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COPD management

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COPD management Powered By Docstoc
					   A Patient-centred, IT-based
  Audit of COPD in Primary Care

                Rupert Jones


GP Plymouth
Respiratory Research Unit
Peninsula Medical School
rupert.jones@pms.ac.uk
                              The impact of COPD
  • 30,000 deaths / year in the UK1–3
  • Currently 5th greatest cause of death
    worldwide – 2.5 million in 20004
  • By 2020, COPD 3rd leading cause of death5
  • Progressive disability and breathlessness6




1. ONS. Mortality Statistics. 2000
2. General Register Office. 2000
3. General Register Office. 2001
4. Murray CJL et al. 2001
5. Murray CJL et al.1997
6. Pauwels RA et al. 2001
  3.0     Coronary
                            Mortality trends
                                                                                 All other
           heart              Stroke         Other CVD           COPD            causes
          disease
  2.5


  2.0


  1.5


  1.0


  0.5

            – 59%             – 64%            – 35%            + 163%            – 7%
    0
         1965–1998          1965–1998        1965–1998        1965–1998        1965–1998

                 Percent change in age-adjusted death rates; proportion of 1965 rate in
                                              the USA
NHLBI/WHO 2002
                Overview
• Early accurate diagnosis
• Guideline based management
  – Smoking cessation
  – Immunisation
  – Appropriate drugs
  – Appropriate non drug treatment
    • Pulmonary rehabilitation
    • Oxygen
      Problems with Primary care
             Spirometry
• Equipment
• Training and support for practice
  nurses
• Quality control
• Interpretation of data
Jones RCM, Freegard S, et al.
The role of the practice nurse in
the management of COPD.
Prim Care Resp J 2001;10:106-108.
        Patients concerns

•   Limitations on activities
•   Loss of independence
•   Fear of breathlessness
•   Fear of dying
         What do patients tell us?
• Want to know what is wrong with lungs
• Compliance good; but lack of information
• Knowledge reduces fear:
         “What I know about, I can deal with”
• Little useful help on:
    –   Self management
    –   Smoking cessation,
    –   Diet
    –   Exercise


Jones RCM, Hyland M et al. 2004 Prim Care Resp J.
Jones RCM, Gray M et al. Thorax 2002; 57 S3:15
                Exercise
• What can they
  safely do?
• Specific info on:
  – type
  – intensity
  – duration
             Diet


• Obesity needs correcting
• BMI falling is poor
  prognostic sign
• Advice for dyspnoeic patient
What are main components of
    a good assessment
•   Lung function
•   Functional ability /exercise tolerance
•   Quality of life
•   Education / Self management
•   Other management as per NICE
    – Drugs
    – Oxygen
    – Pulmonary rehab
    – Referrals to specialist (doctor, nurse,
      physio)
      What does GMS contract
             address?
•   Register
•   Diagnosis by spirometry recorded
•   Smoking record
•   Smoking advice record
•   FEV1 record
•   Inhaler technique record
•   Influenza immunisation record
   Plymouth Audit outline 1
• Standard PCT approved assessment
  package
• Involves patient-centred outcomes
• Performed by independent trained
  nurses visiting practices
            Plymouth Audit
•   Nurse assessment
•   Patient self-assessment
•   Education
•   Action plan
•   Reports
•   Follow up
        Nurse section

– Core data
– Exacerbations
– Smoking
– Spirometry
    Patient self assessment
• MRC dyspnoea scale
• Clinical COPD Questionnaire
• Lung Information Needs Questionnaire
               Reports
• To patients
• To GPs/practice nurses
  – Severity
  – Exacerbation status
  – Smoking status
  – Questionnaire scores
  – Information needs
  – Recommendations for Rx as per NICE
                 Report to patient
We have assessed your lung disease and this is a report of our findings.

Spirometry (breathing tests): These shows that your disease is
  classified as being Moderate. Your disease shows reversibility to
  relieving medication.

Exacerbations: You have had 4 exacerbations in the last 12 months.
  You have had 0 admissions to hospital for COPD.
  A written action plan is recommended and will be provided by the
  nurse
Smoking: You are a smoker. Your total cigarette consumption is 66.0
  pack years (one pack year is 20 cigarettes a day for 1 year)

Your breathing status: I am not troubled by breathlessness except on
  strenuous exercise (MRC dyspnoea scale grade 1)

Nutrition
For your height your weight is classified as being: Underweight (BMI 18).
   Underweight = <18.5 ; Normal weight = 18.5-24.9; Overweight = 25-
   29.9; Obesity = BMI of 30 or greater
                    Report to patients 2
The Clinical COPD Questionnaire
   CCQ measures how the disease affects your life, the higher the score the worse the
   quality of life. 0 (very good) to 6 (extremely poor).
   Your scores were as follows:
Total score: 3.4 Symptoms: 3 Function: 3.5 Mental state: 5

The Lung Information Needs questionnaire
  LINQ measures information needs, the higher the score, the greater the need for
  further information. In any domain if the score is more than 2, we suggest you seek
  information.
        Your scores were as follows:
        Disease knowledge: 5
        Medicines:             1
        Self management: 4
        Smoking:               3
        Exercise:              5
        Diet:              1


British Lung Foundation leaflets are available from the nurse or at the practice.
Further information is available from their website - www.britishlungfoundation.org
                      Patient report 3
Treatment
According to guidelines the following steps are recommended for patients at your
   stage of the disease, which is Moderate

Smoking cessation- please see your practice nurse
Influenza vaccination - your vaccination status is up to date
Pneumococcal vaccination - your vaccination status is not up to date
Keep active and eat a healthy diet

Your current drug treatment is optimum for you and no changes are
  recommended.

For any patient MRC grade 3 and above:
   Pulmonary rehabilitation - a programme of exercise and education is usually
   recommended, but it is not suitable for everyone, so you should discuss this
   with your GP/practice nurse.
Oxygen Treatment
An Oxygen Assessment is not recommended.
            Action plans
• Administered to all with exacerbations
• Includes colour chart
              Audit cycle
• Repeat after 1 year
• Look at outcomes
  – Bed days
  – Questionnaires
  – Prescribing
  – Smoking
  – Referral
       Benefits to patients
• All get expert assessment
• All get a report
• Opportunity to involve themselves in
  their disease management
• Appropriate management including
  drugs and referrals to smoking
  cessation, pulmonary rehab etc.
         Benefits to practices
•   Expert nurse assessing their patients
•   GMS contract quality marker points
•   No cost to them
•   Education for the practice
               Benefits to PCT
• Uniform data about all involved practices
• Rational prescribing of „expensive‟ treatments
• Guideline led management-
  – Educational for doctors, nurses and patients
  – May reduce hospital & other costs
• Money from GMS for improved outcomes not
  just ticking boxes

				
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