Chronic Obstructive Pulmonary Disease (COPD)

COPD - Rationale for Inclusion of Indicator Set
COPD is a common disabling condition with a high mortality. The most effective treatment is smoking cessation. Oxygen therapy has been shown to prolong life in the later stages of the disease and has also been shown to have a beneficial impact on exercise capacity and mental state. Some patients respond to inhaled steroids. Many patients respond symptomatically to inhaled beta agonists and anti-cholinergics. Pulmonary rehabilitation has been shown to produce an improvement in quality of life.

The majority of patients with COPD are managed by general practitioners and members of the primary healthcare team with onward referral to secondary care when required. Consultation rates in patients with COPD are 2 to 4 times higher than the equivalent rates for patients with angina. This indicator set focuses on the diagnosis and management of patients with symptomatic COPD.

COPD Indicator 1
The practice can produce a register of patients with COPD

COPD 1.1 Rationale
A register is a prerequisite for monitoring patients with COPD.

A diagnosis of COPD should be considered in any patient who has symptoms of persistent cough, sputum production, or dyspnoea, and/or a history of exposure to risk factors for the disease. The diagnosis is confirmed by spirometry.

See COPD 3.1.

Where patients have a long standing diagnosis of COPD and the clinical picture is clear, it would not be essential to confirm the diagnosis by spirometry. However, where there is doubt about the diagnosis practices may wish to carry out spirometry for confirmation.

COPD 1.2 Preferred Coding
COPD* H32

*There are a number of codes which are more disease specific but prospectively this code could be used for the COPD register.

COPD 1.3 Reporting and verification
The practice reports the number of patients on its COPD disease register and the number of patients on its COPD disease register as a proportion of total list size.

Verification - PCOs may compare the expected prevalence with the reported prevalence.

COPD Indicator 2
The percentage of patients in whom diagnosis has been confirmed by spirometry including reversibility testing for newly diagnosed patients with effect from 1 April 2003

COPD 2.1 Rationale
COPD is diagnosed if:

the patient has an FEV1 of less than 70% of predicted normal
and has an FEV1/FVC ratio of less than 70%
and there is a less than 15% response to a reversibility test.

All of these elements are required to make the diagnosis of COPD and to exclude co-existing asthma. It is acknowledged that COPD and asthma can co-exist and that many patients with asthma who smoke will eventually develop irreversible airways obstruction. However, where asthma is present, these patients should be managed as asthma patients.

The FEV1 is set at 70% although the GOLD and BTS guidelines state 80%. The rationale is that a significant number of patients with an FEV1 less than 80% predicted may have minimal symptoms. The use of 70% enables clinicians to concentrate on symptomatic COPD.

Unlike asthma, airflow obstruction in COPD as measured by the FEV1 can never be returned to normal values.

Further information:
BTS COPD Guidelines www.brit-thoracic.org.uk/guide/download_guide.html
GOLD Guidelines www.goldcopd.com/

It is recognised that spirometry has not been standard practice or available in many general practices across the UK until recently. This indicator is therefore prospective, and only applies to new diagnoses of COPD. This will encourage more accurate diagnosis of COPD.

COPD 2.2 Preferred Coding
Spirometry - reversability positive SSG1

OPD 2.3 Reporting and Verification
Practices should report the percentage of patients who were diagnosed after 1 April 2003 who have a record of diagnosis confirmed by spirometry including reversibility testing.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:

1.Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of records of patients with COPD diagnosed after 1 April 2003 to look at the proportion with a record of spirometry
3. Inspection of a sample of records of patients diagnosed after 1 April 2003 for whom a record of spirometry is claimed, to see if there is evidence of this in the medical records.

COPD Indicator 3
The percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing

COPD 3.1 Rational
Some practices have been carrying out spirometry in COPD for some time. This indicator enables practices to be rewarded for work already done. Practices may also
wish to review older patients with a view to making a more accurate diagnosis. The analysis is the same as for indicator COPD2 but involves all patients with a diagnosis of COPD.

COPD 3.2 Preferred Coding
Spirometry – reversibility positive 33G1

COPD 3.3 Reporting and Verification
Practices should report the percentage of patients who are on their COPD register who have a record of diagnosis confirmed by spirometry including reversibility testing.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:

1. Inspection of the output from a computer search that has been used to provide information on this indicator

2. Inspection of a sample of records of patients with COPD to look at the proportion with a record of spirometry

3. Inspection of a sample of records of patients for whom a record of spirometry is claimed, to see if there is evidence of this in the medical records.

COPD Indicator 4
The percentage of patients with COPD in whom there is a record of smoking status in the previous 15 months

COPD 4.1 Rationale
Smoking cessation is the single most effective - and cost-effective - intervention to reduce the risk of developing COPD and stop its progression.
Grade A Evidence GOLD Guidelines

Further Information:GOLD Guidelines www.goldcopd.com/

There is no evidence relating to the frequency that smoking status should be recorded but it is important to promote cessation and continued abstinence. Smoking status should be reviewed annually.

COPD 4.2 Preferred Coding
Never Smoked 1371
Ex-Smoker 137L
Smoker 137R

COPD 4.3 Reporting and Verification
The practice should report the percentage of patients on the COPD register in whom smoking status has been recorded in the last 15 months.

COPD Indicator 5
The percentage of patients with COPD who smoke, whose notes contain a record that smoking cessation advice or referral to a specialist service, if available, has been offered in the past 15 months

COPD 5.1 Rationale
Brief tobacco dependence treatment is effective and every tobacco user should be offered at least this treatment at every visit to the health care provider.
Grade A Evidence GOLD Guideline

Further Information:GOLD Guidelines www.goldcopd.com/

The criterion does not specify the form of advice, which could range from simple advice to substitute prescribing to attendance at smoking cessation clinics.

COPD 5.2 Preferred Coding
Smoking cessation advice 8CAL

COPD 5.3 Reporting and Verification
The practice should report the percentage of patients on the COPD register who are current smokers who have been offered smoking cessation advice in the last 15 months.

COPD Indicator 6
The percentage of patients with COPD with a record of FEV1 in the previous 27 months

COPD 6.1 Rationale
There is a gradual deterioration in lung function in patients with COPD. This deterioration accelerates with the passage of time. There are important interventions which can improve quality of life in patients with severe COPD. It is therefore important to monitor respiratory function in order to identify patients who might benefit from pulmonary rehabilitation or continuous oxygen therapy.

There are no clear guidelines with regard to the optimum frequency of spirometry for patients with COPD. This has been pragmatically set in the quality framework at every two years. The purpose of regular monitoring is to identify patients with increasing severity of disease who may benefit from referral for more intensive treatments.

The quality framework does not set specific criteria for the management of severe COPD. However practices should identify by symptoms and regular spirometry those patients who would benefit from long-term oxygen therapy and pulmonary rehabilitation.

These measures usually require specialist referral because of the need to measure arterial oxygen saturation to assess suitability for oxygen therapy, and the advisability of specialist review of patients prior to starting pulmonary rehabilitation.

The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival and improve exercise capacity.
Grade A Evidence GOLD Guidelines

Further Information:GOLD Guidelines www.goldcopd.com/

Referral can be to a general physician, a respiratory physician or a GP with a special interest (GPSCI) in respiratory disease. It is suggested that consideration for referral should be given in patients with FEV1 of less than 50% predicted or in patients with disabling symptoms.

COPD 6.2 Preferred Coding
Spirometry Screening 68M

COPD 6.3 Reporting and Verification
Practices should report the percentage of patients on the COPD register who have had spirometry performed in the last 27 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:

1. Inspection of the output from a computer search that has been used to provide information on this indicator

2. Inspection of a sample of records of patients with COPD to look at the proportion with spirometry results in last two years

3. Inspection of a sample of records of patients with COPD for whom a record of spirometry is claimed, to see if there is evidence of this in the medical records.

COPD Indicator 7
The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the preceding 27 months

COPD 7.1 Rationale
All patients should be managed according to the BTS COPD guidelines. All symptomatic patients should be given a short-acting beta agonist and if still symptomatic a trial of regular use of an inhaled anticholinergic. Symptomatic patients should also be given a trial of inhaled steroids. Where there is no objective benefit inhaled steroids should not be continued. Exacerbations should generally be treated with a combination of antibiotics and oral steroids.
BTS COPD Guidelines

Further information: www.brit-thoracic.org.uk/guide/download_guide.html

There is evidence that inhaled therapies can improve the quality of life in some patients with COPD. However, there is evidence that patients require training in inhaler technique and that such training requires reinforcement. There is no clear indication from the literature as to the required frequency of checking inhaler technique. A pragmatic view has been taken that this should be at least every two years.

COPD 7.2 Preferred Coding
Inhaler technique observed 6637

COPD 7.3 Reporting and Verification
The practice should report the percentage of patients on the COPD register in whom inhaler technique has been checked in the last 27 months. Patients not on therapy which involves the use of inhalers should be exception-reported.

COPD Indicator 8
The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March

COPD 8.1 Rationale
This is a current recommendation from the Departments of Health and the Joint Committee on Vaccination and Immunisation (http://www.doh.gov.uk/greenbook/).

COPD 8.2 Preferred Coding
Flu Vaccination given 65E
Flu vac contra-indicated 8I2F

COPD 8.3 Reporting and Verification
The percentage of patients on the COPD register who have had an influenza vaccination administered on the preceding 1 September to 31 March.