A national clinical strategy (previously national service framework) for COPD is being developed by the DoH. This 10-year plan will be the first strategy for a respiratory disease in England, and it is expected to be published shortly.
Recognise the at-risk population
The strategy will aim to increase awareness of COPD among those at risk. Practices should have a good understanding of the demographic of their local population and its needs.
The importance of lung health needs to be recognised among the population. This message will be linked with campaigns aimed at smoking cessation in recognition of the fact that 80 per cent of people with COPD have been or are smokers.
The strategy will also aim to increase awareness of other causes of COPD, for example occupational and environmental exposure to causative agents. Ensure you are aware of the at-risk population for COPD, and be clear on the policy for supporting smoking cessation.
The strategy will make recommendations on how to identify COPD as early as possible through opportunistic and proactive case finding.
To find the true COPD population for your practice, look at COPD registers and QOF prevalence and compare these against practices in your area. If the prevalence is low, look for patients presenting with winter chest infections or receiving antibiotic prescriptions for chest infections.
NICE guidelines suggest that case finding can be improved opportunistically by targeting smokers over the age of 35 years with any risk factor (see box).1
The British Lung Foundation estimates there are around one million COPD patients, but probably twice as many cases that are not known and therefore not diagnosed or treated.2
Patients often deny significant symptoms of dyspnoea on superficial enquiry, hence asking patients with risk factors probing questions about changes in activity levels and symptoms over time will be important in identifying the disease earlier.
GPs are likely to see patients who are either asymptomatic or in the early stages of their disease, and so are ideally placed to make an early diagnosis and consider interventions.
The strategy will recommend that people are accurately diagnosed, using appropriate tests including spirometry.
There will probably be an increased emphasis on competency in undertaking and interpreting spirometry.3 Consider how well spirometry is undertaken and interpreted within the practice. It may be time to ensure that spirometry and its interpretation are undertaken only by those trained in the technique.
Target smokers aged over 35 with any of the following:
The strategy will recommend that people diagnosed with COPD are managed within the same broad chronic care model as other long-term conditions.
The aim is that interactions between people with COPD and health and social care professionals are productive, with patients seen as partners in the management of their condition.
Patients will receive regular reviews, the timing depending on disease severity. Personalised action plans for patients should fit with the long-term strategy and complement a patient's care, improving support, information and empowerment.
There will also be recommendations aimed at managing people with mild COPD, and on improving access to and standardising the quality of pulmonary rehabilitation services.
While some patients with COPD will die from unrelated causes, others will die from their disease or from the complex effects of their comorbidities. Evidence suggests that it is difficult to determine a clear trajectory for the disease and therefore many patients do not receive end-of-life care.
Where a patient is not expected to survive until the following year, it may be useful to initiate end-of-life discussions and to manage these patients in accordance with the Gold Standards Framework. The COPD national strategy will therefore make recommendations to ensure that patient wishes around end-of-life care are taken into account and that patients can access appropriate services.
We need to shift focus from the reactive, acute management of problems associated with COPD to chronic care provision, including comorbidities, and work towards preventing disease complications.
Patients and healthcare providers will need encouragement to understand that COPD is treatable and that strategies are available to improve symptoms and quality of life, as well as reduce morbidity and mortality.
Interventions must improve well-being, limit the effect of exacerbations, address health and social care needs and prevent disease progression, as well as manage comorbidities.
The most important intervention is smoking cessation as this slows the rate of lung function decline. All patients with COPD should get smoking cessation counselling or reinforcement of the importance of staying smoke free (for former smokers).4,5
Influenza vaccination can reduce morbidity and mortality in patients with underlying respiratory conditions and is recommended for those with COPD. Although there is less evidence for pneumonia vaccination it is advised for patients with COPD, as research shows a 29 per cent reduction in death and 49 per cent reduction in admissions for pneumonia and influenza.6
Pulmonary rehabilitation is essential as it improves quality of life and ability to exercise, and hence reduces hospitalisation and exacerbation rates. Contact your local respiratory nurse specialist for details of local services.
Chronic oxygen therapy (at least 18 hours per day) reduces mortality in COPD patients with resting hypoxaemia. We need to be proactive in screening to identify those who need long-term oxygen therapy with pulse oximetry; those who do not need oxygen should be taught to manage their breathlessness and be reassured they will not benefit from oxygen.
Review and support
Patients need to be reviewed following an exacerbation or hospitalisation as well as regularly to identify any problems, including psychosocial issues.
The strategy supports the use of technology (telephone, text message and email) to deliver and monitor care and enable patients to self-manage. Consider the care of housebound patients who may have been exempt from registers and reviews.
The strategy will set standards for improving supportive care for patients and carers at all stages of the disease, including end of life. This has ramifications for palliative care services and may mean appropriate use of the Gold Standards Framework.
Key themes are improving communication and providing high-quality symptom control and other non-curative interventions earlier. The strategy also suggests working with local health and social care services. Clinical networks, based on existing cardiac and cancer networks, will be encouraged.
The strategy will focus on high-quality care but we will have to provide value for money. We need to look at current provision and see where we can improve.
When the national clinical strategy is published, we can expect changes to COPD care delivery. The emphasis will be on early and appropriate diagnosis, high-quality assessment and care throughout life, with healthcare professionals working as teams to improve the patient experience.
- Jane Scullion is a respiratory nurse consultant at the University Hospitals of Leicester; Dr Holmes is a GP in Shepton Mallet, Somerset, and education lead for the General Practice Airways Group
|Questions to consider|
1. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004; 59 Suppl 1:i1-199.
2. British Lung Foundation. Invisible lives: chronic obstructive pulmonary disease (COPD) - finding the missing millions. November 2007.
3. Levy ML, Quanjer PH, Booker R et al. Diagnostic spirometry in primary care: proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J 2009; 18(3): 130-47.
4. van Schayck OC, Pinnock H, Ostrem A et al. IPCRG Consensus statement: tackling the smoking epidemic - practical guidance for primary care. Prim Care Respir J 2008; 17: 185-93.
5. Strassmann R, Bausch B, Spaar A et al. Smoking cessation interventions in COPD. Eur Respir J 2009; 34: 634-40.
6. Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med 1999; 159: 2437-42.