COPD
Public Health Wales
Chronic Obstructive
Pulmonary Disease
(COPD)
Quality improvement toolkit
Author: Primary
Care Quality and Information Service
Date: July 2008
Version: 1
Status: Final
Intended audience: Public (Internet) / NHS Wales (Intranet) /PHW (Intranet)
The former Public Health Wales Primary Care Quality Team, now incorporated
within the Primary and Community Care Development and Innovation Hub,
developed a series of quality improvement toolkits to assist practices in
collating and reviewing information. From information received, practices still
find these toolkits useful, therefore they will remain on this webpage for your
ease of reference. Please note, however, that the date of publication is clearly
stated in the toolkit and that the evidence within may have changed since
publication
Purpose and summary of document:
This document is for use by general practitioners treating patients with a diagnosis of
COPD. The purpose of this toolkit is to support practices to review and reflect on the
service they provide and the information they record following patients COPD
consultation.
This audit may be of particular interest to clinicians who have seen the recent
WeMeReC Bulletin (No ) and the accompanying distance-learning education module
(No 25). This audit is designed to reinforce the summary of evidence and the main
points within the Bulletin and case study.
This toolkit provides patient review criteria and guidance on how to complete a
straightforward small-sample audit. Also included is a review section that follows each
timed audit phase. This is designed to prompt reflection and comment on the results of
the audit process. Completion of this audit would constitute a suitable piece of
Continuing Professional Development that could be included within the appraisal
process.
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
1
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
Publication / distribution:
 Publication in PHW document database (Primary Care Quality and Information)
 Link from PHW e-bulletin
Page Number
Contents
Introduction and background
3
Aim of the quality monitoring toolkit
3
Methodology
3
Exclusion / Inclusion Criteria
4
Audit Criteria
4
Reference
6
Links
6
Appendix A -
Data collection sheet
7
Appendix B -
Practice Review Sheet
8
Appendix C -
Assessment of severity scale
9
Appendix D -
Sampling Matrix
10
Appendix E -
Read Codes
11
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
2
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
1
Introduction and Background
Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The
airflow obstruction is not fully reversible and is usually slowly progressive. 1
COPD generally affects those over the age of 35yrs who have a risk factor (invariably a history of
smoking) presenting with symptoms of persistent cough, sputum production, or dyspnoea and / or
a history of exposure to risk factors for COPD 1,3,4,5
COPD is a common disabling condition with a high mortality. The most effective way to reduce
deterioration 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. Many patients respond symptomatically to inhaled beta agonists and
anti-cholinergics. Some patients respond to inhaled steroids. 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. 2
2
Aim
This small-sample audit offers criteria on which to base a review of the care offered to patients
with COPD in a general practice setting. The audit is designed to reinforce the summary of
evidence and the main points within the WeMeReC COPD Bulletin and case study. The audit
aims to support practices to assess whether the care provided to patients diagnosed with
COPD reflects best practice.
3
Methodology
3.1
Use retrospective data over a 12 month period
3.2
Set a start and end date for the audit
3.3
Compile a list of patients from the practice computer system of all patients with a
diagnosis of COPD on practice register
3.4
Select a patient sample (suggest using sampling matrix - Appendix D), to a maximum
of 50 patients with a diagnosis of COPD
3.5
Collect relevant data and record using the data collection sheet provided
(See Appendix A)
3.6
Collate and analyse results of the data collection process
3.7
Reflect on the results of the audit and decide any changes to practice that you consider
appropriate (Using the practice review form enclosed – Appendix B)
3.8
Decide on a date to re-audit to confirm changes (if recommended)
The PCQIS recognises that some of the criteria in this audit may involve data that is not
currently kept routinely by the practice. Therefore it is recommended that for this audit
the practice consider recording this information prospectively, so that these criteria
could be successfully reviewed in any future audits of this type.
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
3
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
Inclusion Criteria
Any patient with a recorded diagnosis of COPD at least 6 months previously
Exclusion Criteria
Patients with a recent diagnosis of COPD (Any patients who have had recent eye, chest or
abdominal surgery, or who have recently had a myocardial infarction or cerebrovascular
accident should not be exposed to Spirometry for six weeks following such an episode 3,4
Audit Criteria
1)
All patients with a record of a diagnosis of COPD have had the following investigations;
a)
b)
c)
d)
Chest X-Ray
FBC
BMI
Pulse Oximetery
2)
The patient has a record of Spirometery within the audit period
Y/N
3)
The patient has a record of reversibility testing recorded
Y/N
4)
The patient has a FEV1 recorded during the audit period
(See appendix C)
5)
The patient has a FEV1 / FVC recorded during the audit period
6)
The patients COPD has been classified and recorded as one of the following
a)
b)
c)
Y/ N
Y/ N
Mild
Moderate
Severe
7)
MRC Severity score recorded in the last 15 months (See Bulletin for dyspnoea scale)
8)
The patient has a smoking status recorded
Y/N
9)
If yes has smoking cessation advice been offered
Y/N
10)
The patient has a record of short acting bronchodilator (SABA) Prescribed Y/N
11)
The patient has a record of Long acting bronchodilator (LABA) prescribed Y/N
12)
The patient has a record that inhaler technique has been checked Y/N
13)
The patient has a record of 2 or more exacerbation within the audit period Y/N
14)
If yes how many COPD related hospital admissions has been recorded
a) 2-3 admissions
b) 4-6 admissions
c) More than 6 admissions
15)
The patient has a record of being on regular inhaled steroids Y/N
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
4
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
16)
How many courses of Oral Corticosteroids has been prescribed within the audit period
a)
b)
c)
d)
17)
None
1-3
4-5
More than 5
How many courses of antibiotics has been prescribed for exacerbations within the audit
period
a)
b)
c)
d)
None
1-3
4-5
More than 5
18)
Medication review recorded Y/ N
19)
Has the patient been given a written self-management plan Y/N
20)
All patients with a BMI of less than 20 has been referred to a dietician Y/N
21)
All patients who’s FVC has fallen by 500ml or more over the last 5 years has been referred
to a respiratory specialist Y/N
22)
The patient has a record of influenza immunisation recorded in the last 15mths
Y/N
23)
The patient has a record of pneumococcal immunisation
Y/N
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
5
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
References
1
National Institute of Clinical Excellence
2
Welsh Assembly Government. GMS Contract Quality and Outcomes
Framework Disease Prevalence 2008/9.
3
Anon. Global Strategy for the Diagnosis, Management and Prevention of
COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2007.
4
British Thoracic Society (1997) BTS guidelines for the management of chronic
obstructive pulmonary disease. Thorax 52(suppl5),S1-S28
5
Association for respiratory technology and physiology (1994) Guidelines for the
measurement of respiratory function. Respiratory medicine 88,3,165-194
6
Welsh Medicines Research Centre (WeMeReC); Chronic Obstructive Pulmonary
Disease Bulletin (June 2008)
http://www.wemerec.org/Documents/Bulletins/BacksBulletinOnlineOPT.pdf
Links
Below is a list of web sites associated with diagnosing and managing COPD.
British Thoracic Society. BTS COPD Consortium was established in 1997 when the BTS
COPD Guideline was published. It aimed to provide related educational materials for
healthcare professionals; and to raise the profile of this "cinderella disease" amongst health
professionals, patients and policy makers. http://www.britthoracic.org.uk/Home/tabid/36/Default.aspx
Welsh Medicines Research Centre (WeMeReC); Chronic Obstructive Pulmonary Disease
Bulletin (June 2008)
http://www.wemerec.org/Documents/Bulletins/BacksBulletinOnlineOPT.pdf
Clinical Knowledge Summary Covers the management of people with persistent symptoms of
chronic obstructive airways disease (COPD). Also covered management of exacerbations and
end stage COPD. http://www.cks.library.nhs.uk/chronic_obstructive_pulmonary_disease
NICE CG12 Chronic obstructive pulmonary disease guideline. www.nice.org.uk
GOLD Guidelines: Global imitative for chronic obstructive lung disease (GOLD)sets out to
improve prevention and treatment of this lung disease. www.goldcopd.com
General Practice Airway’s group
http://www.gpiag.org
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
6
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
Appendix A
Data Collection Sheet
Patient
1a
1b
1c
1d
2
3
4
5
6a
6b
6c
7
8
9
10
11
12
13
14a
14b
14c
15
16a
16b
16c
16d
17a
17b
17c
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Total
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
7
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
17d
18
19
20
21
22
23
Total
COPD
Public Health Wales
Appendix B
Practice Review Sheet
A. What lessons did the practice discover from carrying out this audit?
B. What changes, if any have the practice agreed to implement as a result of this audit?
C. What support would enable the practice to enhance the service it provides to patients?
This audit was compiled by;
Name(s)
Signature(s)
______________________________________________________
________________________________________________________
Practice (name and address)
___________________________________________________________________
__________________________________________________________________
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
8
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
Appendix C
Assessment of severity scale
The following scale is an assessment of the severity of airflow obstruction based on FEV1 as a
percentage of predicted value.
NICE
FEV1
GOLD
-
>80%
Stage1:Mild
Mild
50-80%
Stage11:Moderate
Moderate
30-49%
Stage111:Severe
Severe
<30%
Stage1V:Very Severe
(Adapted from NICE and Global Initiative for Chronic Obstructive Lung Disease
(GOLD) guidelines) 6
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
9
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
Appendix D
Sampling Matrix
Population size
Total number of patients with COPD
Sample size:
95% confidence; +/- 5%)
50
44
100
79
150
108
200
132
500
217
1000
278
2000
322
5000
357
United Bristol Hospital Trust 2008
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
10
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS
COPD
Public Health Wales
Appendix E
Read Codes
The following are suggested read codes for COPD monitoring and diagnosis:
H3… Chronic obstructive pulmonary disease
H31.. Chronic bronchitis
H310. Simple chronic bronchitis
H3100 Chronic catarrhal bronchitis
H310z Simple chronic bronchitis NOS
H32.. Emphysema
H32z. Emphysema NOS
H36.. Mild chronic obstructive pulmonary disease
H37.. Moderate chronic obstructive pulmonary disease
H38.. Severe chronic obstructive pulmonary disease
H3y.. Other specified chronic obstructive airways disease
H3y0. Chronic obstructive pulmonary disease with acute lower respiratory infection
H3y1. Chronic obstructive pulmonary disease with acute exacerbation, unspecified
H3z. Chronic obstructive airways disease NOS
173H. MRC Breathlessness Scale: Grade 1
173I. MRC Breathlessness Scale: Grade 2
173J. MRC Breathlessness Scale: Grade 3
173K. MRC Breathlessness Scale: Grade 4
173L. MRC Breathlessness Scale: Grade 5
Author
Primary care quality and information service
Date
July 2008
Status; Final
WeMeReC COPD Audit Version; 0g
11
Intended audience: Public (Internet) / NHS
(Intranet) PHW (Intranet) / PCQIS