template allows individual NHS organisations and local health economies to quickly assess the impact guidance will have on local budgets.
Guide for commissioners: chronic obstructive pulmonary disease
The guide for commissioners is a resource to assist commissioners, clinicians, and managers to commission high-quality and evidence-based services across England.
NICE support for service improvement systems and audit
Audit support is developed to support the implementation of NICE guidance. The aim is to assist organisations with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations.
Baseline assessment tool
The baseline assessment is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
NICE support for education and learning
The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.
- COPD is a large and rising cause of emergency admissions; active planned treatment in primary care can reduce its impact
- There should be a focus on case finding of at-risk groups and CCGs could consider specific incentive schemes (e.g. LES) for practices to effect this
- CCGs should ensure there are effective and accessible smoking cessation services to support any patients found through case finding
- CCGs should ensure that local guidelines emphasise the risk of over treatment; they could consider holding educational events for GPs and practice nurses to mitigate against this. Such initiatives would help reduce expenditure on inhaled products and are likely to be cost effective
- The use of pulmonary rehabilitation is evidence based but it is an intervention that is not available universally—such schemes reduce admissions for COPD and are likely to be cost effective
- NICE has published draft indicators for the Commissioning Outcomes Framework, which cover mortality from respiratory disease in people aged under 75 years, referral to pulmonary rehabilitation for people with COPD (usually MRC score ≥3 or above), and emergency readmission rates for people with COPD
- If the above indicators are adopted, payment of the quality premium to CCGs will be dependent on performance against these standards
- Tariff prices for COPD emergency admissions = £1711 (DZ21K).a
COPD=chronic obstructive pulmonary disease; CCG=clinical commissioning groups; LES=local enhanced services; MRC=Medical Research Council
- Pauwels R, Buist A, Calverley P et al (on behalf of the GOLD Scientific Committee). Global strategy for diagnosis, management, and preventions of COPD: NHLBI/WHO Workshop summary. Am J Respir Crit Care Med 2001; 163: 1256–1276.
- World Health Organization. World Health Statistics 2008. WHO, 2008.
- British Thoracic Society. Burden of lung disease. 2nd edition. London: BTS, 2006.
- Westminster Health Forum. Moving towards a national strategy for chronic obstructive pulmonary disease (COPD). Westminster Health Forum Keynote Seminar Transcript, 2011.
- Office for National Statistics. Mortality statistics by cause. Series DH2 no. 32. London: The Stationery Office, 2006.
- Britton M. The burden of COPD in the UK: results from the Confronting COPD survey. Respir Med 2003; 97 (Suppl C): S71–S79.
- National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: NCGC, 2010. Available at: www.rcplondon.ac.uk/clinical-standards/ncgc/Pages/published-guidelines.aspx
- National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in primary and secondary care. Clinical Guideline 12. London: NICE, 2004.
- Celli B, MacNee W, Agusti A et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23 (6): 932–946.
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD, 2011. Available at: www.goldcopd.org
- Fletcher C, Elmes P, Fairbairn A et al. Significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br Med J 1959; 2: 257–266.
- Primary Care Respiratory Society UK. Diagnosis and management of COPD in primary care: a guide for those working in primary care. PCRS UK, 2010. Available at: www.pcrs-uk.org
- Lacasse Y, Goldstein R, Lasserson T et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2006; Issue 4: CD003793.
- Frank T, Hazell M, Linehan M et al. The estimated prevalence of chronic obstructive pulmonary disease in a general practice population. Prim Care Respir J 2007; 16 (3): 169–173.
- Cox B. Blood pressure and respiratory function. In: The health and lifestyle survey. Preliminary report of a nationwide survey of the physical and mental health, attitudes and lifestyle of a random sample of 9003 British adults. London: Health Promotion Trust, 1987: 17–33.
- Renwick D, Connolly M. Prevalence and treatment of chronic airways obstruction in adults over the age of 45. Thorax 1996: 51 (2); 164–168.
- Seamark D, Williams S, Timon S et al. Home or surgery based screening for chronic obstructive pulmonary disease (COPD)? Prim Care Resp J 2001; 10 (2): 30–33.
- The NHS Information Centre. Quality and outcomes framework achievement data 2010/11. IC, 2012. Available at: www.qof.ic.nhs.uk
- The NHS Information Centre. Quality and outcomes framework achievement data 2009/10. IC, 2010. Available at: www.qof.ic.nhs.uk
- Department of Health. Consultation on a strategy for services for COPD in England. London: DH, 2010. Available at: webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Consultations/Liveconsultations/DH_112977
- Primary Care Respiratory Society UK, British Thoracic Society. IMPRESS Guide to the relative value of COPD interventions. PCRS, BTS, 2012. Available at: www.impressresp.com/index.php?option=com_docman&Itemid=82
- Jones R, Dickson-Spillmann M, Mather M et al.
Accuracy of diagnostic registers and management of chronic obstructive pulmonary disease: the Devon primary care audit. Respir Res 2008; 9: 62. G