Ten Points to Quality
Dr Lorna Gold continues her series on achieving the necessary standards to meet the quality framework by looking at COPD care
Complete your asthma register before attempting to create a COPD register
There is a practical reason for doing this. Many of the drug therapies used for asthma and COPD overlap. Performing a computer search of prescribing information to find COPD patients will be much easier if you can exclude those who are already on your asthma register.
Forget about chronic bronchitis and emphysema
Chronic bronchitis is a symptom-based diagnosis, emphysema is a pathological term, and in practice these phenomena co-exist in almost all patients with COPD. The same diagnostic criteria and treatment guidelines in primary care apply throughout the 'blue bloater' to 'pink puffer' continuum.
Keep your COPD register simple
There is no need to screen patients at risk of COPD but with normal lung function, or to use the four-point classification of COPD severity which features in the GOLD guidelines. Recording the diagnosis of COPD using code H32 or another code agreed within your practice is sufficient and is worth five quality points.
Set up an annual recall system
Many patients with COPD only seek medical advice when they have an acute exacerbation requiring antibiotics and oral steroids. Although they may be seen several times every winter, such patients may miss out on health promotion advice and objective assessment of their lung function, and the practice may miss out on quality points which could be earned by offering more pro-active care. Routine reviews are likely to be done most effectively by a practice nurse with an interest in respiratory disease working to a protocol
Focus on smoking
COPD occurs almost exclusively in smokers, and smoking cessation is the only intervention which significantly improves the prognosis for lung function and survival in COPD. In recognition of this, your practice can earn six points for recording the smoking status of 90 per cent of patients on your COPD register within the past 15 months, and a further six points for recording that 90 per cent of smokers have been offered smoking cessation advice.
Use spirometry to make the diagnosis in all new patients
Although chest radiology is still useful for excluding alternative diagnoses such as bronchiectasis or lung cancer, spirometry is now the investigation of choice. Five points are available if the diagnosis has been confirmed by spirometry in 90 per cent of patients first diagnosed as having COPD after April 1, 2003. Hand-held spirometers are relatively inexpensive and can be used in general practice, but it is perfectly acceptable to refer all patients suspected of having COPD to a respiratory physician or a GP with a special interest in respiratory disease for diagnosis. COPD is confirmed if the patient has:
mFEV1 less than 70 per cent of the predicted normal.
mFEV1/FVC ratio of less than 70 per cent.
mLess than 15 per cent improvement on reversibility testing.
Include spirometry in COPD patients' annual reviews
Five points are available if 90 per cent of all patients (not only newly-diagnosed patients) on the COPD register have had the diagnosis confirmed by spirometry. This is intended to reward those practices that have been using spirometry routinely for some time and to encourage all GPs to check the accuracy of the diagnosis of COPD in existing patients. A further six points are available if 70 per cent of all COPD patients have had their FEV1 recorded within the previous 27 months to assess the rate of decline of lung function.
Get to grips with reversibility testing
There are two types of reversibility test to consider. A bronchodilator reversibility test is intended to distinguish COPD from asthma, and the most straightforward way of performing it is to measure FEV1 or peak flow before and 30 minutes after administration of nebulised salbutamol. An improvement of more than 15 per cent means the patient should be regarded as having asthma. A steroid reversibility test is designed to identify the relatively few COPD patients who are steroid-responsive. Measure FEV1 before and after two weeks of 30mg oral steroids daily (or six weeks of high-dose inhaled steroids). It is only worth prescribing long-term inhaled steroids to patients whose FEV1 improves by more than 200ml.
Check inhaler techniques
The contract recommends COPD should be managed according to the British Thoracic Society guidelines, starting with short-acting inhaled
?-agonists and progressing if needed to inhaled anticholinergics and a trial of steroids before considering regular use of oral medication. Inhaler technique needs to be taught, then reviewed and reinforced regularly. The optimum frequency for checking inhaler technique is unknown and the contract has settled on two years. Six points are available for 90 per cent coverage. Patients who are not using any inhaled treatment should be exception-reported for this indicator.
Offer influenza immunisation to all COPD patients
Practices that immunise 85 per cent of the patients on their COPD register against influenza this winter will earn six points, and offering pneumococcal vaccine at the same time will earn an extra item-of-service fee.