This primary care report combines publicly available data, sourced from the Quality and Outcomes Framework (QOF) 2014–15, Public Health England’s (PHE’s) tobacco control profiles, and the INteractive Health Atlas of Lung conditions in England (INHALE), with results from the audit report for Wales 2014–15.
It aims to provide English general practice with recommendations regarding the care and diagnosis of people with chronic obstructive pulmonary disease (COPD) and, fundamentally, to support primary care clinicians who are currently working under considerable pressure to deliver the standard of care.
A diagnosis of COPD should be made accurately and early. If the diagnosis is incorrect, any subsequent treatment will be of no value.
- People who have breathlessness and/or cough that does not go away or frequent ‘chest infections’ should have access to health professionals who have been trained to know what to do and have the resources to reach a diagnosis in a timely way. Spirometry is fundamental to a diagnosis of COPD and patients should be assured that their test has been performed and interpreted in the right way.
- Trained and competent health workers should offer people with a risk factor and symptoms suggestive of COPD a comprehensive and structured assessment.
- Clinical symptoms, risk factors and evidence of post-bronchodilator airways obstruction are all essential factors when making a diagnosis.
- People who are at risk of COPD are at a higher risk of lung cancer, and chest X-ray is an essential part of the breathlessness assessment and diagnosis of COPD.
People with COPD should be offered interventions according to value-based medicine principles.
- Tobacco dependence treatment is safe, well tolerated and effective at prolonging life: it reduces flare ups and has a wider impact on health. However, it is underused. Health professionals who treat people with COPD should be trained to have the right conversation; to know how to assess dependency; and to feel confident and have the resource to treat it.
- Flu vaccination is effective and safe but underused in people with COPD. System leaders should identify where variation exists and ensure that people with COPD have the best information to make the right decision for them.
- Anyone with a Medical Research Council (MRC) breathlessness score of 3 or more should be offered and encouraged to do pulmonary rehabilitation by their primary care health professional and have timely and easy access to an appropriate provider of this evidence-based therapy.
- Health professionals providing inhaler therapy for COPD should have up-to-date knowledge about what devices are available and ensure that people are able to use their devices (NICE CG101, 184.108.40.206 to 220.127.116.11); are offered optimal bronchodilator medication (NICE CG101, 1.1.6); and are issued with inhaled corticosteroids (ICS) only when it is likely to be beneficial (NICE CG101, 18.104.22.168 and 22.214.171.124). They should ensure that safety of long-term, high-dose inhaled steroids is discussed (NICE CG101 1.1.8).
People with severe disease (categorised according to the extent of airflow limitation) should be identified for optimal therapy. COPD encompasses a broad spectrum of conditions and health statuses and a personalised approach is essential.
- People having frequent exacerbations of COPD need to be identified, as they are at higher risk of an accelerated decline in their condition and may require specialist review both to manage symptoms and to slow decline. The recording of ‘number of exacerbations in the last year’ allows this group to be better identified by practices and prioritised.
- Long-term oxygen therapy is a life prolonging intervention for people with COPD who have hypoxia. When primary care health professionals detect low oxygen saturation in the primary care setting, referral to a suitable assessment and review service should be offered. Primary care should record the use of oxygen on patient notes as they would any other long-term medication, to ensure timely review for assessment of safety and effectiveness.
There should be better coding and recording of COPD consultations, prescribing and referrals.
- As patient access to personal health records improves and patients’ involvement in their own care becomes an expected norm, there will be opportunities to support people with COPD to ‘know their numbers’ or, in other words, to understand why their spirometry test is consistent with COPD. They should be able to record quality of life assessments, their ability and confidence to use inhalers and their understanding of how to help themselves through access to and involvement with self-care documentation and action plans.
- Much of the variation seen in the data suggests variance in electronic coding. In order to link datasets across the system in the future, we ask the wider system (whether through development of the Systematised Nomenclature of Medicine coding system or other activity) to make standard recording templates available to ensure that the right things are recorded and that health professionals can spend more time with patients by avoiding the time spent on duplicate entries or manual entry. Health boards and clusters of GP surgeries should consider the use of a standardised set of codes and templates.
Who is it for?
This report is relevant to anyone with an interest in COPD. Along with the national secondary care and pulmonary rehabilitation audit reports, this report helps to complete a picture of the care offered to people with COPD living in England. It is equally of interest to other UK nations; and it will enable lay people, as well as experts, to understand where change needs to occur.
What will you learn?
The information, key findings and recommendations outlined in this report are designed to provide readers with a basis for identifying areas in need of change and to facilitate development of improvement programmes that are relevant not only to primary care services, but also to commissioners and policymakers.