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An outcomes strategy for COPD and asthma in practice

The Outcomes Strategy from the DH outlines a vision for improvements in COPD and asthma care.

What is the Outcomes Strategy?

The Outcomes Strategy is a strategic and a visionary document produced by the Department of Health1 as a complimentary document to the Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England2 which also included a chapter on asthma. Recognising that the recommendations in the Consultation document2 had already identified best practice, this is an important supplementary document for primary care because it sets out the overarching vision for improvements in COPD and Asthma care by providing the aspirations for these disorders (Box 1). The document was produced by aworking group involving generalists and specialists, respiratory organisations, patients and carers who identified the outcomes they considered essential to reducing deaths and improving the patient's quality of life.1 Perhaps of more importance for primary care is that the document acknowledges that it is at practice level that adoption of the vision and strategic changes will make a difference to care1 and recognises that the majority of care for asthma and COPD is undertaken in primary care.

Possibly add something about why this is relevant to primary care nurses specifically and why they should take heed of the outcomes strategy.

So what are the aspirations?

There are three main aspirations of the Outcomes Strategy1, set around variations in practice, improving outcomes and involving clinicians (Box 1).

Address variations in practice

Whilst there are many practices that give excellent respiratory care, there are others where the care could be improved. There is a growing recognition that similar practices with comparable patient populations have very different outcomes with regard to asthma and COPD. Bellamy and Smith attribute some of the factors contributing to this as a poor knowledge of and low adherence to guideline recommendations on the part of some healthcare professionals, and a lack of understanding of the significance and severity of the disease on the part of patients.3 We need to be aware of current guidelines and to incorporate these into our day-to-day practice. We also need to ensure we have the correct skills to care for patients and that these are up-to-date.

Improve outcomes

The mortality from asthma of around 1,131 people per annum and from COPD at around 27,000 people per annum is shocking.1,2,4 The UK currently has the second highest mortality rates for COPD and asthma in Europe, with premature mortality for COPD almost twice as high in the UK as in the rest of Europe, and for asthma 1.5 times higher.1,5 Reducing inequalities and improving prevention and ongoing care are key outcomes in a new strategy for COPD and asthma. Improving COPD and asthma outcomes to EU average would save 2000 lives a year in the UK.5

Mortality also varies around England, and if all parts of the country reduced their death rates to the level of those areas with the lowest death rates, up to 8,000 lives a year would be saved from COPD alone.1

The morbidity of the two conditions also represents a huge cost for the NHS and for patients - together COPD and asthma cost the NHS more than £2 billion a year and COPD alone is responsible for 24 million lost working days.1

Involve clinicians

The Outcomes Strategy1 recognises that it is health care professionals who understand their populations that will help improve care and drive up standards in respiratory care. This means that we can be responsive to the local needs of our population and recognise that there are different needs in differing parts of the country.

So how should we consider implementation in primary care?

If considering implementation of the Strategy in primary care, we can look at the six objectives set out in the strategy and understand what our role could be within these.

1. To improve the respiratory health and well-being of all communities and minimise inequalities between communities

Evidence now suggests that COPD is both preventable and treatable when it is diagnosed early and treated effectively. The availability of effective treatments for asthma means that if diagnosed and treated patients should have a 'normal' life. However if we are to make an impact we need to know our population and compare ourselves to similar practices. One of the ways we can implement these aspirations in primary care is by knowing our population and comparing our prevalence on the Quality and Outcomes Framework (QoF) register6 with the expected for our area. We can also look at and understand our local data. This is freely available on various websites.

Our starting point should be our COPD and asthma registers. We need to ensure that these are accurate and there are estimates are that around 27% of people on our COPD registers who have other diagnoses or normal spirometry.7 The QOF does incentivise good asthma care but the threshold for full payments for annual reviews (Asthma 6) is 70%, meaning that many patients with asthma can be missed from reviewand these may be those that have poorer outcomes.

We also need to think about our hard-to-reach populations in our practice. Exception reporting may involve the very people that would benefit from review. We may need to think about new ways of working to get to hard-to-reach populations. Innovations such as home review, telephone and emailreview provide newer ways to interact with COPD and asthma patients and their families (though at the current time email and telephone review are not approved for QOF). 8,9,

2. To reduce the number of people who develop COPD by ensuring they are aware of the importance of good lung health and well-being, with risk factors understood, avoided or minimised, and proactively address health inequalities.

Often respiratory care has been reactive and intervention at the later symptomatic stages of the disease. Smoking cessation needs to be an essential part of all of our encounters with patients and seen as a treatment for COPD and asthma.

Public health is particularly relevant to respiratory care with a focus on reducing smoking rates and looking at occupational factors that impact on the levels of COPD and asthma and which are amenable to interventions. The wide variation in asthma morbidity and mortality should be amenable to more targeted interventions.10

3. To reduce the number of people with COPD who die prematurely through a proactive approach to early identification, diagnosis and intervention, and proactive care and management at all stages of the disease, with a particular focus on the disadvantaged groups and areas with high prevalence.

If we aim to improve outcomes we need to find those with asthma and COPD. Often a lack of recognition of symptoms leads to late diagnosis and poor outcomes - an estimated one in 8 adults aged over 35 has COPD that has not been diagnosed.2

We know that primary care clinicians can play a crucial role in early diagnosis of at-risk people.3 This may entail making the most of all encounters with patients to think about possible diagnoses of asthma and COPD. It may also mean screening our at risk populations so looking at our smokers of over thirty-five or through case finding.1,2

What we know is that early diagnosis and effective management of asthma and COPD can make a big difference. Primary care staff can educate patients to recognise the early symptoms of COPD, avoid the risk factors, such as smoking, and encourage early presentation to a primary care professional.3 The key to early diagnosis in COPD is the recognition of the clinical features of persistent cough, chronic sputum production, breathlessness on exertion and a history of exposure to tobacco smoke.3 The early diagnosis of asthma and control of symptoms is also important. We can also encourage those with asthma to recognise their symptoms and take appropriate medication.

To work with our patients we need effective communication skills so that patients are encouraged to manage what are essentially long term problems.11 Those with COPD and asthma should have a care planning discussion with their healthcare professional. This will allow individuals to personalise their care and plan their lung health on an ongoing basis so that they can identify any problems and seek help before their symptoms worsen.1

4. To enhance quality of life for people with COPD, across all social groups, with a positive, enabling experience of care and support right through to the end of life

One of the recognitions of the Consultation document and the Outcomes Strategy is that for those respiratory patients particularly with COPD there is a declining disease trajectory that ultimately ends with the person dying with or of their illness1,2. End of Life in the primary care consultation involves the recognition of declining function and readiness to discuss declining health. Use of the Gold Standards Framework (GSF) for those identified is appropriate12 and there are tools such as the DOSE index which has been developed for use in primary care to help us recognise end stage COPD.13 The DOSE uses the Clinical COPD Questionnaire with four components: dyspnoea (D), airflow obstruction (O), smoking status (S), and exacerbation frequency (E).13

The Strategy recognises that both asthma and COPD are chronic conditions and that care management and treatment runs from prevention and diagnosis through to end of life care.

5. To ensure that people with COPD, across all social groups, receive safe and effective care, which minimises progression, enhances recovery and promotes independence

Whilst recognition of COPD is often missed or delayed in primary care, there is also a problem that when it is recognized, COPD is often under-treated or episodically treated, focusing on acute exacerbations without establishing maintenance treatment to control ongoing disease.

Similarly, evidence suggests that effective implementation of non-pharmacological and pharmacological interventions can improve the management of COPD patients at the primary care level. This means an emphasis on smoking cessation and access to pulmonary rehabilitation for our patients alongside appropriate pharmacological treatments relevant to disease severity. Patient-focused and evidence-based options enable primary care practices to manage COPD longitudinally and improve patient outcomes through the course of the disease.8 Smoking cessation has been proven to slow the rate of lung function decline. Maintenance pharmacotherapy and immunizations reduce exacerbations. Pulmonary rehabilitation improves respiratory symptoms and physical functioning and reduces re-hospitalisations and mortality after exacerbations. Self-management education improves health-related quality of life and reduces inpatient and emergency care usage.8

The actual effectiveness achieved in practice with any COPD therapies depends on patients' inhaler technique, adherence, and persistence with treatment. Medication usage rates and inhaler proficiency may be improved by concordance, in which the health care provider and patient collaborate to make shared and agreed treatment plans sustainable in the patient's daily life.8 This is as applicable to asthma as it is to COPD.

6. To ensure that people with asthma, across all social groups, will be free of symptoms because of prompt and accurate diagnosis, shared decision making regarding treatment, and on-going support as they self manage their own condition and to reduce the need for unscheduled health care and risk of death.

In the SIGN/BTS guidelines we have a continually updated guideline providing the best summary of the evidence we have on asthma care.14 The challenge, however, is not only to be familiar with the guidelines but to be able to use the guideline when we see our patients combining the advice with high quality communication and shared decision making to improve the quality of life and outcomes for our patients and their families.10 There is good evidence that our current admission levels and degree of control for people with asthma is well below the standards we could achieve.10

Underpinning principles

To support the principles of the Strategy and the objectives there are three underpinning principles.

Working across boundaries

To effectively work across boundaries we need to think about health and social care and public health as at various times the needs of people with respiratory disorders may have needs that are not purely health related.8 We know that there is a class gradient in respiratory disorders and this may be as a consequence of social factors. Those with respiratory conditions may interact at different times with different health care sectors so the ability to communicate and support the patient regardless of setting is important. True integrated care means recognising the various interactions and needs patient may have at certain times.

Improving the quality of care

Improving the quality of care is now well supported by the various guidelines and strategic documents that are available. It should be remembered however that to really improve the quality of care usually requires more than just good clinicians. The whole system of access/recording/time with patients and systems to follow up and inform patients are required.

Taking a long term view

Improving respiratory disorders will not be a short-term endeavour and to make an impact there will need to be a long-term view for improvements in the future. This means prevention and early and prompt diagnosis are relevant. To make a difference in future years we have to start to focus on prevention and early detection especially to work with the estimated two million COPD patients missing from our registers.3

Conclusion

The outcomes strategy clearly has a primary care focus as the place where good early diagnosis, treatment and ongoing management and care through the disease trajectory will have an impact on future outcomes for both COPD and asthma.  We need to be inspirational in respiratory care and believing that we can make differences will have a positive impact now and in the future.

REFERENCES

1. Department of Health. An Outcomes Strategy for People with Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England. London: DH; 2011.

2. Department of Health. Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England. London: DH; 2010.

3. Bellamy D, Smith J. Role of primary care in early diagnosis and effective management of COPD. Int J Clin Pract. 2007;61(8):1380-9.

4. Asthma UK website. Available at: www.asthma.org.uk. (Retrieved 9th January 2012)

5.  Mayor S. Improving COPD and asthma outcomes to EU average would save 2000 lives a year in the UK BMJ 2011;343:d4651

6. The NHS Information Centre. QOF online results database. Available at: www.qof.ic.nhs.uk.  (Retrieved 9th January 2012)

7. Jones RCM, Dickson-Spillmann M, Mather MJC, et al. Accuracy of diagnostic registers and management of chronic

obstructive pulmonary disease: the Devon primary care audit. Respiratory Research. 2008;9:62.

8. Fromer L, Barnes T, Garvey C, et al. Innovations to achieve excellence in COPD diagnosis and treatment in primary care. Postgrad Med. 2010;122(5):150-64.

9. Pinnock H, Bawden R, Proctor S, et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ. 2003;326:477.

10. Holmes S, Scullion J.Strategy for respiratory conditions provides aspirational targets.Guidelines in Practice. 2011;14(11).

11 . Holmes S, Scullion JE. Better asthma control could reduce majority of hospital admissions. Guidelines in Practice. 2011;14(7).

12. The Gold Standards Framework website. Available at: www.goldstandardsframework.org.uk. (Retrieved 8th January 2012)

13. Jones RC, Donaldson GC, Chavannes NH, et al. Derivation and validation of a composite index of severity in chronic obstructive pulmonary disease: the DOSE Index. Am J Respir Crit Care Med. 2009;5;180(12):1189-95.

14. British Thoracic Society/Scottish Intercollegiate Guideline Newtwork (2011). British Guideline on the Management of Asthma: A national clinical guideline. Available from: www.brit-thoracic.org.uk/clinical-information/asthma/asthma-guidelines.aspx

RESOURCES

The Primary Care Respiratory Society (PCRS-UK) www.pcrs-uk.org.uk

IMPRESS www.impressresp.com

The British Thoracic Society www.brit-thoracic.org.uk

Respiratory Education UK www.respiratoryeduk.com

Education for Health www.educationforhealth.org

Department of Health www.dh.gov.uk

NHS Quality Observatories in England www.qualityobservatory.nhs.uk

NHS Better Care, Better Value Indicators www.productivity.nhs.uk

Quality Observatory Presentations www.erpho.org.uk/qualityintelligenceeast.aspx