Clinical Audit on Chronic Obstructive Pulmonary Disease (COPD) Management in Primary Care: A Quality Improvement Project from Hong Kong

Figures & data

Table 1 List of Audit Criteria and Performance Standard of the Study

Item No.	Recommendations and Audit Criteria	Standard
1	Recommendations: All COPD patients should receive a regular review for monitoring of symptoms and discussion on management plan. Criterion 1: % of COPD patients with a pre-scheduled appointment in GOPC.	85%
2	Recommendations: All COPD smokers should be advised on smoking cessation and be referred to Smoking Counselling and Cessation Services (SCCS).
	Criterion 2: COPD patients who are smokers:
	a. % of COPD patients referred to SCCS in the audit phase; or	55%
	b. % of COPD patients ever attended SCCS in the audit phase.	50%
3	Recommendations: All COPD patients should receive seasonal influenza vaccine (SIV) annually unless contraindicated. Criterion 3: % of COPD patients received SIV in the audit phase.	50%
4	Recommendations: All COPD patients should receive pneumococcal vaccine (PCV) unless contraindicated. Criterion 4: % of COPD patients received PCV before.	50%
5	Recommendations: Spirometry is recommended for all COPD cases at diagnosis or when the alternative diagnosis needs to be ruled out, and to monitor the disease progression. Criterion 5: % of COPD patients with spirometry test done before.	50%
6	Recommendations: All efforts should be made to reduce the acute exacerbation of COPD (AECOPD). Criterion 6: % of COPD patients admitted to hospitals due to AECOPD during the audit phase.	<10%

Table 2 Summaries of Areas of Deficiencies and Strategies Implemented

Areas of Deficiencies	Strategies Implemented
Policy level
Lack of a responsible team to coordinate the service delivery centrally for COPD care	Set up of COPD Audit Working Group in each cluster led by QA subcommittee member of COC (FM) in HAHK. The members of the audit Working Group are from both doctors and nurses, with audit subject officer or coordinator assigned.
Lack of regular review to monitor the service performance	Annual service review by Head Office Primary Health Care team on COPD care in all clusters and share out data for FU action.
Inadequate collaboration with SOPDs	Collaborate with respiratory specialists in regional hospitals Delineate clearer referral criteria of handling severe COPD cases and download mechanism for stable COPD cases.
Practice Level
Lack of COPD data capture	“COPD Module” has been set up in the CMS since 2016 to facilitate the COPD-related data capture.
Lack of case registry	COPD case list of each cluster was retrieved by the HAHO statistical team and shared out with all COC(FM) QA subcom members.
Lack of guideline or protocol	Adopt standard guidelines and structural COPD assessment form or checklist.
Lack of aligned workflow	COPD management workflow was streamlined at cluster level. All doctors will book regular FU for COPD cases during routine consultation. COPD patients without a regular FU appointment were contacted by nursing staff to enquire about symptom control and a FU appointment would be offered if the patient had not received proper assessment in the recent one year.
Lack of office-based spirometry	More office spirometry machines had been purchased in local GOPCs to cater for the increasing service demand.
Lack of drugs for COPD care, such as LAMA/LABA	Introduced LAMA/LABA to Family Medicine Specialist Clinic in some clusters since 2018.
Staff
Knowledge gap on COPD management	Improvement on education and training through online class, workshops and journal clubs.
Poor compliance to COPD management guideline	All COPD patients were managed according to the grouping based on the latest GOLD guideline, compliance supervised by clinic doctor in charge.
Lack of communication and collaboration within the team	Sharing of workload among staff of all ranks in the team and closer collaboration with allied health team such as physiotherapist, occupational therapist and dietitian. CMS reminder had been set up by clerical staff upon patient’s registration to remind them to receive vaccination.
Lack of feedback	Quarterly to biannually review on the progress at local clinic level, and deficiencies were tackled promptly.
Patient
Lack of awareness, knowledge and/or motivation on smoking cessation	Regular health talks and nurse counselling on smoking cessation were held at clinic level.
Lack of self-empowerment programs on COPD care	Closer collaboration with allied health workers to organize self-empowerment class and patient support groups on COPD care.

Table 3 Demographic Characteristics of COPD Patients in the Two Phases

	Phase 1	Phase 2	P value
COPD cases included in data analysis (n)	10,385	9513	–
Gender			0.53
Male	9108 (87.7%)	8371 (88.0%)
Female	1277 (12.3%)	1142 (12.0%)
Age (years)	75.3±9.9	75.1±9.8	0.92
<40–49	117 (1.1%)	92 (1.0%)	0.12
50–64	1559 (15.0%)	1450 (15.2%)
65–79	5031 (48.4%)	4732 (49.7%)
≥80	3678 (35.4%)	3239 (34.0%)
Smoker	3102 (29.9%)	3008 (31.6%)	0.08
Case referred to specialist care during the audit period	1144 (11.0%)	1057 (11.1%)	0.83

Notes: Data are shown as no. (%) of cases or mean±standard deviation.

Table 4 Comparison of the Performance on the Audit Criteria Among COPD Patients Included in Phase 1 and Phase 2

Item No.	Audit Criteria	Phase 1 (n=10,385)	Phase 2 (n=9513)	P value
1	COPD patients with pre-scheduled appointments in GOPC	8496 (81.8%)	8345 (87.7%)	0.00001
2	COPD smokers	3102 (29.9%)	3008 (31.6%)	0.08
	a. Have ever been referred to SCCS before	1788 (57.6%)	1842 (61.2%)	0.004
	b. Have ever attended SCCS before	1578 (50.9%)	1653 (55.0%)	0.001
3	COPD patients who have received SIV in the preceding year	4866 (46.9%)	5422 (57.0%)	<0.00001
	<65 years old	324 (6.7%)	484 (8.9%)	0.00002
	≥65 years old	4542 (93.3%)	4938 (91.1%)
4	COPD patients with have received PCV	4227 (40.7%)	5665 (59.6%)	<0.00001
5	COPD patients with spirometry test done	1983 (19.1%)	6140 (64.5%)	<0.00001
6	COPD patients admitted to hospitals due to acute exacerbation (AECOPD)	1327 (12.8%)	910 (9.6%)	<0.00001
	Frequencies of hospital admission
	Nil	9058 (87.2%)	8603 (90.4%)	<0.00001
	Once	824 (7.9%)	583 (6.1%)
	Twice	283 (2.7%)	187 (2.0%)
	≥3 times	220 (2.1%)	140 (1.5%)

Note: Data are shown as no. (%).

Figure 1 Comparison of hospital admission rate due to AECOPD among different age groups between the two phases.