COPD diagnosis must improve, says report by Royal College of Physicians

BMJ 2016; 355 doi: (Published 18 November 2016) Cite this as: BMJ 2016;355:i6184
  1. Jacqui Wise
  1. Kent

Accurate diagnosis of chronic obstructive pulmonary disease (COPD) must improve to avoid expensive, unsafe, and ineffective treatments being prescribed to people who do not have the condition, a report from the Royal College of Physicians has found.1

The report, COPD in England—Finding the Measure of Success, also suggests that some of the most clinically useful and cost effective treatments for COPD, such as nicotine replacement therapy, targeted drug treatment, and pulmonary rehabilitation, are underused.

Some 1.2 million people in the United Kingdom have had COPD diagnosed, and 30 000 people die of the disease each year. Previous national COPD audits have concentrated on acute management of COPD in secondary and tertiary care, but the current report looked at primary care.

The audit programme originally intended to collect data directly from general practices in England, but this was not possible. Instead, the report combines publicly available data from 2014-15 in England with relevant audit data extracted from Welsh general practices.

Data from the Quality and Outcomes Framework (QOF) in England show that spirometry was used to confirm the diagnosis in about 90% of people with COPD—a similar figure to that reported from the Welsh QOF data. However, when data were extracted directly from Welsh general practices, only 20% were found to have an electronic record of post-bronchodilator FEV1/FVC (forced expiratory volume in one second; forced vital capacity) ratio. And, of the people on the COPD register who did have this test recorded, 27% had a value that was not consistent with COPD.

The report says that spirometry is fundamental to a diagnosis of COPD and should be carried out by trained and competent healthcare workers. It recommends that general practices and clinical commissioning groups review their registers and consider whether evidence is sufficient for all patients to be on the COPD register. Those with an FEV1/FVC ratio higher than 0.7 should be reassessed for an alternative cause of symptoms.

It adds that tobacco dependence treatment is underused in patients with COPD, as is flu vaccination. It recommends that anyone with a Medical Research Council breathlessness grade of 3 or higher should be offered and encouraged to do pulmonary rehabilitation.

GPs should also ensure that patients with COPD are able to use their inhaler devices, are offered optimal bronchodilator medicine, and are issued with inhaled corticosteroids only when this is likely to be beneficial.

Noel Baxter, clinical lead for the audit’s primary care work stream, said, “It will come as no surprise to people working in and with general practice who are interested in outcomes for people with COPD that the high achieving QOF results have provided false assurance about the quality of care for these people.

“Detailed, coded data from Welsh general practice has raised the alarm about how confident we can be about the metrics we are measuring and, subsequently, about what is actually happening in terms of the quality of diagnosis and the utilisation of the right interventions.”


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