Use weather reports to reduce COPD admissions
Dr Peter Moore explains how his practice team used Met Office forecasts to cut COPD admissions
Dr Peter Moore explains how his practice team used Met Office forecasts to cut COPD admissions
We British enjoy moaning about the weather. And we have had plenty to moan about with recent floods in one of the wettest summers on record. We also like to moan about our ailments. But to combine the weather and our ailments is even better: ‘It's the weather, Doc – always plays me up.'
The Victorians with respiratory problems may have come to South Devon for the healthy air but it did not seem to be helping the 10,600 patients in our Torquay practice.
I kept seeing COPD articles in the medical press and these left me asking where our practice's COPD masterplan was.
Our project worked on the theory that predictions from the Met Office could reduce admissions for COPD.
Our project started when we discovered that if we became involved in a collaborative looking at chronic disease, we would get £4,000 for our practice from the Department of Health via the Improvement Foundation. We had no idea what it entailed and sent one of our nurses, Julia Avery, and our IT manager on a study day organised by the PCT. During the day, Dr William Bird from the Met Office gave a talk on how the weather can predict COPD exacerbations.
At the next meeting Julia found a Met Office stand and talked to the development manager. She managed to persuade them to give a talk to the GP partners and nurses back at the surgery.
Unfortunately, GPs are natural cynics – especially when looking at ideas endorsed by the Department of Health. When the Met Office development manager came to the practice to explain the project proposal, our practice nurse's optimism was not met with enthusiasm from all the GPs – one spent the meeting complaining how the Met Office had failed to predict rain and ruined his holiday in Cornwall.
Not everyone shared the vision of our nursing team.
Despite this setback, two of our nurses decided to go ahead and lead a pilot.
At this point I must say that for me to take credit for this project would be like taking credit for a goal scored when I was standing on the terraces. It has taught me the importance of ensuring, before starting any project, that there are enthusiastic team members who will drive it forward.
Weather and COPD
Health forecasting figures from the Met Office were impressive. For every 1°C drop in temperature below 5°C there is a 15% rise in GP respiratory consultations. Apparently the rhinovirus replicates faster in a cold nose – and a rise in respiratory infections means a rise in exacerbations of COPD.
In the summer, COPD patients suffer from a combination of the heat and poor air quality.
Liaising with the Met Office and contacting patients before changes in the weather should lead to a fall in hospital admissions because steroid or antibiotic courses can be prescribed before the weather takes its toll.
The idea has Government approval.
A Department of Health report in June 2006 suggested that using Met Office forecasting to help COPD patients should lead to a greater focusing on the disease. This means better identification of patients, empowering patients, closer disease control, managing exacerbations and a reduction in hospital admissions.
In short, the Government feels that health forecasting offers significant potential for improvement in the management of COPD.
In the planning stages the nurses had to ask themselves:
• What are we trying to achieve?
• How do we know this will lead to an improvement?
• What changes do we need to make to get there?
Before starting, it is important to sort out your data. Our COPD register had not been validated, so the first job was to set criteria for COPD and compare them with the patients on the register. We also needed to search for patients who were not on the register through searches for appropriate medication and by straining the memories of the practice team.
We believed that we had a highly organised practice offering a high level of care.
Sadly, the figures did not support our inflated opinion of ourselves. There had been 35 admissions in a year and eight patients had been admitted at least three times. This added up to a total of 275 days in hospital.
To make the situation worse we had no systematic follow-up and no management plans. Housebound patients only saw a GP
if they fell ill and called for a visit.
The project was financed initially through the payment for the collaborative. Good care of COPD patients would boost our QOF points and we had growth money for a specialist nurse through our PMS contract.
We decided to implement the following:
• an annual review of all mild to moderate patients with six-month review of severe cases
• education packs and meetings for newly diagnosed patients
• a computer template with minimum agreed data so that even GPs would know what to ask and what tests were needed
• offering personalised management to a small number of more severe patients.
We also validated our smoking cessation service by putting systems in place to find out which patients were still not smoking at six and 12 months.
Julia decided to become a specialist nurse. This was not completely new territory for us as we had previously employed a specialist nurse for the elderly.
We also appointed one of our administrative staff as co-ordinator.
Deciding outcome measures
But how could we demonstrate cause and effect? Would there be a reduction in admissions and, if there was, how did we know it was due to our programme? As an outcome measure we wanted to see:
• a 10% reduction in unscheduled admissions for COPD
• a reduction in prescribing costs for inhaled steroids in these patients
• a reduction in secondary care follow-ups.
Once we had a verifiable disease register we contacted our COPD patients. They were coded into mild, moderate and severe according to the NICE guidelines.
We then divided them into four groups, based on their admission rate in the previous year:
• Group 1 three or more admissions
• Group 2 one or two admissions
• Group 3 contact with the practice for exacerbations
• Group 4 the rest.
They were then sent a standard letter explaining that we would receive the weather forecast twice a week and that they may be contacted if the weather was likely to put them at risk. The letter also included basic advice explaining the early signs of a deterioration. They were advised to have a thermometer to ensure the house was warm in the winter, to wear warm clothes when going outside, told who to contact if unwell and to check that they had had a flu and pneumonia immunisation.
The surgery arranged a dedicated phone line to the co-ordinator.
Each patient was then seen by one of the two nurses in the surgery or at home for a full COPD review including medication and inhaler check. This meant seeing a total of 177 patients.
Julia repeated the advice on the letter and explained that we would contact them if the weather forecast was worrying. For some patients prescriptions were given for steroids and antibiotics to take if warned of a potential weather-related exacerbation.
Twice a week we receive an email from the Met Office, which predicts both the risk of exacerbations and hospital admissions. Our PCT pays the Met Office a fee for this service, which was locally negotiated as we are a pilot project. These emails give the predicted risk as average, above average, high, very high or exceptional. The prediction is not only based on the weather but also disease prevalence from the RCGP and the current levels of infectious disease. If the risk is high our specialist nurse or the co-ordinator rings patients.
When we started the project only patients in level one (with three or more admissions) were contacted, but now we have increased the surveillance to include levels two and three.
Undoubtedly, our management of COPD has improved. Admissions dropped steadily from 35 in 2004 to five in 2006. The programme has badgered the whole practice into organising the care of our COPD patients. Even the partner who blamed the Met Office for his ruined holiday would now admit that patients have benefited.
What is not clear is how much the improvement is due to the Met Office project and how much to our improved management of COPD.
An effective research project would need far larger numbers and a comparison between a practice which introduced all our changes except the link with the Met Office, and one following our procedures. But as a non-scientific project it has proved cost- effective and dramatically improved the quality of patient care in COPD. It also demonstrates the value of an enthusiastic nurse even when the GPs are cynical.
The PCT has been enthusiastic, and when the story made local and national press headlines they were delighted to bask in the glory. Now they plan to roll it out across the PCT as a local enhanced service (LES).
To qualify for the LES money, as well as health forecasting, a practice will need a named lead COPD nurse with a recognised qualification, desktop spirometry, a named person trained in spirometry with annual refresher training and a validated COPD register. They will then need to stratify their COPD patients using percentages of predicted FEV1.
LINK TO PBC
Our success in reducing COPD admissions by more than 80% was recognised when we were awarded the Department of Health's Innovative Service Award and the Improvement Foundation hailed the PCT-wide rollout as a service redesign that ‘clearly underpins the DH's strategic plan for practice-based commissioning development'. The NHS Alliance has also highlighted the potential benefit of using Met Office forecasts to reduce COPD admissions via PBC.
Dr Peter Moore is a GP in Torquay, Devon
60 second summary
Initiative Using Met Office predictions to forewarn patients in a single practice of a potential exacerbation of their COPD symptoms and so avoid hospital admissions. Part of a wider practice initiative to improve COPD care which includes a specialist nurse, and personalised care for severe cases.
Policy link Supporting People with Long-term Conditions, Department of Health guidance, June 2004.
Staffing Two nurses and one co-ordinator.
Results • COPD admissions for 10,600 patient practice reduced from 35 in 2004 to five in 2006.
• Improved care of COPD. PCT now plans to roll pilot out to all practices as a local enhanced service.
Savings £90,000 a year based on a single COPD admission costing NHS £3,000.
Contact email@example.comEven the partner who blamed the Met Office for his ruined holiday now admits patients have benefitedEven the partner who blamed the Met Office for his ruined holiday now admits patients have benefited Even the partner who blamed the Met Office for his ruined holiday now admits patients have benefited