CLINICAL MANAGEMENT

Published: 24/03/2005, Volume II5, No. 5947 Page 30 31 32

The drive to reduce emergency bed days should act as a spur for better integration of COPD management. But, as Ann Dix reports, there is a long way to go

If primary care trusts are serious about reducing unplanned hospital admissions they will have chronic obstructive pulmonary disease in their sights. At least, as GP specialist in respiratory disease Dr Noel O'Kelly puts it, 'they would be mad not to'.

COPD is a major source of A&E intake, as a recent King's Fund report shows. It accounts for more than 300,000 emergency admissions a year and more than 10 per cent of all acute admissions, the latter costing the NHS around£600m a year.

At East Lincolnshire primary care trust, Dr O'Kelly and his team have managed to cut hospital admissions for the disease by over a fifth through improvements in patient care achieved by an integrated primary care programme. They are now aiming to halve admission rates through the introduction of intermediate care services across primary and secondary care.

But while East Lincolnshire has got off to a head start, other areas of the country are faring less well.

As British Lung Foundation chief executive Dame Helena Shovelton explains, COPD has a history of neglect, not helped by the stigma of it being largely smoking-related. It is the fifth biggest killer in England and Wales, causing 30,000 deaths a year, yet public awareness remains low. 'I can't think of another disease that affects so many people but nobody's heard of.' She says the lack of a national service framework for respiratory disease has been a major barrier to progress. 'Almost right the way across the board respiratory diseases have been ignored.'

The problem was highlighted last month by the publication of a UK audit of hospital COPD services by the Royal College of Physicians and the British Thoracic Society. It showed that more than one in 10 COPD patients die within 90 days of being admitted to hospital. And over a third of those admitted are readmitted during the 90-day period. It also revealed wide variations between hospitals in process of care and survival rates that could not be accounted for by case-mix alone.

Patients had a better chance of survival and stayed fewer days in hospital if the unit they were admitted to had a respiratory consultant. But only 30 per cent of patients were admitted under a respiratory specialist and a third of trusts had fewer than the British Thoracic Society minimum recommendations of two on any one site. Over half of patients were not in the care of a respiratory specialist while they were in hospital.

'The only real factor that influenced survival rates was the number of chest physicians, ' explains Professor Mike Roberts, COPD associate director of the RCP's clinical effectiveness and evaluation unit. 'We are not saying that it is the chest specialists who are saving lives, but hospitals that invest in chest specialists also invest in other things that give patients a better deal.' For example, units led by respiratory specialists were also more likely to have an early discharge scheme, which reduced length of stay but were present in only 44 per cent of units.

Professor Roberts says the RCP, the BTS and the BLF intend to take this further in a process of peer review to improve standards (see First Opinion, page 32).

Recent initiatives are moving COPD up the agenda, but they only address part of the problem, he says. The government's policy to improve the management of people with long-term conditions is a major driver for change, as is the inclusion of COPD in the new GP contract.

'But most of the initiative is coming from primary care. That is not going to deliver the process of care in hospital. We have to look at the whole patient pathway.' A particular problem, he says, is the 'lack of an interface between patients being discharged from hospital and being picked up in primary care'.

The National Institute for Clinical Excellence has published guidelines on COPD management, including the need for multidisciplinary teams across primary and secondary care. But Professor Roberts is concerned that 'these are only recommendations: they are not mandatory'.

The scope for reducing COPD hospital admissions through improved management in primary care was highlighted recently by the King's Fund. Research published in November last year showed wide variations across the country in frequency and duration of admissions between trusts and primary care organisations. While deprivation was shown to be a major contributor to higher rates of medical admissions for COPD, large variations in areas with similar deprivation levels suggest the potential for improving clinical performance.

King's Fund policy director Jennifer Dixon said that PCTs with high admission rates should review their COPD management. 'It may be appropriate, but there may be something they can do in primary care to reduce those rates.' The King's Fund first became interested in COPD when researching high admission rates in London. 'We found COPD was one of the most common causes of frequent admissions in the capital, ' she said. 'In every PCT it was in the top five, and it was often number one. We suggested to PCTs that for these high-risk patients they actually interview them to see what the problem is. Sometimes medical care is the problem, but it may be culture-related or to do with social care.'

Effective measures But reducing COPD admissions is not always easy, as Runcorn GP Dr David Lyon testifies. Dr Lyon is clinical lead for the national primary care collaborative, which for the past year has been working to improve COPD management. The work has focused on 100 practices across 20 PCTs, with a target of achieving a 40 per cent reduction in hospital admissions.

Ruth Kennedy is chief executive of the National primary care development team, which runs the NPCC programme. She said the work will be introduced nationally and will focus on measures shown to be effective; namely, improving the interface between primary and secondary care, better self-care and the case management of people with complex needs.

But as Dr Lyon explains the first year has been 'tricky' because of problems in collecting the data.

After 12 months, 'we do not seem to have made any difference in admissions, but we now have accurate data'.

He stresses that there have been successes, including a 156 per cent improvement in spirometry, largely achieved by training staff to use dormant equipment.

Results from his own practice, which is 'one year ahead', show what can be achieved by focusing on the most severe cases and drawing up individual care plans, he says. A 30 per cent reduction in admissions compared to last winter has mainly been achieved by 'simply ensuring that the most severely ill patients have antibiotics on their shelves and know how to use them'.

The treatment of COPD is almost entirely about controlling symptoms, particularly the problem of breathlessness, he explains. Many emergency admissions are due to patients panicking in the night, which only makes their symptoms worse. 'It is after 7pm, It is getting dark and they think they're going to die.

'If patients feel more in control of their illness, they feel more confident and less frightened, which results in fewer crises and fewer blue lights.' He is excited by the involvement of patients in the NPCC workshops. Patients' first-hand accounts of their experience of living with COPD are having a 'galvanising effect' on GPs and practice nurses, because it gives them a perspective that cannot always be gained in the course of a brief medical consultation, he says.

'It is often the small things like being able to walk an extra 10 yards to the front door that make a huge difference to people's lives.'

Find out more

Chronic obstructive pulmonary disease: management of COPD in adults in primary and secondary care.

NICE 2004.

www. nice. nhs. org Repor t of the 2003 national COPD audit.

Royal College of Physicians and the British Thoracic Society. 2004.

www. rcplondon. ac. uk

COPD Medical Admissions in Emergency Admissions in London, 1997 to 2001.

Emergency Admissions in London, 1997 to 2001.

King's Fund.

www. kingsfund. org. uk

AN INTEGRATED APPROACH

Plymouth primary care trust is already reaping the benefits of integrated COPD management across primary and secondary care (pictured, left).

In 2000, it set up a patient pathways group.

This led to an intermediate care service for managing people with moderate to severe COPD in their homes. An outreach team of specialist nurses and a physiotherapist provides support and education for patients, as well as enhanced liaison between primary and secondary care.

A comparison of 73 patients a year before being enrolled on to the service and a year after showed a drop in over a third in admissions and bed days, showing the effectiveness of the service for patients with a history of recurrent admissions.

Psychological support COPD nurse specialist Maggie Barnett (pictured left) says that as well as assessing patients and helping them with their medication, nurses provide education and psychological support.

'A lot of patients think they've got asthma.

They do not realise they've got COPD.' 'There is huge element of anxiety. A lot of patients tend to hyperventilate and get panic attacks.' The aim is to help them manage the symptoms and build confidence, she says.

Last year alone the service saved 1,260 bed days, to a value of£165,000. It has been so successful that the number of nurse specialists has been increased from two to six and the service extended to seven days a week.

Process driven Dr Rupert Jones, a GP with a special interest in respiratory disease, is clinical lead for COPD and chair of the PCT's patient pathway group.

He explains that the PCT is also piloting a new audit system, which includes measuring the impact of the disease on patients' quality of life.

Current measures are very process-driven, he says. 'They do not tell us whether patients are better off.' The new software allows patients to input their own data, giving a quality of life score and their perceived information needs.

Reports are then produced for the GP, recommending treatment according to National Institute for Clinical Excellence guidelines and providing patients with tailored information on their condition and its management.

'Education for patients with long-term conditions is sadly neglected because It is so time-consuming for staff, ' he says. 'The beauty of this system is that it doesn't take up anyone's time except for the patient's.' The hope is to make it available through the national IT programme.

EAST LINCS LINK UP

Reducing COPD admissions by 50 per cent sounds an ambitious target. But East Lincolnshire primary care trust is almost half way to achieving it.

Through an integrated scheme of identification, diagnosis and management in primary care it has improved services to patients and reduced emergency COPD admissions by 22.4 per cent.

The PCT has now set up a multidisciplinary care team across primary and secondary care to build on this success, which will focus on developing intermediate services in the community and the management of patients with complex needs.

GP with a special interest in respiratory disease Dr Noel O'Kelly says the initial driver was work by the national primary care collaborative on capacity and demand management.

Piloted by five of the PCT's practices in 2001, it involved targeting suspected COPD patients for spirometry to confirm diagnosis, training primary care clinicians to manage COPD and setting up specialist respiratory clinics in practices.

Treatment plans were developed for three levels of severity by clinicians from primary and secondary care, who also provided ongoing support to the practices.

To date, 29 of the PCT's 38 practices have joined the programme, which has saved£335,000 a year on hospital admissions. 'For every£1 the PCT has put in, it has saved£3, ' says Dr O'Kelly.

Intermediate care services will include an acute assessment service for managing patients at home, community review for patients four to six weeks following an acute episode, and assessment and management of patients with complex needs within primary care.

Key points

COPD causes many emergency hospital admissions, over 10 per cent of all acute admissions , and 30,000 deaths a year in England and Wales.

East Lincolnshire PCT has cut COPD hospital admissions by a third through its integrated programme.

Work by the national primary care collaborative has revealed problems of poor data in many PCT pilot areas, which has slowed progress.