Ensuring that your practice has the right skill mix will be important for gaining maximum points for the new contract’s COPD indicators, says Dr Peter Saul
Management of patients with chronic obstructive pulmonary disease (COPD) is an important area in the clinical domain of the new GMS contract and represents a potential 45 quality points.1 More importantly, the COPD clinical indicators set a challenge for practices to tackle the fifth most common cause of death in England and Wales.
Publication of the new NICE guideline on COPD,2 which updates the British Thoracic Society COPD guideline and has been endorsed by the BTS, is very timely as it will help inform implementation of the GMS clinical indicators. It will help clinicians to establish the diagnosis accurately and plan ongoing follow-up and supervision.
Clinical indicators for COPD
As with all the indicators, good administrative support is important. Careful planning involving all the team members should be carried out to ensure that systems are in place to address all the COPD indicators (Table 1, below), with each staff member being clear about his or her own role.
Remember, too, that skill mix needs to be thought out, with appropriate levels of expertise being devoted to each task and doctors and nurses addressing the more challenging aspects of diagnosis and treatment.
|Table 1: Clinical indicators for chronic obstructive pulmonary disease|
|Disease/ indicator no||Clinical indicator||Points||Qualifier||Preferred Read code||Exception reporting and Read code||Payment stages|
|COPD 1||The practice can produce a register of patients with COPD||5||COPD H32||Patient refuses 9h50
Patient unfit 9h51
Patient dissent 9h52
|COPD 2||The percentage of patients in whom diagnosis has been confirmed by spirometry including reversibility testing for newly diagnosed patients||5||From 1.4.03||Spirometry – reversibility positive SSG1||25-90%|
|COPD 3||The percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing||5||Spirometry – reversibility positive 33G1||25-90%|
|COPD 4||The percentage of patients with COPD in whom there is a record of smoking status||6||In past 15 months||Never smoked 1371
|COPD 5||The percentage of patients with COPD who smoke, whose notes contain a record that smoking cessation advice or referral to a specialist service, if available, has been offered||6||In past 15 months||Smoking cessation advice 8CAL||25-90%|
|COPD 6||The percentage of patients with COPD with a record of FEV1||6||In past 27 months||Spirometry screening 68M||25-70%|
|COPD 7||The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked||6||In the preceding 2 years||Inhaler technique
|COPD 8||The percentage of patients with COPD who have had influenza immunisation||6||In the preceding 1 September to 31 March||Flu vaccination given 65E||Flu vaccination
Records (COPD 1)
Good clinical records form the basis of identifying COPD patients and monitoring their care.
Some practices will have clinically coded for COPD on their computer systems; others may have to rely on prescribing data to find patients. Searching for bronchodilator use would be effective, but notes would have to be manually screened to exclude other respiratory conditions. In many cases, a full clinical review will be required to establish the diagnosis.
Since smoking is the main cause of COPD, with individuals who have been smoking for 20 years or more at high risk, a practice might additionally wish to screen all smokers over the age of 40 or 45 years; studies have shown that identification rates of up to 27% might be expected.3
Initial diagnosis (COPD 2 and 3)
Indicators 2 and 3 rightly emphasise the need for accurate diagnosis. A comprehensive summary of the diagnostic indicators is given in the NICE guideline and should be used in conjunction with the GMS indicators.
In essence, the condition should be considered in patients over 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.
Airflow obstruction should be confirmed by spirometry with an FEV1 and an FEV1/FVC ratio of less than 70% predicted.
Spirometry, including reversibility testing for both new and existing patients, attracts quality points reflecting advice offered in the 1997 BTS guideline. Critically, the NICE guideline diverges, pointing out that reversibility testing may be "unhelpful or misleading”. It points out that home-based peak flow readings can be used to look for reversibility which, if present, would cast doubt on the diagnosis of COPD. Because of this, the quality indicator is currently under review and may be changed.
Access to a spirometer is clearly important but may involve significant capital expenditure by practices. Other options include sharing with nearby practices or asking the local hospital to provide the service. Doctors and practice staff should be trained in interpretation.
Ongoing management (COPD 4-8)
The fact that smoking is the major determinant in COPD is recognised in indicators 4 and 5, which require practices to record and track smoking status and to offer cessation advice where appropriate.
The NICE guideline recommends that clinicians go into additional detail and establish the number of ‘pack years’ an individual has smoked and back up anti-smoking advice with pharmacological measures for patients trying to quit.
Tracking FEV1 every 27 months (COPD 6) should identify rapidly progressive disease, a loss of 500 ml over 5 years being regarded as severe.4 The NICE guideline regards good practice as seeing patients with mild to moderate disease annually and those with severe disease more frequently, usually in a shared care situation. It is surprising that the GMS indicators do not recommend more frequent review of FEV1 for patients with severe disease.
Treatment is considered in COPD 7, which recommends checking patients’ inhaler technique. This is a useful reference point to ensure that treatment is optimal, and is in accordance with the NICE guideline.
Interestingly, no quality markers are allocated to measures such as patient referral to pulmonary rehabilitation and self-management plans for exacerbations, both of which the NICE guideline regards as valuable clinical interventions.
Respiratory infections such as influenza can be devastating for COPD patients so it is not surprising that COPD 8 is directed at ensuring targeting with annual immunisation. However, given the Chief Medical Officer’s recommendation, it is surprising that there is no reference to pneumococcal immunisation as this, too, has proven benefits in COPD.5
The contract presents a challenge with respect to elderly and ill patients, many of whom are housebound or in care homes. Practices will need to develop a system of domiciliary monitoring for most of these patients.
Practices will find a very wide spread of disease symptomatology among their COPD patients. Data collection and monitoring will be the exclusive responsibility of the practice in mild to moderate cases. For severely ill patients, effective information exchange in a shared care setting should help populate target data and avoid unnecessary duplication.
With all patients, the COPD indicators should help clinicians pick out and target some key areas of care, and to gain maximum quality points each will need to be carefully considered.
A much more detailed multidisciplinary approach will be needed for patients with more severe disease. The NICE guideline is particularly helpful in outlining severity assessment and management options and offers very comprehensive, sensible and practical advice.
I anticipate that we may see some revisions to the clinical indicators. Few practices have experience in reversibility testing and in the light of the NICE guideline I expect most will seize on the opportunity to dispense with it, assuming that the change is approved by the NHS executive.
- Investing in General Practice:The New General Medical Services Contract. www.bma.org.uk
- National Institute for Clinical Excellence. Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline No 12. London: NICE, 2004.
- Stratelis G, Jakobsson P, Molstad S, Zetterstrom O. Early detection of COPD in primary care: screening by invitation of smokers aged 40 to 55 years. Br J Gen Pract 2004; 54: 201-6.
- COPD Guidelines Group of the Standards of Care Committee of the BTS. BTS guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997; 52 (Suppl 5): S1-28.
- Department of Health, Chief Medical Officer. Adult Immunisation Update. London, DoH, 8 August 2003