Practices can combine spirometry, review of inhaler technique an influenza immunisation to tackle the updated COPD indicators, says Dr Peter Saul


   

The introduction of six new disease areas into QOF21 poses additional challenges for practices during the coming year. To be in a position to deliver the new targets, and yet maintain or improve on last year's score, a quick review of last year's performance is worthwhile.

Acceptable performance can be verified, areas of concern identified and remedial measures can be taken before focusing on new areas.

This is particularly important for chronic obstructive pulmonary disease (COPD) because, along with epilepsy, it has been the most challenging area to score maximum points,2 with spirometry causing the most difficulty.

The original inclusion of COPD in the QOF was an important step towards bringing this Cinderella clinical area into the mainstream and ensuring that practices focused on it. A recent report by the Healthcare Commission emphasizes this importance, highlighting concerns, which include public perception, diagnosis and management.3 This report heralds a National Service Framework (NSF) for COPD due for release in 2008.

Not surprisingly, COPD still remains an important indicator and accounts for 33 points (Table 1). Previously there were 45 points allocated to this domain but there has been some redistribution of points in QOF2 – the effect being to further incentivise achievement for some indicators and transfer other points to the new smoking domain.

Table 1 : Clinical indicators for COPD
Disease indicator
Clinical indicator
Points Payment stages
      Min (%) Max (%)
COPD 1
The practice can produce a register of patients with COPD
3    
COPD 9
% patients of all patients with COPD in whom diagnosis has been confirmed by spirometry, including reversibility testing
10 40 80
COPD 10
% patients with COPD with a record of FEV1 in the previous 15 months
7 40 70
COPD 11
% 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
COPD 8
% patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March
6 40 85

COPD 1 (Patient register)

Disease registers form the bedrock of patient tracking with any chronic condition. The practice register is particularly important because it will show the disease prevalence and form the basis of payment calculations.

My experience as a QOF visitor for our PCO has shown wide variation in prevalence between practices of comparable social and ethnic composition. This may reflect inaccurate diagnosis, with many patients included who do not actually have COPD and other COPD patients who have not been diagnosed. This experience is supported by audit data from the General Practice Airways Group (GPIAG)4 and the Healthcare Commission.3

Even when considering a wider area, a reported COPD prevalence of 1.8% in Scotland (the same prevalence as the previous year)2 and of 1.4% in England in 20055 is difficult to square with other evidence suggesting prevalence rates of up to 5%.6

Diagnosis relies on having an index of suspicion, history, clinical findings and spirometry. Practices cannot go wrong if they use the diagnostic criteria and algorithm listed in the NICE COPD guidance.7 Active case finding to improve the disease register should be considered. Some authors have suggested inviting all smokers over the age of 45 for spirometry every 3 years,8 and the GPIAG and the Healthcare Commission back the use of questionnaires to identify patients.

These strategies are clearly resource intensive and practices will need to consider carefully how to deploy staff.

COPD 9 (Initial diagnosis)

This is one of the indicators relating to spirometry (including reversibility testing) and directly replaces COPD 2 and 3. Last year it was the hardest of the COPD indicators to achieve. Evidence from Scotland this year indicates this to be the case again.2 Although a good diagnostic indicator, particularly when clinical history is taken into account, COPD 9 relies on identifying and checking the 'at risk' population and those with suggestive symptoms.

To gain points the process needs to be completed, but to provide meaningful information, which will guide patient management, the process must be done correctly. Like colleagues in many other areas of the country, my practice has been fortunate enough to have training for its clinical staff from the respiratory department of the local hospital.

Practices need ongoing support, so periodic visits from specialist respiratory nurses would be welcome. In my locality, some practices have started grouping together to share expertise and experience, and COPD has been one of our initial areas of focus.

With the QOF likely to become increasingly demanding and the forthcoming NSF in COPD, co-operative working must become more important. Spirometry can be a difficult procedure and this is one particular area where practices can help each other. The GPIAG publishes a useful document on this topic detailing procedure and basic interpretation.9

The issue of reversibility testing has been controversial with the NICE guidance and QOF1 having different perspectives. However, QOF2 has prevailed, and it is supported by recent evidence, which suggests that using spirometry alone will result in 27% fewer diagnoses of COPD.10 This indicator is one of the hardest to achieve in the QOF but now looks firmly embedded.

COPD 10 (FEV1) and COPD 11 (Inhaler technique)

These indicators directly relate to the previous indicators COPD 6 and COPD 7. There is a marginal rise in the payment thresholds and the time period between reviews has been shortened from a target two years (or 27 months) to 15 months. This is bound to increase workload.

An average practice with 7000 patients can expect to have 200 patients with COPD. If an annual review with the nurse takes 20 minutes and only 70% attend, then an additional 24 hours of consulting time will be needed each year.Taken together with the new QOF indicators, practices will need to re-examine the need for additional nurse hours or alter their skill and task-mix to allow more time for QOF activity.

COPD 8 (Influenza immunisation)

This indicator is essentially unchanged. Although not part of the indicator, practices should also ensure that patients are offered pneumococcal vaccination in line with current good practice.11

This annual vaccination visit is a convenient time to check spirometry and inhaler technique, thereby ensuring better compliance from the patient. Our practice schedules longer appointments for COPD patients at influenza vaccination time to allow the practice nurse to complete a more thorough review.

The COPD review

AAlthough most commonly performed by nurses, all practice staff need to be involved in the planning and execution of COPD reviews. With 2 years of the QOF under the belt and minor modifications made to the COPD indicators, it may be time to review procedures. Some issues for consideration are listed in Table 2.

The GPIAG has a tool available to assist review and audit. It prompts GPs and practice nurses to record detailed information, ensuring a well-structured review.

The GPIAG Research Unit at the University of Aberdeen is able to analyse the information gathered via the template and compare results from practices to determine the real burden of COPD in primary care.

This tool is available free by emailing templates@gpiag.org, quoting 'COPD' in the message header and your contact information in the message body. It is compatible with most common general practice computer systems. It covers all the areas related to QOF2, but also prompts for a more detailed assessment looking at COPD management and issues to do with patient quality of life.

Table 2: Planning the annual COPD review
  • Are current mechanisms for inviting patients proving successful? If not, perhaps consider telephone
  • Are nurse hours sufficient? Can healthcare assistants be used for some tasks?
  • Can the review combine other disease areas where these are present in the patient?
  • Is there a need for further training, e.g. in spirometry?

Challenges

The QOF is not just about maximising points and income, but should also be a vehicle for improvement in clinical care. As in other domains, the standards required for COPD management have become more stringent. These challenges can be advantageous to both patient and practice if they result in better clinical care. For the patient this means better quality of life and for the practice it means less unscheduled care – ticking the boxes is, therefore, not enough.

Parameters from the QOF should be used to guide treatment as outlined in the NICE guidance. To achieve this there needs to be effective case finding, accurate assessment, and oversight by a competent clinician using therapies recommended by the latest guidelines.

Given the increased challenges in QOF2 one is hesitant to identify other aspects of COPD which need scrutiny; however, it is puzzling, given the high incidence of depression in COPD patients, that unlike the cardiovascular domain, enquiry into psychological state has not been included.

The QOF places challenging demands on practices with respect to COPD, but PCOs also need to play their part by commissioning secondary care services and, in particular, educational support for practices as well as pulmonary rehabilitation services, as emphasised by NICE.

The forthcoming NSF on COPD looks set to be published just in time for the next QOF revision and will be sure to keep us on our toes.

 

Guidelines in Practice, August 2006, Volume 9(8)
© 2006 MGP Ltd
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  1. British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.
  2. Scottish Health Statistics. www.isdscotland.org/isd/
  3. Healthcare Commission. Clearing the air: A national study of chronic obstructive pulmonary disease. London: Commission for Healthcare Audit and Inspection, 2006.
  4. COPD register errors. Pulse 2006; 6 July: p. 6. London: CMP Information, 2006
  5. National Quality and Outcomes Framework Statistics for England 2004/05. www.ic.nhs.uk/services/qof/data
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