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Patient screening - COPD case-finding saves NHS funding

Dr Anita Sharma and Nawaz Ali describe how their practice identifies patients with early symptoms of COPD.

Dr Sharma: early screening for COPD can save the NHS money
Dr Sharma: early screening for COPD can save the NHS money

COPD is an important cause of morbidity and mortality, yet it is significantly under-diagnosed.

The National Clinical Strategy, published in June 2010, emphasises early COPD identification, accurate diagnosis and severity assessment.

At my practice, we had decided to target case identification in June 2009, in part because of the above average number of smokers in the local population.

As well as early diagnosis and management to prevent disease progression, our programme included smoking cessation and patient education.

The positive screening questionnaires and targeted case identification spirometry we used picked up early cases and saved money for the NHS.

We managed this without receiving additional funding. Our in-house smoking cessation counsellor provided early intervention with the aims of reducing the rate of lung function decline and exacerbation.

Hospital admission rate
Our efforts are reflected in PCT figures for 2009/10 that show the practice's COPD hospital admission rate was the lowest in one locality.

The practice is in Chadderton, a working class borough of Oldham in Greater Manchester with a population of 33,000. We have around 3,220 patients who are mostly from a lower socio-economic background. The percentage of smokers is above average, as is the admission rate for COPD exacerbation.

As there is insufficient evidence to do mass spirometry screening for asymptomatic patients, we decided to screen patients between 35 and 70 years of age who were smokers or ex-smokers or who had suffered at least two chest infections in the past 12 months.

We identified target patients by computer search and also put an alert message on the records of the target group to enable opportunistic screening.

The Monday afternoon and Tuesday morning nurse surgeries became dedicated screening clinics and patients were invited for 30-minute appointments.

Informing our staff
Before the clinics began, we held a practice meeting to inform the receptionists about the aims of and process involved in the screening.

Our healthcare assistant (HCA) designed a special template to aid correct data entry and make clinical auditing easy.

Our practice nurse received spirometry training from an approved trainer as performing the test and interpreting it correctly is crucial.

Lung function was assessed with a spirometer that displayed and printed out the flow volume curve. The spirometer was calibrated before, and once during the test, and the patient had to produce three acceptable curves.

To assess lung function we asked patients to complete this questionnaire.

A score of 17 or above is suggestive of COPD. All patients with an obstructive pattern were invited for a reversibility test to check poor bronchodilator reversibility - defined as FEV1<15 per cent reversibility (or increase <200ml) 20 minutes after an inhaled short-acting beta-2 agonist compared with baseline value.

Ours is a training and undergraduate teaching practice.

A third year medical student from University of Manchester, who was attached to the practice, analysed the screening results.

By the end of June 2010, 135 out of 137 patients invited for screening had been screened. Of these, 12 were diagnosed with COPD, ranging from mild to moderate severity. A further nine patients were diagnosed with restrictive lung disease. All patients accepted a smoking cessation referral.

The programme cost £3,801 including buying a spirometer, training the practice nurse and extra nursing hours.

So what is the potential for NHS savings from early COPD diagnosis and intervention?

To take our situation as an example, there is no screening service at the local hospital. An outpatient referral with symptoms suggesting COPD would cost £254.50. Adding a follow-up appointment for a confirmed case would be another £144.08. An acute episode needing admission would cost £2,345.

Referring 135 at-risk patients to the hospital clinic would have cost £34,357.50 (ignoring follow-up appointment).

If, of the 12 diagnosed with COPD, 10 needed an admission for an acute episode that would add another £23,450.

This clearly shows that early screening is cost-effective.

CPD Impact: Earn More Credits

These further action points may allow you to claim more credits.

  • Consider your practice's approach to diagnosing and managing COPD. What steps could be easily taken to improve the service? Draw up a plan and timetable for implementation.
  • Identify patients who are smokers and ex-smokers. Could the GPs, nurses and HCAs opportunistically screen for early COPD symptoms using the questionnaire here or a similar one?
  • Adopt a targeted approach to screening by setting up clinic sessions for invited patients.
  • Check with nurses and HCAs if they need spirometry training and organise this.

Record all your learning with your free online CPD Organiser 

  • Dr Sharma is a GP in Oldham and Nawaz Ali is a medical student Manchester University

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