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Gold, incentives and meh

Maximising your quality markers with COPD patients

Even well-organised practices will find it difficult to earn the maximum 45 points available for COPD, says Dr Lorna Gold

Chronic obstructive pulmonary disease (COPD), like stroke, has until recently been a relatively neglected disease. This may be because medical intervention has very little impact upon its course, maintenance treatment with inhalers is of limited value in improving day-to-day functioning, and patients often lurch from one respiratory crisis to another before the terminal decline into permanent immobility, oxygen dependency and cachexia. The outlook for survival in advanced COPD is worse than that for many cancers. Add to this the fact that COPD is largely self-inflicted (very few cases occur in non-smokers) and it is not surprising that GPs and governments have preferred to focus on asthma.

COPD is included as a quality marker in the new contract because it is common, disabling, has a high mortality, and many patients gain some benefit from appropriate treatment.

The bulk of both acute and long-term COPD care takes place in primary care, and in recognition of this 45 quality indicator points are available. Even practices whose COPD management is already well-organised will find it difficult to earn maximum points.

To meet the quality criteria for COPD management, practices should:

 · Produce a COPD register (five points). As the treatment for COPD overlaps with asthma, drawing up a register of COPD patients is unlikely to be as straightforward as doing a computer search on your prescribing data. Searching on anticholinergics and anticholinergic/bronchodilator combinations, oral xanthine derivatives, oral steroids in patients over the age of 50, and oxygen cylinders, will give the best yield but will miss those patients using only inhaled bronchodilators or not taking any treatment between exacerbations. PCOs may check the figures by comparing them with the expected prevalence.

 · Confirm the diagnosis by spirometry, including reversibility testing, in patients diagnosed after April 1, 2003 (five points for 90 per cent coverage). The diagnostic parameters in the contract are FEV1 70 per cent of predicted normal (not 80 per cent as in the GOLD and BTS guidelines), FEV1/FVC ratio of less than 70 per cent, and reversibility of less than 15 per cent. Patients in whom asthma co-exists with COPD may demonstrate greater reversibility, and these patients should be managed as asthma patients.

 · Enter spirometry data, including reversibility testing, for your existing patients where this has been performed, and invite all patients who have not yet had spirometry and reversibility testing to be tested in-house or refer them to secondary care for assessment (five points for 90 per cent coverage).

 · Continue to record FEV1 at least every two years (six points for 70 per cent coverage). The rationale for this is that regular monitoring may help to detect patients whose condition is deteriorating and who will benefit from more intensive intervention such as pulmonary rehabilitation or continuous oxygen therapy.

At present practices will not be judged on the medical management of these patients. Patients who do not attend for review despite repeated invitations should be exception-reported.

 · Record smoking status annually in all COPD patients (six points for 90 per cent coverage) and record that all smokers are offered smoking cessation advice (six points for 90 per cent coverage). Smoking cessation is the only intervention proven to reduce the progression of COPD and smoking cessation advice in primary care is extremely cost-effective ­ one in 20 patients will act upon smoking cessation advice from their medical attendants, a NNT achieved by few pharmaceutical products in any area of preventive medicine. Use the full range of supportive treatments including

nicotine replacement therapy, bupropion and referral to specialist smoking cessation clinics.

 · Check patients' inhaler technique at least once every two years (six points for 90 per cent coverage). The early stages of the BTS guidelines for the management of COPD are based on inhaled therapy. As with asthma, COPD patients need to be offered an inhaler that suits their individual requirements and taught how to use it. Regular reviews are essential because technique can become lax with time, the development of other medical conditions such as osteoarthritis or cognitive impairment may make some devices inappropriate, as may a drop in FEV1 to below a critical level. Patients not on inhaled therapy should be exception-reported.

 · Offer influenza vaccination annually (six points for 85 per cent coverage). Include COPD patients under the age of 65 in your target patient group, and ensure all patients are strongly encouraged to be immunised. Although it is not one of the contract criteria, check the pneumococcal vaccine status of these patients at the same time.

COPD quality markers

Preferred Read codes


Spirometry ­ reversibility positive 33G1

Never smoked 1371

Ex-smoker 137L

Smoker 137R

Smoking cessation advice 8CAL

Spirometry screening 68M

Inhaler technique observed 6637

Flu vaccine given 65E

Flu vaccine contraindicated 8I2F

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