Dr Dermot Ryan offers an approach to commissioning cost-effective services for improving the diagnosis, assessment, and management of people with COPD
- COPD is currently underdiagnosed
- Early diagnosis facilitates early management
- Exacerbation prevention helps prevent disease progression
- Smoking cessation is the single most important intervention
- Systematic annual clinical review assists in optimising patient management
- There is a need to:
- invest in professional education
- rationalise pharmacotherapy
- provide integrated care that has a collaborative approach
- develop and provide non-pharmacological interventions
- admit patients to a dedicated unit rather than A&E.
Chronic obstructive pulmonary disease (COPD) was for many years largely ignored as a disease area, partly because of a dearth of specific therapies available to treat the condition. This all changed in 2010 with the publication of the Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England,1 launched in response to rising levels of hospital admissions for COPD, which were running at approximately 1 million bed days per annum.
The Department of Health, in partnership with a range of stakeholders, subsequently published An outcomes strategy for COPD and asthma in England,2 the six objectives of which are shown in Box 1.
Box 1: Objectives to improve outcomes for those people with COPD and asthma2
- Objective 1: To improve the respiratory health and wellbeing of all communities and minimise inequalities between communities
- Objective 2: To reduce the number of people who develop COPD by ensuring they are aware of the importance of good lung health and wellbeing, with risk factors understood, avoided or minimised, and proactively address health inequalities
- Objective 3: To reduce the number of people with COPD who die prematurely through a proactive approach to early identification, diagnosis and intervention, and proactive care and management at all stages of the disease, with a particular focus on the disadvantaged groups and areas with high prevalence
- Objective 4: To enhance quality of life for people with COPD, across all social groups, with a positive, enabling, experience of care and support right through to the end of life
- Objective 5: To ensure that people with COPD, across all social groups, receive safe and effective care, which minimises progression, enhances recovery and promotes independence
- Objective 6: To ensure that people with asthma, across all social groups, are free of symptoms because of prompt and accurate diagnosis, shared decision making regarding treatment, and on-going support as they self manage their own condition, and to reduce need for unscheduled healthcare and risk of death.
- Department of Health. An outcomes strategy for COPD and asthma in England. London: DH, 2011. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/216139/dh_128428.pdf
- COPD=chronic obstructive pulmonary disease
Building a service
When planning and organising a service for COPD, it is critical to take into account the goals of management, which are to:3
- relieve symptoms
- improve exercise tolerance
- improve health status
- prevent disease progression
- prevent and treat exacerbations
- reduce mortality.
The optimum way to commission services is to take a system-wide approach by developing a network that encompasses all the relevant stakeholders. It then becomes possible to plan systematically what solutions best meet the needs of the local population. Further documents have informed this process; a list of these is available on page 4 of the Department of Health’s outcomes strategy.2
The British Lung Foundation4 has support groups throughout the UK: both the permanent staff, and patients from the ‘Breathe Easy’5 groups, are useful allies when improving or developing new services.
Local standards of care
Obtaining healthcare data on COPD in the local area is useful in determining aspects for improvement (e.g. ratio of reported to expected prevalence, emergency admissions and re-admissions), and for comparing the performance of your clinical commissioning group (CCG) with that of the national average. The interactive health atlas for lung conditions in England is now available at www.inhale.nhs.uk/data-and-tools/,6 providing an excellent starting point for commissioners to examine respiratory data stratified by CCGs. Most tables also provide longitudinal data up to 2011, which allow the tracking of progress to date. The plan is that this atlas will be updated as annual data become available. Within each CCG, the index of variability from practice to practice will be similar: for example in Leicestershire County and Rutland, the recorded prevalence of COPD varied 8-fold between practices.6
A systematic approach to improving healthcare delivery and the development of care pathways should help organisations to achieve the domains in the NHS Outcomes Framework7 (see Box 2).
Primary, secondary, and community care have a number of responsibilities regarding provision of COPD services, as highlighted in Box 3.
Box 2: NHS Outcomes Framework ‘five domains’7
- Domain 1—preventing people from dying prematurely
- Domain 2—enhancing quality of life for people with long-term conditions
- Domain 3—helping people to recover from episodes of ill health, or following injury
- Domain 4—ensuring that people have a positive experience of care
- Domain 5—treating and caring for people in a safe environment; and protecting them from avoidable harm.
Box 3: Commissioning COPD services
The following aspects should be considered when commissioning a service for COPD:
- Primary care
- spirometry training and accreditation
- inhaler technique training
- detailed annual structured review
- post-review hospitalisation/exacerbation
- case review where diagnosis has not been confirmed
- case finding
- Secondary care
- dedicated respiratory units
- discharge bundles
- ‘difficult’ COPD clinic
- Services bridging primary/secondary/community care
- pulmonary rehabilitation
- oxygen assessment services
- respiratory nursing teams.
- COPD=chronic obstructive pulmonary disease
Essentials for clinical practice
Confirming diagnosis using spirometry
A diagnosis of COPD requires spirometry and the interpretation of results to be performed to a consistent standard. Not only does spirometry assist in confirming the diagnosis, it also allows stratification of the patient by severity of the disease, which in turn informs treatment. Clinical commissioning groups should either commission a service to provide spirometry, or incentivise practices to carry out spirometry themselves. Happily, there are standards drawn up by GPs for GPs, which may facilitate the latter.8
Importance of good inhaler technique
Although inhalers have been in use for over 30 years, it is a lamentable fact that the majority of doctors and nurses do not know how to use an inhaler; they are therefore ill-placed to instruct a patient on how to do so, or to check their technique. Consequently, most patients have poor inhaler technique, which in turn means that expensive medications will have reduced benefit.9,10 Clinical commissioning groups need to invest in educational programmes for healthcare professionals to ensure that they learn the basic principles of inhaler technique and how to pass on instructions to patients; failure to do so will mean that any other investment in the service is bound to fail.
Prevalence and case finding
The Government’s consultation strategy on COPD1 acknowledged that a large proportion of people who have COPD have yet to receive a formal diagnosis. A case-finding approach is therefore recommended to identify them.2 The identification of this patient group is critical: interventions are less likely to be offered to the undiagnosed, missing the opportunity to reduce exacerbations and address accelerated decline of lung function in people with COPD.11
The interactive health atlas for lung conditions in England6 demonstrates the marked differences in recorded prevalence of COPD from one CCG to another, indicating geographical inconsistencies in the diagnosis of the condition.
One of the simplest ways of case finding is to identify people who:
- are smokers or ex-smokers
- have other relevant exposure to smoke
- have at least one respiratory symptom
- are aged over 40 years.
Performing spirometry in this patient group using a hand-held spirometer can be done quickly and will identify individuals who should undergo full spirometry; approximately one-third of people screened in this way will have COPD.12 Questionnaire-based approaches are also available.13
The individual patient must be assessed to determine their immediate and future needs. Assessment of lung function (an indicator of prognosis as well as a guide to treatment) needs to be accompanied by a functional assessment (the Medical Research Council [MRC] score): many patients with milder disease, as determined by lung function, may nevertheless be severely impaired, either by a co-morbidity (e.g. heart disease)14 or by deconditioning.
It is important to emphasise that smokers should be encouraged to quit, and referred appropriately. Smoking cessation is the only intervention that halts progression of COPD.
People with COPD and who are either obese or underweight will benefit from a dietary assessment. Low body mass index (<20 kg/m2) is a poor prognostic indicator and referral to a dietitian should be considered.
A new requirement from the quality and outcomes framework is to check pulse oximetry in patients with COPD.15 Every practitioner should have a pulse oximeter on their desk: it is a tool as essential as a stethoscope. Anyone with a resting oxygen level of ≤92% requires an assessment.
Oxygen assessment is complex and requires great expertise. It is beyond the technical ability of nearly all GPs (and most secondary care respiratory specialists) to perform such an assessment. Commissioners need to ensure that there is an accessible and immediately available oxygen assessment service that is open 7 days a week. It should be sufficiently staffed so as not to develop a waiting list. This service should straddle both the primary and secondary care sectors. It is important to note that oxygen is a dangerous drug when inappropriately prescribed, and is very expensive.
Pulmonary rehabilitation is a multidisciplinary programme designed to improve patients’ physical and social status by preventing deconditioning and improving coping skills. It is carried out in a group setting, usually twice weekly for 8 weeks, although programmes vary. There is evidence that commencement of pulmonary rehabilitation within one month of exacerbation enhances outcomes, something commissioners need to bear in mind.16
Pulmonary rehabilitation is an essential component of delivering a high-quality COPD service. It is:
- extremely cost effective
- highly effective for improving quality of life and exercise tolerance, and reducing hospital admissions.
Any patient with COPD who has an MRC score of 3 or above should be considered for referral to pulmonary rehabilitation.16 Understanding the percentage of patients who fulfil this criterion in the locality will help guide commissioning of an appropriate number of pulmonary rehabilitation services. Pulmonary rehabilitation should, if possible, be provided in the community, close to where patients live and work, to promote accessibility and attendance.
The British Thoracic Society has recently published a new guideline on pulmonary rehabilitation, the recommendations of which should inform the design of commissioned pulmonary rehabilitation programmes.16 It may also be useful for commissioners to refer to the London Respiratory Team ‘value pyramid’ in the IMPRESS guide to the relative value of COPD interventions;17 this gives an insight into the relative value of different interventions for COPD.
A discussion of pharmacotherapy is beyond the scope of this article but full details may be found in the National Clinical Guideline Centre update guidance on COPD.18 Bronchodilation is the mainstay of treatment, with inhaled steroids reserved for people with an asthmatic phenotype, or frequent exacerbations. There is an increasing trend to prescribe high-dose inhaled corticosteroids for all patients with COPD, which ignores the emerging literature on the potential risks.19,20 Of particular concern is the association of high-dose inhaled corticosteroids with increased prevalence and severity of diabetes, and increased risk of pneumonia.21
It is likely that significant savings could be made by rationalising prescribing, freeing up resources to develop and incentivise the provision of high-quality COPD care in primary and community settings.
A significant percentage of patients with COPD are depressed.22 Recognition and treatment of depression is an important element in re-motivating patients to care for themselves.
The question, ‘Do I think this patient will be alive in 1 year?’ is as pertinent in COPD as it is in cancer. Addressing this issue allows a sensible plan to be drawn up and acted upon in the last months of life. The plan will include medications previously contraindicated in individuals with respiratory disease, such as opiates and benzodiazepines, which are used to alleviate anxiety and distress as a result of breathing difficulties. Negotiations need to be conducted concerning the place of death: many patients die in an ambulance on the way to hospital, or in A&E. It should and must be possible to give these people a dignified and peaceful death.
An annual review will be sufficient for most patients with COPD. This should cover all the elements under the headings outlined above, and should also include:
- education and advice on lifestyle and exercise
- ensuring annual influenza vaccination
- checking inhaler technique.
The patient should also be given a rudimentary self-management plan, together with home rescue packs of antibiotics and/or steroids. A self-management plan helps people recognise their exacerbations and enables them to institute treatment earlier, using their home rescue packs. The precise details of what should be incorporated in a self-management plan are currently being investigated in a pilot study.23
Many exacerbations of COPD are unrecognised and untreated because the patient does not present to a formal healthcare setting when these exacerbations occur, leading to further impairment of lung function and quality of life.3,24 Signs of exacerbations include:
- increased shortness of breath
- increased volume of sputum
- purulence of sputum.
Recommendation 188 of the National Clinical Guideline Centre update guidance on COPD18 states that before the patient is discharged, the patient, family and physician should be confident that he or she can manage their condition successfully, and when there is remaining doubt a formal ‘activities of daily living’ assessment may be helpful. It is therefore advisable that a structured review should take place within 2 weeks of an exacerbation and/or hospital admission, with a view to identifying what precipitated the exacerbation and what gaps currently exist in the individual’s care. Currently, these reviews are not adequately resourced and need to be commissioned separately, as they represent a significant tranche of new work.
Management of patients with co-existing conditions
Most patients with COPD have one or more co-morbidities, all of which impact on one another,14 in particular:
- diabetes mellitus
- gastro-oesophageal reflux disease
- heart failure
- ischaemic heart disease
It is the clinician’s task to recognise these co-morbidities and to negotiate a management plan to optimise the patient’s situation. The resulting plan for managing comorbidities may not fit neatly with guidelines proposed for single conditions.25
Avoiding hospital admissions and emergency attendance
Reductions in admissions (in particular readmissions) cannot be achieved without the provision of appropriate services for COPD across the board.
Outcomes are worse and readmission rates are higher when patients with COPD are admitted to a non-respiratory unit.26,27 Commissioners need to establish a pathway to ensure prompt and direct admission for people with COPD to a dedicated respiratory unit, where they will be adequately assessed and managed. They should be sent home with a discharge bundle that includes:28
- smoking cessation advice
- assessment for pulmonary rehabilitation
- patient education
- satisfactory use of inhaler technique demonstrated and understood
- provision of a follow-up outpatient appointment.
Adopting the initiatives listed above will help reduce COPD readmission rates.28
For such a pathway to be successful, however, it is critical to negotiate with the ambulance service to overcome the default position of COPD patients being sent to A&E, so delaying the start of appropriate management.
Community respiratory nursing teams
A further initiative for reducing COPD admissions and length of stay are community respiratory nursing teams, which can prevent admissions or facilitate early discharge from hospital.29
‘Difficult’ COPD clinic
A number of patients will have frequent exacerbations or admissions, despite receiving apparently optimum care. There is an emerging concept of the ‘difficult’ COPD clinic, where a patient is assessed by a multidisciplinary team over the course of a day as an outpatient—this may result in optimised pharmacotherapy, a new diagnosis (e.g. lung cancer, bronchiectasis, cor pumonale), or an opportunity to address the patient’s fears and anxieties. There is no literature on the cost and clinical effectiveness of ‘difficult’ COPD clinics at this time, but a clinic that ensures the patient receives the care that they need, while eliminating anything they do not require, should lead to an overall reduction in resource utilisation.
No article on commissioning of COPD services would be complete without mentioning telehealth, aspects of which have been commissioned (in the author’s opinion) crudely, inefficiently, and ineffectively, on a wave of ill-informed optimism.30 Well-constructed randomised controlled trials conducted in the UK demonstrate no benefit.31,32 This does not mean that telehealth will not have a role in the care of people with COPD, but it needs to be made clear precisely what needs to be monitored, how often, how to recognise when an intervention is needed, and the likely nature of the intervention. Currently, we are quite a long way from this.
There has to date been only one large-scale reorganisation of COPD services in the world, conducted in Finland. It was predicated on an informed workforce delivering care in a structured fashion. Gains were incremental and slow in coming, but accelerated 5 years into the programme, with significant improvements in costs and outcomes at 10 years.33
There are no ‘quick fixes’ for commissioning COPD services. Knowledge and skills deficits in professionals involved in the care of people with COPD have to be rectified urgently, as such knowledge and skills are essential for an effective, integrated service. Multidisciplinary collaboration and cooperation are also essential for successful outcomes, in order to build efficient and effective pathways.
- The NICE quality standard for COPD (QS10) (see publications.nice.org.uk/chronic-obstructive-pulmonary-disease-quality-standard-qs10)34 should be the standard to which CCGs aspire35
- There is an urgent need to invest in training to improve knowledge and skills in primary care
- A network approach to developing integrated care pathways is recommended
- Most CCGs will need to work collaboratively with neighbouring CCGs to develop services in order to achieve a critical mass of patients
- NICE quality standards35 are ambitious and will require significant investment outside of General Medical Services payments.
- Department of Health. Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England. London, DH: 2010. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/135922/dh_113279.pdf.pdf
- Department of Health. An outcomes strategy for COPD and asthma in England. London, DH: 2011. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/151852/dh_128428.pdf.
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Teaching slide set. GOLD, 2013. Available at: www.goldcopd.org/other-resources-gold-teaching-slide-set.html
- British Lung Foundation website. www.blf.org.uk/Home.
- British Lung Foundation website. Breathe Easy British Lung Foundation support groups. www.blf.org.uk/BreatheEasy
- Public Health England. The interactive health atlas for lung conditions in England website. Data and tools. Available at: www.inhale.nhs.uk/data-and-tools/ (accessed 30 August 2013).
- Department of Health. The NHS outcomes framework 2013/14. London: Stationery Office, 2012. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/127106/121109-NHS-Outcomes-Framework-2013-14.pdf.
- 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. Prim Care Respir J 2009; 18 (3): 130–147.
- Lavorini F, Levy M, Dekhuijzen P. Inhaler choice and inhalation technique: key factors for asthma control. Prim Care Respir J 2009; 18 (4): 241–242.
- Molimard M, Raherison C, Lignot S. Assessment of handling inhaler devices in real life: an observational study in 3811 patients in primary care. J Aerosol Med 2003; 16 (3): 249–254.
- Suissa S, Dell Anniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality. Thorax 2012; 67 (11): 957–963.
- Ulrik C, Lokke A, Dahl R et al. Early detection of COPD in general practice. Int J Chron Obstruct Pulmon Dis 2011; 6: 123–127.
- Price D, Tinkelman D, Halbert R et al. Symptom-based questionnaire for identifying COPD in smokers. Respiration 2006; 73 (3): 285–295.
- Barnett K, Mercer S, Norbury M. Epidemiology of multimorbidity and implications for health care, research and medical education: a cross-sectional study. Lancet 2012; 380 (9836): 37–43.
- British Medical Association, NHS Employers. Quality and outcomes framework 2013/14. London: BMA, NHS Employers 2013. Available at: www.nhsemployers/org/Aboutus/Publications/Documents/qof-2013-14.pdf
- Bolton C, Bevan-Smith E, Blakey J et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013; 68 (9): ii1–ii30.
- British Thoracic Society and the Primary Care Respiratory Society UK. IMPRESS Guide to the relative value of COPD interventions. 2012. Available at:www.impressresp.com/index.php?option=com_docman&task=doc_view&gid=51&Itemid=82
- National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. Update guideline. London: National Clinical Guideline Centre, 2010. Available at: www.nice.org.uk/nicemedia/live/13029/49425/49425.pdf
- Suissa S, Kezouh A, Ernst P. Inhaled corticosteroids and the risks of diabetes onset and progression. Am J Med 2010; 123 (11): 1001–1006.
- Price D, Yawn B, Bruselle G, Rossi A. Risk-to-benefit ratio of inhaled corticosteroids in patients with COPD. Prim Care Respir J 2013; 22 (1): 92–100.
- Janson C, Larsson K, Lisspers K et al. Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting ß2 agonist: observational matched cohort study (PATHOS). BMJ 2013; 346: f3306.
- Schneider C, Jick S, Bothner U, Meier C. COPD and the risk of depression. Chest 2010; 137 (2): 341–347.
- Apps L, Mitchell K, Harrison S et al. The development and pilot testing of the self-management programme of activity, coping and education for chronic obstructive pulmonary disease (SPACE for COPD). Int J Chron Obstruct Pulmon Dis 2013; 8: 317–327.
- Seemungal T, Hurst J, Wedzicha J. Exacerbation rate, health status and mortality in COPD—a review of potential interventions. Int J Chron Obstruct Pulmon Dis 2009; 4: 203–223.
- Roland M, Paddison C. Better management of patients with multimorbidity. BMJ 2013; 346. f2510.
- Hosker H, Anstey K, Lowe D et al. Variability in the organization and management of hospital care for COPD exacerbations in the UK. Respir Med 2007; 101 (4): 754–761.
- George P, Stone R, Buckingham R et al. Changes in NHS organizations of care and management of hospital admissions with COPD exacerbations between the national COPD audits of 2003 and 2008. QJM 2011; 104 (10): 859–866.
- Hopkinson N, Englebretsen C, Cooley N et al. Designing and implementing a COPD discharge care bundle. Thorax 2012: 67 (1): 90–92.
- Utens C, Goossens L, Smeenk F et al. Early assisted discharge with generic community nursing for chronic obstructive pulmonary disease exacerbations: results of a randomized controlled trial. BMJ Open 2012; 2 (5): e001684.
- Department of Health. Whole system demonstrator programme. Headline findings —December 2011. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/215264/dh_131689.pdf
- Pinnock H, McCloughlan L, Todd A et al. Clinical effectiveness of telemonitoring for chronic obstructive pulmonary disease (COPD): randomized controlled trial. Thorax 2012; 67: A27.
- Ure J, Pinnock H, Hanley J et al. Piloting tele-monitoring in COPD: a mixed methods exploration of issues in design and implementation. Prim Care Respir J 2012; 21 (1): 57–64.
- Kinnula V, Vasankari T, Kontula E et al. The 10-year COPD programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality. Prim Care Respir J 2011; 20 (2): 178–183.
- NICE website. Chronic obstructive pulmonary disease. Quality Standard 10. www.nice.org.uk/qs10 (accessed 19 August 2013).
- NICE website. Centre for clinical practice. Quality Standards programme, 2011. Available at: www.nice.org.uk/media/714/EC/COPDQualityStandard.pdf