Public Health Wales COPD

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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 1 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 2 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 3 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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) Chest X-Ray
b) FBC
c) BMI
d) 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 Y/ N

(See appendix C)
5) The patient has a FEV1 / FVC recorded during the audit period Y/ N

6) The patients COPD has been classified and recorded as one of the following
a) Mild
b) Moderate
c) 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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 4 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

16) How many courses of Oral Corticosteroids has been prescribed within the audit period
a) None
b) 1-3
c) 4-5
d) More than 5
17) How many courses of antibiotics has been prescribed for exacerbations within the audit
period
a) None
b) 1-3
c) 4-5
d) 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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 5 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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.brit-
thoracic.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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 6 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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 17d 18 19 20 21 22 23 Total

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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 7 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 8 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 9 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

Appendix D

Sampling Matrix

Population size Sample size:

Total number of patients with COPD 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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 10 (Intranet) PHW (Intranet) / PCQIS
 Public Health Wales COPD

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 Date
Status; Final
Primary care quality and information service July 2008
Intended audience: Public (Internet) / NHS
WeMeReC COPD Audit Version; 0g 11 (Intranet) PHW (Intranet) / PCQIS