|COPD: Clinical Indicators|
|Register of patients with COPD||Register||3|
|All patients with COPD with diagnosis confirmed by spirometry including reversibility testing||80||10|
|Record of FEV1 in past 15 months||70||7|
|Patients receiving inhaled treatment with record that inhaler technique has been checked in past 15 months||90||7|
|Influenza immunisation in preceding September to March||85||6|
- National prevalence rates for 2006/7 were 1.4 per cent in England, and 1.5 per cent in Northern Ireland. Prevalence rates for 2005/6 for Scotland were 1.8 per cent and for Wales 1.9 per cent.
- Average exception reporting rates for COPD in England in 2005/6 were 7.03 per cent.
- There were several changes to this indicator set in 2006/7. First, it was acknowledged that patients would be on both asthma and COPD registers. Second, the timescale for recording FEV1 and checking inhaler technique is now annual. Third, the two former indicators on spirometry were combined.
- The focus is on diagnosis and management of patients with symptomatic COPD.
Step 1: Setting up the register
- The main work is producing an accurate register. The points available for this have been reduced, on the basis that much of the work will already have been done.
- There are three points in this section for producing a register of patients with COPD and a further ten points for making sure all patients on the register have the diagnosis confirmed by spirometry.
- The original indicator set split the incentives for spirometry to confirm diagnosis between newly diagnosed and all existing diagnoses, but this no longer exists, creating a larger and more difficult group of patients to cover.
- All practices need access to spirometry, including reversibility testing. Consider buying a spirometer if you do not have one. Training in technique, maintaining equipment and interpreting results will be essential. Alternatively, lung function laboratories in some hospitals offer open access spirometry, or your PCO may fund it.
- To earn maximum points, all patients will need to be reviewed, with spirometry and reversibility testing to check the diagnosis before they are placed on the register.
- The new contract criteria for diagnosis:
- The patient has an FEV1 of less than 70 per cent of predicted normal.
- The patient has an FEV1/FVC ratio of less than 70 per cent.
- There is a less than 15 per cent response to a reversibility test.
- The FEV1 criterion is set at 70 per cent, while the NICE guideline is 80 per cent. The rationale is that a significant number of patients with FEV1 below 80 per cent predicted may have minimal symptoms. The 70 per cent is designed to enable practices to concentrate on symptomatic COPD.
- An important change to guidance for 2006/7 was the acceptance that patients with asthma and COPD should be on both registers.
- Building your asthma register may reveal some patients for the COPD register. If you have not done so, run a search on respiratory drugs prescribed in the past 12 months. This will help you find patients for asthma and COPD registers. Other searches might include adults on anticholinergic inhalers, patients prescribed oxygen, respiratory patients on regular or frequent oral steroids, and past or present asthmatic smokers over 50 years.
- The framework guidance says that diagnosis of COPD should be considered in any patient with persistent cough, sputum production or dyspnoea, and/or a history of exposure to risk factors for the disease. Diagnosis must be confirmed by spirometry. Spirometry done from three months before to 12 months after a diagnosis of COPD would be considered to meet the requirements of this indicator.
Step 2: From now onwards
- The indicators require annual spirometry and checks on inhaler technique (with three months for slippage). You may need to review your call and recall system. Decide whether a GP or a practice nurse with respiratory training will do the work.
- Consider organising an educational session on the NICE guideline on COPD and spirometry. This could be used to decide what the practice will cover in annual reviews.
- Decide who will carry out most of the spirometry. You might want to delegate this to a practice nurse or employ a respiratory technician to undertake reversibility tests.
- The framework guidance suggests that referral should be considered for patients with FEV1 of less than 50 per cent predicted or in patients with disabling symptoms.
- Patients not on therapy involving the use of inhalers should be exception reported.
- Limit repeat prescriptions of COPD drugs to 12 months to encourage review attendance.
- Set up a system to add patients diagnosed in secondary care with COPD to the register, along with the results of their spirometry.
Step 3: September to November
- The last indicator requires 85 per cent of patients on the register to have had an influenza vaccination between 1 September 2007 and 31 March 2008. This will necessitate a proactive campaign, with use of exception coding where appropriate.
Step 4: December onwards
- Search for patients on the register who have not attended for annual review and invite them to do so. Those who attend could also receive influenza vaccination.
Useful Resources for COPD
1. National Institute for Health and Clinical Excellence (NICE)
2. Department of Health and the Joint Committee on Vaccination and Immunisation - recommendation on influenza immunisation