Dr Kevin Gruffydd-Jones describes the NICE quality statements on chronic obstructive pulmonary disease and how to provide care that meets them
In July 2011, NICE published its quality standard for chronic obstructive pulmonary disease (COPD)—a set of markers of high-quality care in the diagnosis and management of this disease.1 This article discusses:
- the rationale for developing the quality standard for COPD in the context of NHS reforms
- the 13 quality statements within the standard
- implications for primary care in implementing the standard.
Rationale for development
Chronic obstructive pulmonary disease is a major cause of mortality and morbidity in the United Kingdom. There are estimated to be over 3 million people with COPD, yet only 900,000 have been diagnosed.2 Over 25,000 people die from COPD each year and it is the second highest cause of emergency hospital admissions. Data from the World Health Organization show that UK premature mortality from COPD in 2008 was nearly twice as high as the rest of Europe.3
The NICE quality standard for COPD, published online in July 2011, defines best clinical practice for patients, clinicians, service providers, and commissioners. It was developed by a group of multidisciplinary professionals and patient representatives who are involved in implementing key areas of the NICE guideline on COPD (drawn up in 2004 and partially updated in 2010).2
Government health policy and COPD
There is a range of publications available that will help with the provision of quality care and services for respiratory conditions:
- NHS outcomes framework (2010)—this sets out national outcome goals for the NHS in England4
- Outcome strategy for COPD and asthma —this was launched in July 2011 and sets out how high-quality healthcare outcomes can be delivered
- NICE quality standards—these provide evidence-based standards that help define a high-quality service (www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp)
- Quality and outcomes framework (QOF)—this shapes the quality of local services provided for patients in primary care5
- Commissioning outcomes framework (COF)—developed by the NHS Commissioning Board to measure outcomes and the quality of care achieved by clinical commissioning groups (CCGs). Indicators for the COF will be developed from NICE quality standard measures.6
The relationships between the above policy guidance are shown in Figure 1.
|Figure 1: The quality improvement system in the NHS for COPD/asthma|
COPD=chronic obstructive pulmonary disease; QOF=quality and outcomes framework; PbR=payment by results
Quality standard for COPD
The NICE quality standard for COPD focuses on assessment, diagnosis, and treatment of the diagnosed patient while the outcomes strategy has a broader scope, which includes disease prevention, case finding, early detection, and organisation of services.1
The COPD quality standard is composed of 13 quality statements, which relate mainly to the management of established disease (see Table 1).
|Table 1: NICE quality standard for COPD1|
|People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by post-bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation|
|People with COPD have a current individualised comprehensive management plan, which includes
high-quality information and educational material about the condition and its management, relevant to the stage of disease
|People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan|
|People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia, and co-morbidities|
|People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support|
|People with COPD meeting appropriate criteria are offered an effective, timely, and accessible multidisciplinary pulmonary rehabilitation programme|
|People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home), and a named contact|
|People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service|
|People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD|
|People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support|
|People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, non-invasive ventilation delivered by appropriately trained staff in a dedicated setting|
|People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge|
|People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social, and emotional needs|
|COPD=chronic obstructive pulmonary disease
National Institute for Health and Care Excellence (NICE) (2010) CG101. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: NICE. Available from www.nice.org.uk/guidance/CG101 Reproduced with permission.
Confirming diagnosis—statement 1
The quality statement on using post-bronchodilator spirometry to confirm diagnosis of COPD is in line with QOF indicator, COPD15.1,5 Spirometry should be carried out on calibrated equipment (where the calibration is checked regularly) and carried out to a high standard by healthcare professionals who are appropriately trained in its performance and interpretation.1
Suggested standards for carrying out spirometry in primary care have been published by the Primary Care Respiratory Society UK (PCRS-UK).7 Alternative models of service provision include specialist hospital-based or community clinics, and peripatetic spirometry services.
Education and self-management—statements 2 and 7
People with COPD should be given information about their condition. In primary care, patients should receive an explanation of their disease at diagnosis, reinforced with educational materials. These can be obtained via a variety of sources. An important source of information both in the form of educational materials and self-help groups is the British Lung Foundation (BLF) (see Box 1, below).
Written advice that is tailored to the individual should be provided to people who have had an exacerbation of COPD. This should include:
- early recognition of future exacerbations
- management strategies
- a named healthcare professional that the patient can contact.
Such action plans in the context of structured educational support can reduce severe exacerbations and subsequent hospital admissions. A key element is early commencement of home antibiotics/oral steroids. There is still an understandable reluctance to provide these therapies for self-treatment especially as patients have their own ideas on how and when they should be used! It is therefore important to issue ‘standby’ antibiotics and oral steroids as part of a written action plan that should include informing a named contact (e.g. lead practice respiratory nurse or GP) when standby treatment has been started.1
Examples of action plans can be obtained via the BLF and PCRS-UK websites (see Box 1, below).
|Box 1: Useful resources|
Inhaled and oral therapies—statement 3
The quality statement on offering inhaled therapies follows the recommendations from the NICE guideline on managing COPD (see Figure 2).1,2
Practices and CCGs can demonstrate adherence to NICE guidance through audit; for example, the number of patients incorrectly prescribed inhaled steroids (ICS) alone (they should be on combination long-acting beta2 agonist [LABA]/ICS therapy if indicated).
Clinical and psychosocial assessment—statement 4
The NICE COPD guideline emphasises that COPD is not just a disease of the lungs but has multiple effects on a person’s life.2 An assessment of COPD severity should include an evaluation of lung function and the Medical Research Council (MRC) breathlessness score—as in the QOF indicators COPD10 and COPD13—and a full multidimensional review comprising health status, frequency of exacerbations, and co-morbidities. The review should be performed at least annually (the QOF recommends every 15 months) and more frequently in higher-risk patients (e.g. 6 monthly).2,5
This quality statement also specifies the importance of a psychosocial assessment including allowances (such as disability benefits) received by the patient and an assessment of carer needs.1
|Figure 2: Use of inhaled therapies for chronic obstructive pulmonary disease2|
* SABA (as required) may continue at all stages
SABA=short-acting beta2 agonist; SAMA=short-acting muscarinic antagonist; FEV1=forced expiratory volume in 1 second; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid
National Institute for Health and Care Excellence (NICE) (2010) CG101. Chronic obstructive pulmonary disease. London: NICE. Reproduced with permission. Available from: www.nice.org.uk/guidance/CG101
A primary care patient-centred approach to assessment and management of COPD is highlighted in an algorithm produced by PCRS-UK (see Figure 3, below). Further details can be found in the PCRS-UK publication, Diagnosis and management of COPD in primary care.8
Smoking cessation support—statement 5
Commissioners will need to demonstrate that patients with COPD who smoke have access to a full range of smoking cessation services from simple advice in general practice to complex specialist interventions. Process markers will be the number of patients referred for smoking cessation and outcome markers will be the number of patients who actually succeed in quitting.
Pulmonary rehabilitation programme—statement 6
Pulmonary rehabilitation can have a significant positive impact on the lives of people with COPD by improving health status, exercise capacity, and reducing the impact of exacerbations. It is not the same as promotion of exercise alone and additionally involves a structured education programme offered by a multidisciplinary team (e.g. physiotherapist, nurse, psychologist, social worker).
Pulmonary rehabilitation should be offered to all patients with an MRC dyspnoea score of ?32 and it has been proposed that this becomes an indicator for the QOF in the near future (pers. comm). In addition, there is evidence that people with COPD who have been discharged from hospital with an acute exacerbation are less likely to be readmitted if they have received pulmonary rehabilitation.
In spite of the proven efficacy of pulmonary rehabilitation, there is still wide variation in its provision at a community level. This should be a priority for commissioners of COPD services in ensuring timely (i.e. minimal waiting time) and local access to pulmonary rehabilitation to patients who need it.
Long-term oxygen therapy—statements 8 and 9
Approximately 85,000 patients (not only individuals with COPD) receive oxygen therapy in England, at a cost of around £110 million pounds per year to the NHS, but it is estimated that between 24%–43% of oxygen prescribed is not used or has no clinical benefit (e.g. the use of short-burst hypoxia in patients who are not hypoxic).9 Conversely, long-term oxygen therapy (LTOT) can prolong life in selected patients, but there is evidence that many individuals are not receiving it.9
Patients with COPD should be referred to a specialist-oxygen service for consideration of LTOT if their oxygen saturation is ?92% while breathing air and when stable.2,9 It has been proposed that a new QOF indicator be introduced where patients with an MRC dyspnoea score ?3 should have their oxygen saturation measured within the last 15 months (pers. comm). However, the use of pulse oximetry has become an essential tool in a variety of situations (e.g. acute respiratory distress from any cause) in general practice, and is quick and easy to carry out so that it is logistically simpler to check oxygen saturations at all routine reviews of people with COPD.
From a commissioning perspective it is important that a local specialist-oxygen service is available (this is not always the case). The responsibility for monitoring appropriate use of LTOT lies with the specialist service, but commissioners may want to consider ways to monitor the prescribing of short-burst oxygen therapy (where much of the wasted prescribing costs are incurred). This could be done at a practice level using prescribing initiatives or be part of the specification of the specialist service. Further guidance can be obtained from the recently published NHS Primary Care Commissioning guide on Home oxygen service—assessment and review.9
|Figure 3: The PCRS-UK patient-centred approach to COPD management in primary care8|
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.
Hospital admission—statements 10, 11, and 12
These statements are concerned with acute admission into hospital. Patients admitted with an acute exacerbation of COPD who are cared for by a specialist respiratory team have improved outcomes, such as reduced mortality and fewer inpatient days. Early discharge schemes can reduce hospital in-bed days, but may only be suitable for 40% of patients who are admitted with an acute exacerbation of COPD.10
A major problem in the management of COPD is the high readmission rate—30% to 40% of patients are readmitted within 3 months.11 Many patients exhibit psychosocial problems, such as depression and social isolation that must be addressed to prevent readmission. In addition, individuals benefit from early post-discharge interventions such as pulmonary rehabilitation, which can reduce readmission rates. It is therefore important that all patients who are discharged from hospital have a structured review within 2 weeks of discharge (ideally sooner). This can be provided by the primary care or community care team, but should cover both medical and psychosocial factors (see Box 2).
Palliative care for patients and carers—statement 13
One of the most difficult decisions in the management of COPD is when to instigate palliative care. The traditional model of palliative care comes from management of cancer where there tends to be a clear cut off from cure to palliation.
Management of COPD involves a continuum of palliative care ranging from the patient who is on maximal therapy yet requires palliative morphine elixir for their cough or breathlessness to patients who require true end-of-life care. The Gold Standards Framework (GSF) suggests that end-of life-care may be needed if a patient with COPD has at least two of the following indicators:12
- Disease assessed to be severe (e.g. forced expiratory volume in 1 second is <30% predicted)
- Recurrent hospital admissions (at least three in last 12 months due to COPD)
- Fulfils long-term oxygen therapy criteria
- MRC grade 4/5—shortness of breath after 100 metres on the level or confined to house
- Signs and symptoms of right heart failure
- Combination of other factors (i.e. anorexia, previous admission to an intensive care unit, received non-invasive ventilation, had resistant organism)
- More than 6 weeks of systemic steroids for COPD in preceding 6 months.
The above indicators should be used in conjunction with the over-arching question ‘Would you be surprised if the patient were to die in the next few months, weeks, or days?’12 The GSF offers guidance regarding identification and management of patients with end-of life needs.
Chronic obstructive pulmonary disease confers a significant burden to the NHS in terms of morbidity, mortality, and cost. The provision of high-quality care for patients with COPD is likely to be a major target for many CCGs. The NICE quality standard for COPD in conjunction with the outcomes strategy for COPD and asthma offers a framework for achieving high-quality and equitable care for all our patients with COPD.
- The quality standard sets out a desired framework for the management of COPD, which in future is likely to be used in the NHS outcomes framework
- Commissioners are likely (subject to legislation) to be judged against such frameworks and this may include a quality premium for clinical commissioning groups
- Commissioners will be expected to secure delivery against these standards though contracts with their providers that specify the required criteria
- The QOF meets some of these standards but misses others for primary care (e.g. oxygen saturation measurement and referral for pulmonary rehabilitation)
- The quality standard recommends local commissioning of long-term oxygen therapy and pulmonary rehabilitation services, but this is often not the case
- Commissioners should consider commissioning specialist COPD services in the community to ensure follow-up post-hospital admission and oxygen assessment without paying full tariff costs
- Tariff for COPD:a
- admission = £1757 (DZ21K)
- outpatient = £232 (new), £109 (follow up).
COPD=chronic obstructive pulmonary disease; QOF=quality and outcomes framework
- NICE website. NICE COPD quality standard. www.nice.org.uk/guidance/qualitystandards/chronicobstructivepulmonarydisease/copdqualitystandard.jsp (accessed 15 September 2011).
- National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). Clinical Guideline 101. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG101
- Department of Health. An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England. London: DH, 2011. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974
- Department of Health. NHS outcomes framework 2011/12. London: DH, 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
- British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2011/12. London: BMA, NHS Employers, 2011. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofguidance2011.jsp
- National Institute for Health and Care Excellence website. About the commissioning outcomes framework (COF). www.nice.org.uk/aboutnice/COF.jsp (accessed 22 September 2011).
- Levy M, Quanjer P, Booker R et al. Diagnostic spirometry in primary care: proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations: a General Practice Airways Group (GPIAG) document, in association with the Association for Respiratory Technology & Physiology (ARTP) and Education for Health. Prim Care Resp J 2009; 18 (3): 130–147.
- Primary Care Respiratory Society UK. Diagnosis and management of COPD in primary care. Leeds: PCRS, 2010. Available at: www.pcrs-uk.org/resources/copd_resources.php
- NHS Primary Care Commissioning. Home oxygen service—assessment and review. Good practice guide. NHS Primary Care Commissioning, 2011. Available at: www.pcc.nhs.uk/home-oxygen-service-good-practice-guide-for-assessment-and-review
- Cotton M, Bucknall C, Dagg K et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax 2000; 55 (11): 902–906
- Royal College of Physicians. National COPD audit 2008. RCP Clinical Effectiveness Unit, 2008.
- The Gold Standards Framework, Royal College of General Practitioners. Prognostic indicator guidance. GSF, 2011. Available at: www.goldstandardsframework.org.uk G