Dr Raj Nair highlights the importance of ensuring that people with chronic obstructive pulmonary disease have access to smoking cessation services and pulmonary rehabilitation

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.

NICE recommendations

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
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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.1417 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.

Spirometry

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.

Service provision

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.

Appropriate prescribing

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.

End-of-life care

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
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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.


Conclusion

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 report Commissioning.eps

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.

Costing template Commissioning.eps

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 Commissioning.eps

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 Audit.eps

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 Commissioning.eps

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

Slide set Education.eps

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.

Key to NICE implementation icons
 Commissioning.eps NICE support for commissioners
  • Support package for commissioners and others for quality standards
  • NICE guide for commissioners
  • NICE cost impact support for guidance (selection from national report/local template/costing statement, dependent on topic)
 Audit.eps NICE support for service improvement systems and audit
  • Forward planner
  • 'How to' guides (generic advice on processes)
  • Local government briefings (with Centre for Public Health Excellence)
  • Baseline assessment tool for guidance
  • Audit support including electronic data collection tools
  • E-learning modules (commissioned)
 Education.eps NICE support for education and learning
  • Clinical case scenarios
  • Learning packages including slide sets
  • Podcasts
  • Shared learning and other local best practice examples

  • 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
awww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132654

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