Dr Steve Holmes discusses the clinical indicators for chronic obstructive pulmonary disease and how they are augmenting the already high level of care provided by GPs

At times there have been disingenuous suggestions that the quality and outcomes framework (QOF) has been a ‘tick box’ exercise. As a riposte, the Department of Health recently sponsored research into the benefits and value of the framework. It is worthwhile noting that the comprehensive research, undertaken by the University of York, suggested in its conclusion that ‘the majority (of GPs) produced markedly higher quality than was required to maximise their financial rewards.’1

Although not particularly widely promoted by the sponsors, the research does fit well with the aims, aspirations, and altruism of primary care. As Professor Martin Roland, Director of the National Primary Care Research and Development Centre, suggests, the QOF ‘… is not a panacea, but rather should be seen as an adjunct to other quality improvement initiatives.’2

The quality and outcomes framework for COPD

Increasing attention has been placed on the diagnosis and management of COPD. Not only is it an important part of the QOF,3 it is the subject of a future national service framework4 (currently in development and due for release in mid-to-late 2008), and a Healthcare Commission report into COPD,5 as well as considerable research highlighting the benefits of treatment.

Many primary care organisations have identified COPD as a key target area, primarily because there are sectors of care where patient needs are not being met (especially around pulmonary rehabilitation, which has been identified as an important factor in the NICE guideline).6 Probably more importantly though, COPD is the commonest cause of acute medical admission in the UK and has the highest costs.7 There has been considerable research demonstrating that admission rates can be reduced by effective pharmacological interventions, and early treatment of exacerbations.

The management of COPD rightly remains an important part of the QOF, thanks to the recognition by GPs that they can make an important difference to these patients in primary care.

This article on the QOF indicators for COPD aims to highlight good practice, as well as interventions that will benefit patients in the longer term. Each of the categories will be covered separately, and, as the average practice in England currently achieves 96% of the total quality points,8 assumptions will be made regarding the basic systems in place within the practice. The COPD indicators are listed in Table 1.

Table 1: Clinical indicators for COPD1

No. Indicator
Points
Payment stages
COPD 1 The practice can produce a register of patients with COPD
3
 
COPD 9 The percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing
10
40–80%
COPD 10 The percentage of patients with COPD with a record of FEV1 in the previous 15 months
7
40–70%
COPD 11 The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the previous 15 months
7
40–90%
COPD8 The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March
6
40–85%

Patient register—COPD 1

Most practice computer systems make production of this register easy, and, indeed, over the 2–3 years since production of the first QOF, practices have made significant strides to populate the register accurately. When the framework started, practices found that young people without symptoms could commonly be coded as having COPD. This was a result of the diagnosis of ‘wheezy bronchitis’ being made when some of our adult patients were children. Unfortunately the Read codes classify ‘wheezy bronchitis’ as COPD. We would now consider this to be the result of either respiratory infection, viral-associated wheeze, or asthma. There were a number of other commonly used ‘diagnoses’ in the past, which could place a person onto the COPD register, for example, chronic or recurrent bronchitis.

National prevalence surveys based on the QOF put the prevalence of COPD at around 1.4%,9 with a range between different strategic health authorities of 0.8–2.3%. Looking at the current epidemiological data would suggest that only around 33–50% of the total number of patients have been identified in this way. Most epidemiological surveys in the UK indicate a prevalence of 4.1% or higher.

It is worthwhile contemplating how close your practice is to the current QOF average. Should it be higher than average because of the demographics of your area (e.g. a high level of smoking, mining, etc) or lower? How closely does your practice match the epidemiological research? What processes are present in the practice to help to diagnose patients with COPD?

Screening for new patients

The debate around whether screening is beneficial according to the Wilson Criteria, which are widely accepted as the criteria for screening programmes,10 is still ongoing. There has been considerable research highlighting the benefits of screening smokers aged over 40 years11 and who have symptoms of breathlessness, cough, or wheeze. This includes some primary care-based screening questionnaires.12 It would appear to be sensible to establish disease as early as possible, especially as there is now good evidence for the benefits of smoking cessation in reducing disease progression, as well as for pulmonary rehabilitation and medications in reducing exacerbations, hospital admissions, and improving quality of life.

Spirometry including reversibility testing—COPD 9

Practices are required to have confirmed spirometry in between 40% and 80% of cases in order to achieve QOF points, although the diagnosis cannot be properly made without confirmatory spirometry. A guideline is available for primary care on the use of spirometry13 and there is also a protocol for best practice.14 Despite increasing moves towards providing spirometry testing in a primary healthcare setting, there is variation in the quality of testing in different centres. It is easy to achieve a recordable value, but ensuring the data is accurate needs trained, competent practitioners.15 If a practice is to purchase expensive spirometry equipment, it should also be investing in appropriate training for operators. Studies have indicated the advantages of using trained personnel to carry out these tests.16

In summary, certain criteria must be satisfied to reach a diagnosis of COPD. These are:3

  • if the patient has an FEV1 of less than 70% of predicted normal
  • and has an FEV1/FVC ratio of less than 70%
  • and there is a less than 15% response to a reversibility test.

It should be noted that this varies slightly from the three major guidelines from the British Thoracic Society (BTS),17 Global Initiative for Chronic Obstructive Lung Disease (GOLD),18 and NICE,6 where an FEV1 of less than 80% is suggested. The rationale quoted is that this allows practitioners to concentrate on cases where the disease is more severe.3 The GMS contract documentation does not clarify the evidence base for this and for many clinicians the concept is counterintuitive, in a similar way that it would be inappropriate to wait to treat patients who smoke and who have raised lipids and blood pressure until they have more established coronary heart disease. For many practices there are two common catches in achieving this category of the QOF. The commonest by far is the failure to code the spirometry adequately when it has been undertaken appropriately. Secondly, and more rarely, is failure to code that the diagnosis was reached without spirometry, either on the basis of a hospital discharge summary or in a clinical context, when the diagnosis is considered likely.

Recording FEV1—COPD 10

The NICE guideline suggests that patients with mild-to-moderate disease should be monitored every year, or more frequently if indicated, and those with severe disease should be reviewed every 6 months in primary care as a way of assessing progress (see Table 2).6 There are several validated high quality spirometers that can measure FEV1 to internationally accepted standards, and these are increasingly becoming cheaper. It is likely that the inaccuracies of the readings are more a result of ‘operator weakness’ than of machine inaccuracy.

It should be remembered that FEV1 does not vary markedly with an acute exacerbation of COPD and is not a useful indicator of severity in this situation, unlike a peak expiratory flow rate in asthma. Helping patients to be more independent and less symptomatic has, similarly, been shown to be a helpful and appreciated method of enabling and empowering our patients. Functional questioning allows a more easily assessable measure of improvement or deterioration. This can be done either using a questionnaire such as the Medical Research Council dyspnoea rating scale19 (see Table 3) or by asking the patient directly about their daily routine (e.g. time taken to get dressed, or walk to the allotment or shops, or ease of doing a weekly shop).

Table 2: Summary of follow-up of patients with COPD in primary care6

  Mild/Moderate Severe
Frequency At least annual At least twice per year
Clinical assessment
  • Smoking status and desire to quit
  • Adequacy of symptom control:
      • breathlessness
      • exercise tolerance
      • estimated exacerbation frequency
  • Presence of complications
  • Effects of each drug treatment
  • Inhaler technique
  • Need for referral to specialist and therapy services
  • Need for pulmonary rehabilitation
  • Smoking status and desire to quit
  • Adequacy of symptom control:
      • breathlessness
      • exercise tolerance
      • estimated exacerbation frequency
  • Presence of cor pulmonale
  • Need for long-term oxygen therapy
  • Patient’s nutritional state
  • Presence of depression
  • Effects of each drug treatment
  • Inhaler technique
  • Need for social services and occupational therapy input
  • Need for referral to specialist and therapy services
  • Need for pulmonary rehabilitation
Measurements to make
  • FEV1 and FVC
  • BMI
  • MRC dyspnoea score
  • FEV1 and FVC
  • BMI
  • MRC dyspnoea score
  • SaO2

COPD=chronic pulmonary disease; FEV1=forced expiratory volume in 1 second; FVC=forced vital capacity; BMI=body mass index; MRC=Medical Research Council; SaO2= oxygen saturation of arterial blood

National Institute for Health and Care Excellence (NICE) (2004) CG12 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.
Reproduced with permission.

Table 3: Medical Research Council dyspnoea scale19

Grade Degree of breathlessness related to activities
1 No breathlessness, except on strenuous exercise
2 Shortness of breath if hurrying or walking up a slight incline
3 Slower pace of walking on level ground than contemporaries because of breathlessness, or has to stop for breath when walking at own pace
4 Stops for breath after walking about 100 metres or after a few minutes on level ground
5 Too breathless to leave the house, or breathlessness when dressing or undressing
Amended with kind permission from the BMJ Publishing Group: Br Med J 1959; 2 (5147): 257–266.

Recording inhaler technique—COPD 11

The full guideline on the management of COPD from the National Collaborating Centre for Chronic Conditions noted some surprise that assessment of inhaler technique is so often neglected,20 despite considerable evidence21,22 and clinician experience recognising the problem. As there is good evidence that interventions including inhaled corticosteroids and long-acting bronchodilators can reduce exacerbation rates, it is important to try, as far as possible, to ensure that these expensive medications are being used effectively.

Clinicians undertaking this task need to be up to date with current inhaler devices and common problems associated with them. With a steadily changing market, it is essential that regular updating takes place, as the benefits, risks, complexities, and nuances of each inhaler system can make considerable differences if chosen appropriately for patients. Similarly, the clinician needs to be aware of the latest information when teaching patients/families how to use inhalers. As use of inhaler devices relies on skill rather than just acquisition of knowledge, it is unlikely that reading an information leaflet alone would leave patients competent to use an inhaler.

Many practices have a list of ‘approved clinicians’ who will deal with inhaler device assessment and problems. The common devices (e.g. pressured metered dose inhalers, common dry powder devices) should be assessable by the majority of clinicians who are managing care for people with COPD.

Influenza immunisation—COPD 8

In order to achieve QOF points in this category, a practice will be required to provide immunisation to a minimum of 40% of people with COPD. Maximum points are available when an immunisation level of 85% is achieved. This is considered beneficial by the Department of Health and the Joint Committee on Vaccination and Immunisation, and is supported by the Cochrane Review on influenza vaccine.23

Additional care for patients with COPD

Research has shown that general practice in the UK is centred on providing good clinical care. The key issues mentioned above will help a practice to achieve the maximum QOF points, but there are several other aspects of care of patients with COPD that should be considered. Areas that practices may wish to consider in the holistic overview of COPD care include looking at:

  • to what extent patients with COPD have self-management plans—this will enable early interventions in people who have exacerbations
  • what percentage of patients have a course of treatment (antibiotics/steroids or a combination of both if needed) available at home for self-initiation
  • how many patients have been assessed for consideration of long-term oxygen therapy—the GPs should screen with pulse oximetry, while more detailed examination is required to be undertaken by the chest physician or specialist team
  • the percentage of patients who have taken part in a pulmonary rehabilitation programme in the preceding 4 years
  • what percentage of patients have been screened and treated for osteoporosis—this has particular relevance for people who have smoked for many years, are less mobile, or have been on corticosteroid therapy for long periods of time, who are all considerably more likely to develop the disease
  • the percentage of patients who have been identified and treated for vascular disease, and what programme the practice has in place to screen people for this—along with lung cancer, cardiovascular diseases are the main causes of death in mild or moderate COPD24
  • what percentage of patients who have COPD with more than two exacerbations in the past 12 months and an FEV1 of less than 50% are on an inhaled corticosteroid
  • how well care is managed within the practice to give individual patients the continuity and personalised care they desire, and that fits in with the best clinical practice and the most cost-effective management resource
  • whether COPD exacerbations are being recorded correctly by Read code on the practice computer system—this will provide practices with an indicator of whether they are reducing the total number of exacerbations in subsequent years.

Conclusion

The QOF points cover some of the areas that are pertinent to high quality care in patients with COPD, but this is really only part of the picture. The challenges are to maintain patient satisfaction with GP care, which is generally high across the UK, and to ensure that patients receive the appropriate quality health interventions that their COPD requires, while producing the robust data to show we practice well and in a timely and efficient manner.

It is good to know that GPs are currently achieving good results with the QOF, but professionally challenging to know that there is still a long way to go to provide optimal respiratory care for our patients with COPD.

  • COPD affects c.1.4% of the population but is a major cause of hospital admissions and health service expenditure
  • Effective interventions as recommended by NICE go beyond the simplicity of the QOF targets, e.g. pulmonary rehabilitation
  • COPD represents a great opportunity for PBC in terms of investing in primary care to recoup the cost of unscheduled admissions and improve quality of life for patients
  • Inhaler costs are often expensive so regular checks on inhaler techniques and compliance are vital (a good role for community pharmacists)
  • Tariff costs:1
      • thoracic medicine outpatient = £201 (new), £101 (follow up)
      • COPD non-elective admission (D40) = £1752
  1. Centre for Health Economics. Doctor behaviour under a pay for performance contract: evidence from the quality and outcomes framework. CHE Research Paper 28. York: Centre for Health Economics, 2007.
  2. Roland M. The quality and outcomes framework: too early for a final verdict. Editorial. Br J Gen Pract 2007; 57 (540): 525–527.
  3. British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.
  4. www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/DH_4138532
  5. Healthcare Commission. Clearing the air—a national study of chronic obstructive pulmonary disease. London: Commission for Healthcare Audit and Inspection, 2006.
  6. National Institute for Clinical Excellence. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in primary and secondary care. Clinical Guideline 12. London: NICE, 2004.
  7. www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4131823
  8. The Information Centre. National Quality and Outcomes Framework Statistics for England 2006/07 Bulletin. www.ic.nhs.uk
  9. Frank T, Hazell M, Linehan M et al. The estimated prevalence of chronic obstructive pulmonary disease in a general practice population. Prim Care Respir J 2007; 16 (3): 169–173.
  10. Wilson J, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization, 1968.
  11. Tinkelman D, Price D, Nordyke R, Halbert R. COPD screening efforts in primary care: what is the yield? Prim Care Respir J 2007; 16 (1): 41–48.
  12. Freeman D, Nordyke R, Isonaka S et al. Questions for COPD diagnostic screening in a primary care setting. Respir Med 2005; 99 (10): 1311–1318.
  13. General Practice Airways Group. Spirometry. IPCRG Opinion No 1, GPIAG Opinion No 7. GPIAG, 2005.
  14. General Practice Airways Group. GPIAG protocols: spirometry in COPD. Protocol number 1. GPIAG, 2007.
  15. Cooper B. Performing good quality spirometry. National Library for Health. www.library.nhs.uk/respiratory
  16. Enright P, Beck K, Sherrill D. Repeatability of spirometry in 18,000 adult patients. Am J Respir Crit Care Med 2004; 169 (2): 235–238.
  17. The 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.
  18. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. www.goldcopd.com, 2006.
  19. Fletcher C, Elmes P, Fairbairn A, Wood C. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br Med J 1959; 2 (5147): 257–266.
  20. National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004; 59 (Suppl 1): 1–232.
  21. Brocklebank D, Ram F, Wright J et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess 2001; 5 (26): 1–149.
  22. Connolly M. Inhaler technique of elderly patients: comparison of metered-dose inhalers and large volume spacer devices. Age and Ageing 1995; 24 (3): 190–192.
  23. Poole P, Chacko E, Wood-Baker R, Cates C. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006; (1): CD002733.
  24. Sin D, Anthonisen N, Soriano J, Agusti A. Mortality in COPD: Role of comorbidities. Eur Respir J 2006; 28 (6): 1245–1257.G