Catherine Tutt and Dr Nigel Masters, winners in the COPD category of the Guidelines in Practice Awards 2006, outline their initiatives and improvements in patient care
At Highfield Surgery, the team responsible for care and management of patients with COPD comprises a GP who is a trainer in primary care, and a respiratory nurse who also trains health professionals around the country on asthma and COPD. This article provides details of those areas that we believe have resulted in continued improvements in COPD care for patients at our surgery, and which led to us winning the COPD category of the Guidelines in Practice Awards 2006.
In 2005, we became aware that the practice had no active plan in place for the management of COPD patients, despite the presence of an enthusiastic respiratory nurse and the incentive of the QOF payment.
What is COPD?
The NICE guideline states that the characteristic feature of COPD is airflow obstruction, which is usually progressive.1 The obstruction results from damage to both the airway and parenchymal tissue caused by chronic inflammation. The condition, which is not completely reversible, is predominantly caused by smoking, but it can also result from the inhalation of any noxious fumes such as exposure to dust and fumes in the work environment.
Aims of the screening process
The number of patients on our register who had ever smoked indicated that there were undiagnosed COPD patients, an issue highlighted by the NICE guideline on the management of COPD1 — nearly 900,000 people in the UK are diagnosed with COPD, and 2 million are thought to be undiagnosed.2 We, therefore, wanted to introduce a proactive approach to try to find those who had not been diagnosed. In particular, we wanted to identify younger smokers with early asymptomatic COPD to warn them of their future risk — case finding and computer searches were used to do this.
Another aim was for the COPD screening to benefit the practice rather than simply focus on the specific disease. Recording job details for all patients and pack years for all those who had ever smoked helped to create high quality medical records, which benefits all patients, not only those with COPD.
Screening for early COPD
In 2005, we undertook a screening programme at Highfield Surgery, and letters offering spirometry screening were sent out to smokers over 40 years of age who had been diagnosed with a chest infection requiring antibiotics in the previous year. The uptake for screening was very poor, with a less than 5% response rate—a similar programme in Sweden only achieved a slightly better uptake by at-risk smokers, despite an intensive campaign.3
Box 1: How to measure smoking units and pack years
In January 2006, we changed our screening approach to a systematic case-finding method, within normal surgeries, using a quick simple screen of patients aged over 40 years to find those with either a pack year history of more than 15 years, or a smoking load of more than 300 units (see Box 1, above). This information is clearly recorded on clinical summaries and attached, as a free-text statement, to the read codes for ‘amount smoked’ for active smokers and ‘ceased smoking’ for ex-smokers. For example, free text stating, ‘15 cigarettes a day for 30 years ÷ 20 = 23 pack years’, may be attached. Respiratory symptoms are not explored at these consultations but patients who have recurrent respiratory symptoms are referred for further evaluation by the respiratory nurse.
Patients identified as being at risk of COPD are offered a free lung check (spirometry) with the specialist practice nurse. Those patients who have ever smoked like the concept of the free lung check, which also provides them with the opportunity to discuss smoking cessation if they so wish. After the spirometry screen, and if the history confirms the diagnosis, these patients are classified on their clinical summaries as normal or as having:
- mild COPD (50–80% of predicted forced expiratory volume [FEV1])
- moderate COPD (30–49% of predicted FEV1)
- severe COPD (<30% of predicted FEV1.
This coding helps the healthcare professionals to check whether the patient has been screened, and motivates the team to continue the screening programme. Repeated in-house audits show rising levels of pack years recorded, spirometry screens, and COPD patients detected.
Spirometry screening results
Table 1 (below) shows the list size at Highfield Surgery, and provides recorded smoking history and spirometry screening results.
Those patients aged over 40 years who had ever smoked totalled around 1280 (out of a list size of 5800), and needed either a pack year or smoking unit load number calculated in routine surgery.
The pick up rate for COPD is about 15% at our practice.
By having running totals (see Table 1, below) we could see if the strategy of screening for smokers was working and this constantly motivated the team. This task has been made easier with the introduction of the pack year calculator in January 2007 at our surgery — we now only record pack year on the clinical summaries and no longer add the smoking load.
Table 1: List size and spirometry screening results
|Total list size||5800|
|Active smokers 15+ years||1018|
|Active smokers 40+ years||589|
|Ever smokers 40+ years||1280|
|Ever smokers 40+ years with pack years recorded||767|
|COPD patients on high-dose inhaled steroids||9|
|Figures for mild, moderate, and severe COPD are based on definitions in the NICE guideline:1 mild=50% of predicted forced expiratory volume (FEV1); moderate=30–49% of predicted FEV1; severe <30% of predicted FEV1|
Since we adopted systematic case finding in everyday surgeries there has been a 55% increase in the number of patients on the COPD register.
Recording pack year on clinical summaries
A smoking morbidity coding, based on the recorded pack years/smoking load, remains on the medical history and can be helpful both in primary care for risk assessment and in secondary care when referrals are arranged, as it will be clearly visible on the referral letter. Pack year totals are increasingly being recognised as an important determinant of disease; for example, smokers with a record of 40 pack years treble their risk of developing macular degeneration.4 The age at which a patient starts smoking can be another important factor in the development of tissue damage, and this can be clearly identified from this type of record keeping. Bladder cancer, for example, is considered inversely related to the age at which a person starts smoking.5 Recent cardiovascular risk calculators use the concept of lifetime smoking risk, and smokers who stopped within the previous 5 years are regarded as current smokers.6
We have found that joint working between a practice nurse and doctor is important for maximally effective diagnosis and management of chest disease, especially as the real diagnosis can be difficult to unravel. Alternative diagnoses to COPD could include a gas transfer problem, interstitial lung disease, asthma, bronchiectasis, bronchopulmonary dysplasia, and obliterative bronchiolitis.
We have identified 16 patients with bronchiectasis at our practice out of a list size of 5800. This is an unusually high figure for a rare condition and it reflects historical data capture and diagnostic testing of patients. There is, therefore, on average, one patient with bronchiectasis at Highfield Surgery for every four patients with COPD. Treatment for this condition is different to typical COPD management, so identification is important.
Noxious fumes and dust can be an important cause of respiratory chest illness and all details of such work are coded onto the clinical summaries at our surgery. This is done simply by free text linked to the job code details. Over 71% of all COPD patients have job details listed on their summaries.
Highfield Surgery has three pulse oximeters, which monitor a patient’s haemoglobin oxygen saturation by means of a probe attached to the finger. All COPD patients have a baseline value recorded in their medical notes when they are well. Exacerbations of COPD often cause a drop in pulse oximetry from the baseline, and treatment, which may include oxygen therapy, can then be rigorous. At our surgery, 59% of COPD patients had baseline pulse oximetry readings, and four of them had an SpO2 measurement below 92% at baseline reading. These four patients were offered referral for hospital assessment for long-term oxygen therapy.
Treatment of COPD
Box 2 gives details of the pharmacological treatment options for COPD according to the NICE guideline.1 Treatment of COPD at our surgery includes offering a pneumococcal vaccination and influenza vaccination to all patients with the condition, in line with guideline recommendations.1 Our vaccination coverage is 80% of all COPD patients.
Box 2: Pharmacological treatment options for COPD
As well as advising patients to stop smoking, the following pharmacological interventions can be made:1
|FEV1=forced expiratory volume|
Recording clinical indications on prescriptions
For the past 3 years we have routinely added clinical indications to repeat prescriptions; for example, ‘Take salmeterol twice daily to relieve COPD respiratory symptoms (green inhaler)’. All inhaler scripts have such information and colour coding to help health staff, carers, and patients, and to explain and encourage appropriate use of their inhalers. Clinical indications are now added to 90% of all repeat prescriptions.
Survey of high-dose inhaled corticosteroid use
In 2005, we surveyed the appropriate use of high-dose inhaled corticosteroids according to the NICE guideline.1 There is little evidence for the use of inhaled corticosteroids in mild COPD, which comprises the major group of patients at our surgery with the condition. The survey showed that only those patients with an asthma element, or with significant COPD and two or more exacerbations a year, were on appropriate inhaled corticosteroids.
Such surveys can fine-tune care and if the results are poor they can be turned into practice audit cycles with targets. However, it is advisable to obtain additional help to implement such audits as they can represent significant extra work.
Full clinical summaries
Patients with COPD often have multiple co-morbidities, with heart disease quite prevalent. Emerging research is suggesting strong associations between heart disease and COPD, with one study demonstrating that COPD was a predictor of hospitalisation and mortality from cardiovascular disease over an average follow-up period of 3 years.7 It is essential to have a holistic approach to care and management of patients with this condition, and full clinical summaries are vital to provide this type of care. We have been including these in patient notes for over 10 years, and a survey in 2005 showed that 87% were up to date.
These summaries allow effective management of patients; for example, an earlier normal spirometry reading noted on the summary for a patient with a new presentation of breathlessness virtually excludes a diagnosis of COPD—this then indicates that other reasons for breathlessness, including cardiovascular causes, would need to be excluded. In addition, depression is clearly marked on our history summaries, as many patients with disabling COPD are significantly depressed, as recognised by the NICE guideline1 (although not yet by the GMS contract quality and outcomes framework8). This ensures that these patients with depression are identified and treated appropriately.
Review of care
Highfield Surgery has a policy of birthday reviews, which allows simple checking of multiple review dates based on a patient’s birth month. This links well with medicine use reviews carried out by the local pharmacist, who checks effective medicine use prior to the practice birth date check, and offers personalised delivery of routine care, in contrast to hospital outpatient care. Those patients with COPD and diabetes/heart disease are, therefore, seen on one single occasion each year, which simplifies administration for both the practice and the staff.
It can be difficult to demonstrate improvements in care of patients with COPD, as the practice has been actively managing patients for the past 10 years. Anecdotally, we lack COPD ‘Frequent Flyers’, a term applied to patients who have frequent hospital admissions. This is said to be a common scenario in severe COPD patients, yet a recent analysis of our practice frequent flyers showed that it applied more to other categories of patients. It has been a long-standing policy for the practice respiratory nurse to follow-up any cases of admission with chest infection to prevent it happening again, and often patient education is a vital part of this process.
Care of patients with COPD has moved on from reactive care to proactive management. We think we have powerful tools at last in primary care to tackle the problem on many fronts, in the form of early screening, smoking cessation advice, and careful drug use. Our innovation of recording pack years on patient summaries is key to improving patient care, both in the early diagnosis of COPD and in all other smoking-related diseases.
To this end, we have used the proceeds from our win in the COPD category of the Guidelines in Practice Awards 2006 to produce the world’s first pack-year calculator, which is available free to all both as a desktop download for primary care or for loading on a WAP device for hospital physicians. Fifteen pack years and over 40 years of age are key screening criteria for a spirometry screen for COPD. Visit www.smokingpackyears.com to see the calculator.
- National Institute for Clinical Excellence. Chronic obstructive pulmonary disease—management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: 2004, NICE.
- Healthcare Commission. Clearing the air—a national study of chronic obstructive pulmonary disease. London: Commission for Healthcare Audit and Inspection, 2006.
- Stratelis G, Jakobsson D, Molstad S, Zetherstrom O. Early detection of COPD in primary care: screening by invitation of smokers aged 40–55 years. Br J Gen Pract 2004; 54 (500): 201–206.
- Khan J, Thuriby D, Shahid H et al. Smoking and age related macular degeneration: the number of pack years of cigarette smoking is a major determinant of risk for both geographic atrophy and choroidal neovascularisation. Br J Ophthalmol 2006; 90 (1): 75–80.
- Bjerregaard B, Raaschou-Nielsen O, Sørensen M et al. Tobacco smoke and bladder cancer—in the European Prospective Investigation into Cancer and Nutrition. Int J Cancer 2006; 119 (10): 2412–2416.
- Williams B, Poulter N, Brown M et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18 (3): 139–185.
- Sidney S, Sorel M, Quesenberry C. COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program. Chest 2005; 128 (4):2068–2075.
- British Medical Association. Revisions to the GMS contract 2006/2007: Delivering Investment in General Practice. London: BMA, 2006. G