Dr Melvyn Jones outlines key priorities for primary care highlighted in the revised 2010 NICE guideline on chronic obstructive pulmonary disease
  • Smoking cessation is still the most effective intervention in preventing both COPD and progression of established COPD
  • Increasing levels of influenza immunisation in people with COPD is probably the most effective intervention in reducing hospital admissions
  • Obtaining an accurate diagnosis of COPD is a key priority
  • Beclometasone and single-ICS inhalers are not licensed for COPD. NICE recommends high-dose steroids in a combination inhaler for patients with more severe COPD
  • The algorithm from the NICE guideline can be used to guide which inhaler should be used and when. Importantly, the algorithm takes a broader view (breathlessness and exacerbations) than looking at FEV1 in isolation
  • Pulmonary rehabilitation is an effective intervention for those with COPD and should not just be limited for patients after hospitalisation or exacerbations.

COPD in the UK is largely managed in primary care.1 The delivery of this care has become influenced increasingly by external factors such as the quality and outcomes framework (QOF) and recommendations from NICE (National Institute for Health and Care Excellence). These two drivers are converging as NICE is managing the new process for developing the QOF indicators. The only changes to the 2009/10 QOF for COPD were the introduction of a breathlessness assessment and a change in how smoking cessation was measured. In the 2011/12 QOF, there was a minor change in the date of diagnosis to April 2011 (indicator COPD15).2

It has now been over a year since the update to the NICE guideline on COPD was published;3,4 Dr Kevin Gruffydd-Jones discussed this update in the August 2010 issue of Guidelines in Practice.5 Although there was some criticism of the COPD guideline,6 it has generally been well received. It is difficult to assess the response of primary care to the revised guideline because evidence has not yet trickled through to publication. We do, however, know that as a result of QOF and the previous NICE COPD guidance (published in 2004), standards of COPD care are already improving, with increased:7

  • rates of COPD diagnosis
  • use of primary care spirometry
  • use of combination inhalers.

In addition, deaths from COPD have decreased, with a falling standardised mortality rate between 1993 and 2009.8 More recently, a comparison of UK national hospital audit data on COPD admissions, while showing little change in apparent mortality between 2003 and 2008, revealed that this is because older and sicker patients are now being admitted. The authors suggest that this may be because of an improvement in long-term COPD disease management in the community.9

NICE key priorities

The revised NICE guideline on the management of COPD listed 12 key priorities for implementation, many of which have been carried over from the original guidance as they are still of fundamental importance (see Box 1, below).3

Box1: NICE key priorities for implementation3

Diagnose COPD

  • A diagnosis of COPD should be considered in people over the age of 35 years who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze
  • The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry
  • All healthcare professionals managing people with COPD should have access to spirometry and be competent in the interpretation of results.

Stop smoking

  • Encouraging people with COPD to stop smoking is one of the most important components of their management. All people with COPD who are still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity.

Promote effective inhaled therapy

  • In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy if FEV1:
    • ?50% predicted: either LABA or LAMA
    • <50% predicted: either LABA with an ICS in a combination inhaler or LAMA
  • Offer LAMA in addition to LABA + ICS to people with COPD who remain breathless or have exacerbations despite taking LABA + ICS, irrespective of their FEV1.

Provide pulmonary rehabilitation for all who need it

  • Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation.

Use non-invasive ventilation

  • Non-invasive ventilation should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use, and aware of its limitations
  • When people are started on non-invasive ventilation, there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed.

Manage exacerbations

  • The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations
  • The impact of exacerbations should be minimised by:
  • giving self-management advice on responding promptly to the symptoms of an exacerbation
  • starting appropriate treatment with oral steroids and/or antibiotics
  • use of non-invasive ventilation when indicated
  • use of hospital-at-home or assisted-discharge schemes.

Multidisciplinary working

  • COPD care should be delivered by a multidisciplinary team.

COPD=chronic obstructive pulmonary disease; FEV1=forced expiratory volume in 1 second; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic agonist; ICS=inhaled corticosteroid

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. Reproduced with permission. Available at: www.nice.org.uk/guidance/CG101

Improving diagnosis

One of the key priorities is obtaining an accurate diagnosis of COPD, which emphasises the importance of clinicians’ ability to interpret spirometry. The near universal use of spirometry in primary care has been a fundamental shift, which has been achieved since the QOF was implemented in 2004. Recently, it has been estimated that GP spirometry use in people with COPD ranges from 76%–96%.10 The current guidance highlights that the use of spirometry requires care with interpretation, particularly with regards to the risk of under diagnosing younger people with breathlessness and over diagnosing older people on the basis of forced expiratory volume in 1 second (FEV1) readings alone. Alternative diagnoses should be considered in older people without typical symptoms of COPD and an FEV1/FVC ratio <0.7, and younger people with symptoms of COPD and an FEV1/FVC ratio ?0.7.3

The NICE guidance reminds us that FEV1 can reflect disability from COPD poorly, and recommends performing a more comprehensive assessment that includes:3

  • degree of airflow obstruction and disability
  • frequency of exacerbations
  • transfer factor for carbon monoxide
  • breathlessness (assessed using the Medical Research Council scale)
  • health status
  • exercise capacity
  • body mass index (BMI)
  • partial pressure of oxygen in arterial blood
  • cor pulmonale.

The NICE guideline also recommends calculation of the BODE (BMI, airflow obstruction, dyspnoea, and exercise capacity) index to assess prognosis (but recognises that some of this information may be unavailable in primary care).3

Smoking

Another key priority in the prevention of COPD and in modifying progression in those with established disease is smoking cessation. National figures vary, but still suggest that there are high levels of smoking in the general population of around 20%,11 with other estimates ranging from 13%–24%.10,12 Figures from the QOF suggest that approximately 10% of the general population have been recorded as receiving smoking cessation support and advice, but patient recollection of such activity is much lower.13 Healthcare professionals are probably performing better in people with COPD, with estimates of smoking cessation inputs ranging from 69%14 to 93%.10

Prescribing in COPD

The updated advice on the role of medication is one of the principal recommendations in the revised guidance, particularly around sequencing and adding to existing pharmacological therapies (see Figure 1, below). Although these drugs can be expensive (e.g. up to £41 for a higher-strength long-acting beta2 agonist [LABA]/inhaled corticosteroid [ICS] combination inhaler15,16), they are less than the cost-effectiveness thresholds applied by NICE when prescribed appropriately.

There has been a four-fold increase over 5 years from March 2003 to March 2008 in prescriptions of ICS plus LABA combinaton inhalers.17 NHS prescriptions in England in 2011 for fluticasone/salmeterol, budesonide/ formoterol fumarate, and tiotropium prescriptions are approximately £160 million per quarter.18

Even before the NICE guidance was published, tiotropium (a long-acting muscarinic agonist [LAMA]) rapidly started to replace ipratropium (a short-acting muscarinic antagonist [SAMA]) in both volume and cost. Although we cannot be sure that the increase in ICS prescribing is for treatment of COPD (as the bulk of ICS prescribing is for asthma rather than COPD), the increase in tiotropium prescribing is much more likely to be related to COPD.

However, prescribing volumes do not provide much information on how appropriate the prescribing is and there are concerns (regarding excess costs and adverse effects from medication) that clinicians might be over treating milder cases of COPD.19 Appropriate use of combination inhalers in individuals with an FEV1 <50% rose from 25% in 2003 to 44% in 2005, but unfortunately more recent data are not available.7

It is worth remembering that beclometasone and single ICSs are not licensed for COPD; however in 2009, 15% of patients were still receiving these inappropriate inhalers.14 NICE recommends the use of combination inhalers with high-dose ICS. The guideline also includes a reminder of the increased risk of pneumonia if using an ICS inhaler.3

Measuring appropriateness of prescribing is not a simple issue as the guidance spells out that increasing treatment is indicated for people with exacerbations and breathlessness despite monotherapy, irrespective of FEV1.3 This means that simple metrics often used by primary care trusts such as linking of FEV1 to ICS rates will not provide data on appropriate prescribing.

Since the NICE guideline was published, a Cochrane review has questioned the effectiveness of triple therapy (LABA, ICS, and LAMA) in COPD management, contradicting the recommendations from NICE.20 However, while most of the included patients had more severe airways limitations, the authors did not attempt to stratify treatment by the degree of severity of airflow obstruction.

Evidence for pulmonary rehabilitation

The NICE recommendation on pulmonary rehabilitation was one of the big changes in the 2010 guideline.3 An audit in 2008 suggested that pulmonary rehabilitation was available in 83% of hospitals, but there are some doubts about how adequately these programmes are staffed with the requisite professionals (e.g. physiotherapists and dietitians). There is also evidence of low continuation rates of this therapy of approximately 41%.21 There are no data on any recent changes in the use of pulmonary rehabilitation as a result of the 2010 recommendations. Commissioning high-quality pulmonary rehabilitation could well be a priority for clinical commissioning groups as it is cost effective and there is increasing evidence that it can reduce hospital admissions.22

Figure 1: Use of inhaled therapies for chronic obstructive pulmonary disease3

graph

*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: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: NICE. Reproduced with permission. Available at: www.nice.org.uk/guidance/CG101

Future improvements in care

There is good evidence of under diagnosis of COPD nationally23—the so-called COPD ‘missing millions’. It is estimated that there are two undiagnosed people with COPD for every person with a diagnosis.10 This is significant as we are less likely to intervene effectively and early in this group (in terms of smoking cessation) and also because those with undiagnosed COPD are at high risk of being admitted to hospital.10

Making best use of NHS resources

Chronic obstructive pulmonary disease is a significant economic burden to the NHS in terms of prescribing and hospital costs. Emergency hospital COPD admissions are not only expensive, but are a huge driver of winter pressures on the NHS. Is there anything else that healthcare professionals can do besides improving diagnosis and providing advice and support for smoking cessation? A striking finding suggests that influenza immunisation is a major factor in reducing hospital admissions.10 Studies suggest that vaccinations are administrated to between 80%14 and 92%10 of patients with COPD, which is good, but that still leaves large numbers of unprotected patients (perhaps 10%–20% of the 800,000 diagnosed).

Nurse-led case management24 has been trialled but may not be the answer.25 Other small studies looking at the introduction of an aspect of NICE guidance show a possible impact on hospital admissions,24,26 but care must be used in interpreting these small studies.

Future revisions to national guidance on COPD

Management of COPD exacerbations,27–29 is an important role for primary care and accessibility to see clinicians in this setting is another major factor in reducing hospital admissions.10 The NICE guideline on COPD suggests that patients should be provided with self-management advice and a course of antibiotic and corticosteroid tablets to keep at home.3 Treatment of COPD exacerbations including self management was unchanged by the 2010 guideline revision.

Secondary care issues such as non-invasive ventilation during exacerbations and oxygen therapy are not covered by this article, but are relevant to those commissioning hospital services for COPD.

The NICE quality standard for COPD30 and the outcomes strategy for COPD and asthma31 have recently been published and make suggestions on how to improve care for patients with COPD.

Summary

There is some early evidence of improved care in COPD management following publication of the NICE 2010 COPD guideline update, but we await longer-term evaluations. In the meantime there is much to be done at the primary care level to improve the care of individual patients.

  • Accurate diagnosis and appropriate care in the community of COPD reduces exacerbations and expensive hospital admissions
  • The NICE guidance is much more in depth than the requirements of the QOF and commissioners could consider local enhanced services to incentivise practices to offer appropriate treatment and self-management plans to COPD patients
  • Commissioners should ensure that pulmonary rehabilitation is available for all patients after hospital admission and for individuals who have been referred by primary care
  • Local formularies should identify licensed inhalers, their indications, and cost
  • Clinical commissioning groups could consider bulk purchase of less costly flu vaccines to reduce prescribing costs, and use the savings to fund community nurses to increase uptake by offering vaccination to the housebound
  • Tariff prices:a
  • COPD emergency admission = £1757 (DZ21K)
  • Respiratory outpatient = £232 (new), £109 (follow up).
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  3. 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/CG101 nhs_accreditation
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