James Gupta (left) and Andrea Gupta give a personal account of how a joint working initiative has improved patient care, nurses’ understanding of the disease, and prescribing costs in COPD


Chronic obstructive pulmonary disease (COPD) is a progressive and incurable condition that is characterised by largely irreversible airway obstruction, which permanently reduces lung function.1 The disease, particularly in its late stages, has debilitating effects on both mortality and quality of life, with many patients requiring oxygen therapy, home support, and frequent hospitalisation.2

As the fifth leading cause of death worldwide, COPD is responsible for 5.1% of all deaths,3 though this is projected to rise.4 Between 80% and 90% of deaths in people with COPD can be attributed to smoking,2 and it is estimated that up to 50% of elderly smokers will eventually develop the disease.5 However, non-smokers are also at risk from the disease through occupational or environmental exposure to noxious particles, and genetic defects, such as an alpha-1 antitrypsin deficiency.1

There is a significant and worrying lack of knowledge among patients, healthcare professionals, and the general public on COPD, with an estimated 89% of people (including 85% of smokers) having never heard of the condition.6 It has been shown that services such as pulmonary rehabilitation are underused,7 as demonstrated by our own practice data, and many COPD patients are being sub-optimally treated to the quality and outcomes framework, rather than the far more comprehensive NICE standards of care. This is shown in our baseline Patient Outcomes and Information Service (POINTS) data.8,9

Studies have shown that patients who are admitted to hospital having experienced an exacerbation of COPD have a high level of modifiable risk factors—an estimated 43% are unable to use their inhalers correctly and 86% have not had pulmonary rehabilitation in the last 12 months.7 Evidence suggests that higher levels of practice nurse staffing are associated with lower rates of COPD hospital admissions, which would seem logical.10


The joint working project

StHealth is a practice-based commissioning (PBC) consortium of 24 practices in Halton and St. Helens, which is a spearhead primary care trust (PCT). It has a total patient population of approximately 138,000, comprising some 44% of the total patient population of the PCT.

Based on the data described above, our own experiences with patients, discussions with other clinicians, and practice data on how our COPD patients were being managed, StHealth Consortium identified three main points:

  • Public awareness and understanding of COPD is worryingly low, even among smokers, who have an estimated 50% chance of developing the disease at some point in their life5
  • Better management of COPD in primary care, with a focus on patient empowerment and self-management, can have significant effects on hospital admissions and bed-days, and is urgently needed11
  • QOF guidance on COPD management is outdated and does not cover our interpretation of what a holistic COPD review should include.

StHealth set up a joint working project with GlaxoSmithKline (GSK) for the enhanced management and early detection of COPD in primary care. The main objective was to improve patient outcomes (see Figure 1), however, we also identified specific, measurable outcomes for all parties involved:

  • Patients:
    • Empowerment through superior understanding of their condition
    • Better management of daily symptoms
    • Reduction in exacerbations
  • NHS:
    • Reduction in COPD-related hospital admissions and bed-days
    • Improved clinician confidence in diagnosing and managing COPD
    • Cost-savings through more appropriate prescribing
  • GSK:
    • Improved relationships with the NHS
    • Increase in the appropriate use of respiratory medications in line with NICE guidelines.

The project started on a small-scale, with GSK offering to fund COPD training (a general course received through one-on-one training with a respiratory nurse consultant) for a StHealth practice nurse. This led to a larger-scale project under the guidance of the Department of Health (DH) joint working toolkit.12 All costs were split evenly between GSK and StHealth.


Figure 1: QIPP targets identified for the joint working project

graph

QIPP=Quality, Innovation, Prevention and Productivity; COPD=chronic obstructive pulmonary disease

Methods

This was a holistic project designed to improve COPD management at all levels, and as such we implemented changes in a number of areas, see Figure 2 (below).

Joint working business case
GlaxoSmithKline and StHealth provided £290,000: this money was used to purchase equipment, provide education, install POINTS software, and develop a Local Enhanced Service (LES) to fund practices to ‘case find’ patients with undiagnosed COPD. The staff costs were also funded by GSK and StHealth.

Using the DH toolkit, we worked together as equal stakeholders and also engaged with primary, secondary, and community care. The joint working aspect of the project was fundamental to its success. Not only did GSK provide funding for training events and new equipment, but also members of GSK’s Respiratory Care Team worked closely with us and provided advice on navigating POINTS data and developing local pathways.

Treatment pathways and protocols
Having decided that QOF-standard COPD reviews were inadequate, we wanted to implement NICE Clinical Guideline 101 (CG101) on the management of COPD in our practices.1

We worked with local stakeholders including GPs, chest physicians, spirometry technicians, COPD community nurses, and members of the British Lung Foundation to develop robust pathways for the diagnosis and management of COPD. These pathways were a summary of best-practice based on national evidence (i.e. NICE CG101) as well as local protocols and service provision.13

We wanted the knowledge obtained by clinicians on the training events to be reinforced and supplemented by clinical guidance tools. We worked with GSK to develop comprehensive computer templates for conducting NICE-standard, holistic COPD reviews. These ensured that all areas of a review were covered and recorded, and it also made identifying areas for improvement much easier, as it standardised the Read codes across all the practices involved.

Clinician training
As our own clinicians had highlighted a lack of understanding of COPD as a major issue, our first step was to provide training for doctors, nurses, and healthcare assistants. Over the past 12 months our funding has facilitated training in a number of specific areas:

  • Pathophysiology of COPD
  • Differential diagnosis of COPD with asthma and chronic heart failure
  • Inhaler technique and compliance
  • Pharmacotherapy
  • Lung-function testing and basic spirometry
  • When to refer
  • The StHealth pathway
  • Understanding POINTS data.

Analysis of POINTS data
GlaxoSmithKline facilitated the installation of POINTS software onto practice servers within the StHealth group. This allows practices to obtain data on how their COPD patients are being managed, such as what percentage of patients have received a flu vaccine, and what sort of treatment patients are receiving.

The data provides a population-level ‘snapshot’ of how a practice is doing, and makes identifying areas for improvement very easy. Over the past year, practice managers and nurses have built strong, transparent relationships with the GSK Respiratory Care Team members of which frequently come into practices and discuss the latest data suggesting areas for improvement, and instructing on how to effectively navigate the data produced.

Investment in Vitalograph COPD-6 monitors
In addition to improving the management of existing COPD patients, we also wanted to increase the detection rate of COPD among our patient population by engaging in screening to discover the disease at an earlier stage. For a mass-screening programme we found that full, post-bronchodilator spirometry was not cost-effective. However, Vitalograph has a range of handheld COPD-6 screening devices that are designed to be easy to operate and can be used to obtain fast, accurate measurements of forced expiratory volume in 1 second (FEV1) and in 6 seconds (FEV6) and the FEV1/ FEV6 ratio. It has been shown that FEV6 readings provide comparable results to forced vital capacity, and they are adequate for the purposes of mass screening for airflow obstruction,14 with abnormal results being followed up by full, post-bronchodilator spirometry.

Measuring patient experience
Twelve months into the project we jointly commissioned a patient experience survey to gauge how the project was doing. Outcomes were also measured by POINTS data and hospital admissions data, an internal survey of StHealth nurses, and feedback from services such as pulmonary rehabilitation.

Implementing NICE Clinical Guideline 101 on management of COPD
We took a holistic approach to implementing the new NICE guideline for COPD, incorporating almost all recommendations into our pathways and clinical practice, although there were a few minor points on which we differed:1

  • NICE does not mention its stance on the provision of ‘standby’ or ‘rescue’ courses of antibiotics and oral steroids. Evidence suggests that when prescribed appropriately in frequently exacerbating patients, standby kits allow patients to start treatment sooner and thereby reduce the severity of the exacerbation.15 Patients who are prescribed standby kits need to be properly educated on how and when to use them
  • NICE does not state a preference for a specific inhaler device. We generally prefer dry-powder inhalers (DPIs) to metered-dose inhaler (MDI) devices: DPIs are more cost effective and often result in increased compliance as patients take one puff twice a day rather than two puffs twice a day. We use clement InCheck dials to measure a patient’s inspiratory flow capacity. These are handheld devices that can be used to determine whether a patient has correct inhaler technique, and if they have sufficient inspiratory flow to use certain devices effectively. If it is sufficient, we will offer them a DPI although in some patients an MDI is the only option (for example, if they have insufficient inspiratory flow to effectively use a DPI). In these cases, maintenance medication should be delivered through a spacer device to optimise delivery
  • Inhaler technique is not mentioned in the latest NICE COPD guidance, but it is a vital part of a good review.16 If you prescribe an inhaler but do not show the patient how to use it, at best they will develop a moderate technique over time, but they are more likely to have a poor technique resulting in none of the medication reaching the lungs. Therefore, the patient will not feel any benefit and as a result they may stop using the inhaler. In some cases, patients will continue to order the inhaler on their repeat prescription to avoid having to explain why they stopped using it. This would cost the practice around £720 a year.17
Figure 2: Diagrammatic summary of methods used to set up the joint working project

graph

POINTS=Patient Outcomes and Information Service software; COPD=chronic pulmonary obstructive disease; FEV1=forced expiratory volume in 1 second

Outcomes

StHealth practice nurse survey
In a survey of 20 StHealth practice nurses, 80% said their training has increased their understanding of COPD a lot, and 20% said their understanding of COPD increased a little.8 Also, 12 months from the start of the project, practice nurses reported an increased level of confidence when managing COPD (see Figure 3).8

Patient experience survey
The results of the patient experience survey suggested that, as a result of the project, patients were receiving a significantly better standard of care, thereby resulting in a better understanding of COPD and how to manage it (see Figure 4).18

We also found that the majority of reviews lasted longer than 20 minutes, with the average review length being 28 minutes. This is a reflection of the standard of reviews now being conducted, and seems to be appropriate when performing a full, holistic review. Only 3% of patients felt that their review was too short.18

Admissions and referral data
Over the past 12 months we have observed a 9.2% reduction in COPD-related hospital admissions, equating to an estimated £100,000 in tariff savings.19 This is very positive and we are confident that next year’s figure will be even greater as the project is refined.

One obvious concern with an initiative such as this is that already stretched respiratory prescribing budgets will increase. However, we have not found this to be the case. One of the practices that has been involved with the management arm of the project and is particularly active in screening patients for COPD, has doubled its list size for affected patients in the last 12 months. A reduction in respiratory prescribing costs has been seen since the inception of the project. Despite this, the practice issues 18% more prescriptions for respiratory system medications (therapeutic groups as defined by the British National Formulary) compared with the local PCT average.

This trend is maintained by increases in appropriate prescribing and cost efficiency, meaning that the practice has a significantly lower prescribing cost per item for respiratory medications (an average of £13.76 compared with £17.51 per item in the PCT average, a difference of 21%). Overall, while the practice’s respiratory prescribing is higher than the PCT average, the overall cost of this is still significantly (7%) lower.20 This is a remarkable achievement, and particularly important given the current economic situation.

On reflection, this result is not as surprising as it appears. Two of our major concerns from the outset of the project were that COPD patients were not being treated effectively or appropriately and that clinicians were not confident with pharmacotherapy for COPD. Through comprehensive, up-to-date training with a focus on patient empowerment (e.g. inhaler technique, compliance, self-management, disease awareness) and a change in culture, clinicians are more confident and more cost aware with regards to appropriate respiratory prescribing.

POINTS data
Comparing our current POINTS data to the baseline, we can see significant changes in the way COPD patients are treated in our practices. Before the project we had a significant number of COPD patients on non-combination inhaled corticosteroid plus long-acting beta agonist therapy;9 however it is often both cheaper and more effective when these therapies are prescribed in combination devices.21,22 We also had many patients on MDI devices when they would receive equal benefit from a DPI,23 which is cheaper in most cases and associated with a lower rate of inhaler technique errors.24

Other outcomes include:

  • a large reduction in prescribing for ‘enteric-coated’ prednisolone, which is eight-times the price of standard prednisolone tablets, and has failed to show superiority in the majority of patients17,25
  • reductions in the amount of patients on nebulisers or similar devices
  • reductions in patients on short-acting muscarinic antagonist plus long-acting muscarinic antagonist (NB there is no evidence to suggest an add-on effect1)9,26
  • significant increases in the number of patients referred for pulmonary rehabilitation9,26
  • increases in the number of patients being given demonstrations of inhaler technique and having their own inhaler technique observed.9,26
Figure 3: Change in the level of StHealth nurses’ confidence in managing COPD8

graph

COPD=chronic obstructive pulmonary disease

Figure 4: Change in patient understanding following their latest COPD review18

graph

COPD=chronic obstructive pulmonary disease


Summary

We have shown that through joint working the standard of care for COPD patients in primary care can be greatly improved, resulting in greater clinician confidence, patient empowerment, and significant decreases in emergency admissions. Furthermore, through more cost-effective and efficient prescribing these improvements in quality can be achieved while simultaneously reducing costs.

Further information about StHealth and the joint working project, including links to the various publications mentioned in this article can be found at: www.sthealth.org.uk/copd_resources.htm.

  1. National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline 101. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG101 nhs_accreditation_1cmyk.eps
  2. Commission for Healthcare Audit and Inspection. Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission, 2006. Available at: www.library.nhs.uk/respiratory/ViewResource.aspx?resID=144395
  3. World Health Organization. The global burden of disease 2004 Update. Geneva: WHO, 2008. Available at: www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
  4. World Health Organization. World health statistics 2008. Geneva: WHO, 2008. Available at: www.who.int/whosis/whostat/2008/en/index.html
  5. Lundbäck B, Lindberg A, Lindström M et al. Not 15 but 50% of smokers develop COPD? Report from the Obstructive Lung Disease in Northern Sweden Studies. Respir Med 2003; 97 (2): 115–122.
  6. British Lung Foundation. Invisible lives. Chronic obstructive pulmonary disease (COPD)—finding the missing millions. BLF, 2007.
  7. Garcia-Aymerich J, Barreiro E, Farrero E et al. Patients hospitalized for COPD have a high prevalence of modifiable risk factors for exacerbation (EFRAM study). Eur Resp J 2000; 16 (6): 1037–1042.
  8. StHealth website. StHealth internal nurse survey 2010. Available at: www.sthealth.org.uk/copd_resources.htm
  9. Sandfield Medical Centre. POINTS baseline data 2009.
  10. Griffiths P, Murrells T, Dawoud D, Jones S. Hospital admissions for asthma, diabetes and COPD: is there an association with practice nurse staffing? A cross sectional study using routinely collected data. BMC Health Serv Res 2010; 10: 276.
  11. Weidinger P, Nilsson J, Lindblad U. Adherence to diagnostic guidelines and quality indicators in asthma and COPD in Swedish primary care. Pharmacoepidemiol Drug Saf 2009; 18 (5): 393–400.
  12. Department of Health. Moving beyond sponsorship: interactive toolkit for joint working between the NHS and the pharmaceutical industry. London: DH, 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082840
  13. StHealth website. StHealth COPD management pathway, February 2011. Available at:
    www.sthealth.org.uk/copd_resources.htm
  14. Represas Represas C, Botana Rial M, Leiro Fernández V et al. Assessment of the portable COPD-6 device for detecting obstructive airway diseases. Arch Bronconeumol 2010; 46 (8): 426–432.
  15. Effing T, Kerstjens H, van der Valk P et al. (Cost)-effectiveness of self-treatment of exacerbations on the severity of exacerbations in patients with COPD: the COPE II study. Thorax 2009; 64 (11): 956–962.
  16. Bell J. Why optimize inhaler technique in asthma and COPD. Br J Prim Care Nursing 2008; 2 (2): 37–39.
  17. British National Formulary. BNF 60. September 2010. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2010.
  18. StHealth website. Ipsos MORI, COPD patient experience survey. May 2010. Available at:
    www.sthealth.org.uk/copd_resources.htm
  19. SUS/SLAM data based on ICD10 primary diagnosis codes J40-J44. StHealth PBC Consortium, July 2010.
  20. Sandfield Medical Centre. Practice prescribing data 2010.
  21. Miravitlles M, Anzueto A. Insights into interventions in managing COPD patients: Lessons from the TORCH and UPLIFT studies. Int J Chron Obstruc Pulmon Dis 2009; 4: 185–201.
  22. Briggs A, Glick H, Lozano-Ortega G et al. Is treatment with ICS and LABA cost-effective for COPD? Multinational economic analysis of the TORCH study. Eur Resp J 2010; 35 (3): 532–539.
  23. Ikeda A, Nishimura K, Koyama H et al. Comparison of the bronchodilator effects of salbutamol delivered via a metered-dose inhaler with spacer, a dry-powder inhaler, and a jet nebulizer in patients with chronic obstructive pulmonary disease. Respiration 1999; 66 (2): 119–123.
  24. Geller D. Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler. Respir Care 2005; 50 (10): 1313–1321.
  25. Adair C, McCallion O, McElnay J et al. A pharmacokinetic and pharmacodynamic comparison of plain and enteric-coated prednisolone tablets. Br J Clin Pharmacol 1992; 33 (5): 495–499.
  26. POINTS data from sample of 923 patients. Collected and supplied by Quintiles. March 2010.G