UK National COPD Resources and Outcomes Project (NCROP): 2008 National Audit Data Presents An Opportunity to Highlight the Areas for Improvement in COPD Care in the Ageing Population

Keywords: :

• COPD
• Elderly
• National Audit

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is a disease of older people and a common cause of chronic disability and death, there being approximately 25,000 deaths annually in the UK (1). It is the second commonest cause of hospital emergency admissions with approximately 100,000 admissions in 2000 (2) associated with 1 million hospital bed-days in England alone.

The 1997 Royal College of Physicians/British Thoracic Society (RCP/BTS) national audit of COPD has previously highlighted that COPD patients usually present to hospital with acute exacerbations: they are serious (14% of these patients die during admission) and nearly a third will be readmitted within 90 days of the initial admission (3, 4). From the patients’ perceptive, acute exacerbations of COPD appear to be one of the most deleterious features to their quality of life (5), probably compounded by the presence of other comorbidities, especially in older patients. This article highlights some key elements of 2008 National COPD Audit to raise awareness of the potential roles general physicians and geriatricians can play in improving COPD care.

Table 1.  Selected Data on Resources and Organisation Care Audit in 239 units

NATIONAL COPD RESOURCES AND OUTCOMES PROJECT (NCROP)

The National COPD Resources and Outcomes Project (NCROP) is a 3-year study that aims to improve NHS services for people affected by COPD. NCROP is funded by The Health Foundation and is being carried out in partnership with the Royal College of Physicians, The British Thoracic Society and the British Lung Foundation.

A previous RCP/BTS audit of 2003 built upon a limited study first undertaken in 1997. The 2008 National COPD Audit was similar to previous audits of acute COPD care undertaken in 1997 and 2003, albeit with 3 additional elements. This is because since 2003, there has been a significant shift in clinical emphasis and responsibility for managing more COPD within the primary care, much of the workload being carried out by Practice Nurses and GP Airways Clinics (6). The 2008 audit therefore included additional elements assessing (1) the organization of COPD services within the primary care, (2) aspects of COPD management within the GP Practices, and (3) comment from patients about their care.

The National COPD Audit 2008 (6) comprised 5 distinct elements: (1) Resources and organization of care in acute NHS units across the UK; (2) Clinical audit of COPD exacerbations admitted to acute NHS units across the UK; (3) Survey of COPD care within UK General Practices; (4) Patient survey; (5) Primary Care Organization resources and organization of care survey. The data were based on responses from 239 units within 180 acute NHS hospital trusts (98% of acute NHS trusts in the UK) for resources and organization of care; 232 units within 177 acute NHS hospital trusts for clinical audit data; 2861 surveys completed by patients admitted to 221 units (estimated response rate of 45%); 2521 surveys completed by General Practitioners (estimated response rate of 43%); 141 completed surveys from Primary Care Organizations (PCOs), with a response rate of 73%.

The term “unit” was used to describe each participating organization and was defined as “a hospital that admits acute unselected emergency admissions”. Thus, where an entire Trust participated in the audit, the term ‘unit’ refers to that Trust. Where a hospital participated as part of a Trust, the term “unit” refers only to that hospital within the Trust. Participants were asked to define “units” in terms of the functionality of their Respiratory Medicine Departments. Each participating unit completed a retrospective case note audit of up to 60 consecutive patients with admissions identified prospectively between March and May 2008.

SUMMARY OF FINDINGS

Selected results are presented in tabular form (Tables 1–5) for these 5 elements included in 2008 NCROP. (http://www.rcplondon.ac.uk/clinicalstandards/ceeu/Currentwork/ Pages/copdaudit.aspx).

Table 2.  Selected clinical audit data of 9716 patients included in the 2008 NCROP audit

Table 3.  Primary Care Audit data from 141 Primary Care Organisation (PCO)

Resources and organization of care audit showed that there has been a 30% increase in provision of some COPD specific services between 2003 and 2008, such as specialty triage, specialist respiratory ward admission, ICU outreach facility, Early Discharge Schemes (EDS) and others. Despite this rise in provision of services, there were still services that fell short of target levels, e.g., nearly half of the Trusts did not provide an EDS service. The majority (85%) of EDS were run by respiratory specialist nurses, while some other units assigned other healthcare professionals such as general nurses and physiotherapists to run EDS. The difficulty in achieving adequate staffing levels may, in part, explain such shortfalls.

Table 4.  Patient survey results

The provision of Non-Invasive Ventilation (NIV) for acute respiratory failure has also increased (89% to 97%). Nevertheless, many quality indicators for NIV and oxygen assessment were still not met, and many COPD-specific services were of variable quality. In particular, there is limited provision of end-of-life and palliative care services –the report specifically highlighting the need to improve such provision (Table 1). Areas of concern also highlighted in the report included staffing levels, which at many units still fall below the staffing level recommended by The Royal College of Physicians. The practice of providing information about end-of-life care to severe COPD patients while in a stable state seems to be still in its infancy, as only 13% of units have adopted this policy. Given that COPD is a chronically progressive and potentially debilitating disease, such policies need to be disseminated more widely.

Table 5.  General Practitioner (GP) Survey Results (N = 2521)

Clinical audit of admissions showed an increase in proportion that were female and one-year increase in mean age for both men and women compared from previous audit (male and female participants were roughly equal constituting 50% of the sample each). Mean age was 73 years (sd.10), 78% being over 65 years. Approximately 90% lived in a house or flat either alone or with someone else, the rest being in sheltered accommodation or residential placement. Actually, 60% of COPD patients audited did not receive any form of personal care. This audit also showed that a third of patients were current smokers at the time of admission. Cardiovascular disease remains as the major co-morbidity factor in COPD patients. Documentation of weight, height and body mass index (BMI) were poor; only recorded for approximately one third of cases and the MRC dyspnoea score recording was also poor (Table 2). The majority of patients (>80%) had some form of limitation to their performance status in the weeks preadmission.

Initial hospital management of patients was by general physician in 55% of cases, with 78% seeing a respiratory specialist during admission compared to 70% in the previous audit. Ninety-day mortality, but not inpatient mortality, has reduced compared to 2003 audit (13.9% vs. 15.5%) median length of stay fell by 1 day compared to 2003, surprisingly only 11% of patients (1021/8971) were discharged under the care of geriatricians.

An analysis of some of the clinical parameters of these patients at and during admission shows that 82% had a respiratory rate >20, nearly all had an increase in their SOB, only 16% showed CXR changes consistent with pneumonia, 20% had acidosis on admission arterial blood gas (ABG) and FEV1 (recorded in only half the patients) was 38% of predicted (IQR 28–52%).

Primary Care Organisation (PCO) resources and organization of care survey revealed that only 44% of PCOs reported formal palliative care arrangements for patients with COPD. There is significant investment in schemes involving case management, community matrons and admission avoidance despite a conflicting evidence base for effectiveness. There are not many stated examples of good practice exemplifying good team working and collaboration between primary and secondary care. Table 3 highlights the need for further improvements in palliative care programmes in COPD as only 40% of units provide them. Despite this, there seems to be a reasonable level of planning for COPD service development. Improvements still need to be made in early discharge and admission avoidance.

Patient survey showed the overwhelming majority (83%) of patients reported frequent exacerbations of COPD with just over half (57%) stating that they normally sought advice over the phone from their GP, respiratory nurse or hospital doctor, and most (84%) felt they could get advice either directly (26%) or the same morning or afternoon (56%). It is interesting to note that 61% of respondents had contacted their GP prior to admission and that 34% of respondents had stated that their admission to hospital had come via GP. It appears that half of COPD patients who contact a GP for worsening symptoms will be referred to the hospital. A fifth of patients will go straight to the hospital for symptoms, whereas about 80% would rather contact someone such as the GP or NHS helpline first. Given the preceding data, this observation needs to be tempered by the fact that 66% thought they would have needed to go to the hospital, no matter what help they had at home (Table 4).

General Practitioner (GP) Survey showed that health services utilization associated with COPD was substantial. Patients included in the audit made a median of 12 contacts with general practice in the 12 months prior to audited admission, three quarters of admitted patients saw their GP in the month prior to admission, and nearly a third (31%) had 3 or more contacts during the month prior to index admission. Only 15% of the patient sample had undergone pulmonary rehabilitation in the 12 months prior to hospital admission; the reasons for this very small number were unclear. The Report recommends, therefore, that contacts with primary care should be seen as opportunities to optimize therapy, and allow better communication between primary and secondary care.

One such opportunity for improvement and therapy optimisation maybe preplanned “rescue packs”, which include inhalers/nebulisers, steroids and antibiotics. At the moment only a third of the patients of respondent GP practices were given these packs. Another would be data to monitor disease progress regularly in community setting to aid future clinical decision making. Over 80% of patients have had at least 1 consultation with their GP in the 12 months previous to admission and that at least 75% had a visit to the GP in the 4 weeks prior to admission (Table 5).

DISCUSSION

This audit, although carried out to highlight specialist respiratory services in COPD care also provided an insight into problems faced in COPD care in general. As a chronically progressive disease, optimizing current support services to maintain satisfactory levels of care appears essential. As most COPD patients are older people, and a considerable proportion of them are looked after by care of the elderly physicians and general physicians, it is important that these specialists are aware of what possibilities and what limitations are out there in COPD care. It is also important for geriatricians and general physicians to know what aspect of these patients’ care remains under development and how they may be involved in improving such aspects. This audit also provides geriatricians and general physicians and other healthcare professionals who deal with COPD patients with information on the care within the community setting and, importantly, patients view on their condition and service they receive.

With the increasing life span of the population seen in Western societies, the number of those aged over 65 years is expected to double by 2025. The 2008 National COPD audit confirms that the average age of patients who are admitted with acute exacerbation of COPD is increasing, and the population projections suggests that it is likely to continue in the future. Geriatricians in the UK are valuable assets for the older population. They work across primary and secondary care and look after both acutely unwell older patients and frail and terminally ill patients. As highlighted in the 2008 National COPD audit, geriatricians and general physicians (some of whom may also be specialists in Care of the Elderly) look after a substantial proportion of COPD patients, at least initially. Their awareness of availability of local respiratory services and support networks would help to improve patients’ experience and care and hence improvement in outcome including quality of life.

It is likely that geriatricians will be increasingly involved in the care of COPD patients who also have other major co-morbidities both in secondary care and intermediate care settings. The task of decision making and management at the primary-secondary care interface and secondary-primary care interface, for the older spectrum of this subset of population with chronic disabling condition, will almost certainly land at the geriatricians’ door. Furthermore, the end-of-life support and advanced care planning are the areas where geriatricians’ skills and experiences are essential for improving patients’ care and relatives’ experience, by working together with primary care practitioners and colleagues from the respiratory teams.

In summary, health care professionals outside the respiratory teams especially geriatricians, general practitioners and general physicians also should actively engage in care of COPD patients in the areas of prevention, limitation of disease progression, improving diagnosis and appropriate management, appropriate and timely referral to local experts and support services, advanced care planning in frail COPD patients with extreme old age and end-of-life care decisions. Being aware of the organizational structure of local respiratory services, referral system and support facilities available in the community and developing close working relationships with respiratory teams and primary care teams, patient groups and relatives, is the suggested path forward.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

ACKNOWLEDGEMENTS

The authors would like to thank the National COPD Resources and Outcome Project (NCROP) Executive Implementation Group for commissioning to write this editorial based on the findings of 2008 COPD RCP/BTS/BLF national audit. We also would like to thank Miss Nancy Pursey, National COPD Audit 2008 Acting Project Manager, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians for her useful comments and suggestions. The authors are grateful to the Royal College of Physicians Clinical Effectiveness and Evaluation unit NCROP team for the provision of data and reports that have contributed to this editorial. Further information on this work may be obtained from www.rcplondon.ac.uk/copd.

Disclaimer

PKM is a steering group member of NCROP.