Audit recommends key areas for improvement in respiratory care

Basic quality respiratory care is improving but there are key areas where practices and teams could transform care, according to the latest report from the National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP).

The data, collected from nearly half (47%) of general practices in Wales during 2017-18, shows that since the last audit there has been: an increase in the proportion of patients having a record of the post-bronchodilator (FEV1/FVC) <0.7 gold standard diagnostic test; a rise in the numbers of eligible patients being referred for pulmonary rehabilitation; and that more adults diagnosed with asthma in the past 2 years have had one or more objective measurement recorded.

But key areas needing improvement are:

Diagnosis: 
Only 35% of patients with COPD had a chest X-ray or CT scan within 6 months of their diagnosis. Only 79% of patients with asthma had some kind of objective test recorded. Only 24% of adults with asthma and 9% of children had a spirometry test

Smoking: 
Only 79% of patients with COPD had their smoking status recorded in the past year. 29% of patients were current smokers. Only 72% of adults with asthma and 34% of children (over 6 years) had their smoking status recorded in the past year. 17% of adults were current smokers. Less than 0.6% of patients were asked about exposure to second-hand smoke.

Providing high value care:
Only 62% of eligible patients with COPD had a record of a pulmonary rehabilitation referral in the past 3 years. 
Three quarters (75%) of adults with asthma and 80% of children had no evidence of a personalised asthma action plan in the past year.
Only 45% of patients with COPD prescribed an inhaler had evidence of an inhaler technique check in the past year. Only 49% of adults with asthma and 35% of children prescribed an inhaler had evidence of an inhaler technique check in the past year.

Mental health:
Nearly one third (32%) of patients with COPD had a diagnosis of anxiety and 32% had a diagnosis of depression. One third (33%) of patients with asthma had a diagnosis of anxiety; 31% had a diagnosis of depression and 10% of 6–18 year olds had mild/moderate mental health illness.

The report’s key recommendations are:

• Ensure all patients with COPD diagnosed in the past 12 months have a record of a chest X-ray within 6 months.
• Ensure all patients with asthma have a diagnosis based on clinical assessment supported by objective tests demonstrating variable airflow obstruction or airway inflammation
• Ensure smoking status is recorded for all patients and that exposure to second-hand smoke is discussed and coded.
• Ensure all patients with asthma have a personalised asthma action plan.
• Ensure inhaler technique checks are completed for all patients.
• Ensure patients are screened for mental health conditions as part of their annual review.

Katherine Hickman, PCRS Executive Vice Chair and NACAP Primary Care Clinical Lead, says: “The data collected in this primary care audit reflects what basic quality care looks like. Care that all patients with COPD and asthma should be entitled to. As a practice you don’t have to commit to overnight transformation in all aspects of care, but how about picking one or two elements you could work on together? I hope the quality improvement suggestions provide the basics of a framework to enable practices to start to make small but significant changes and improve the quality of respiratory care patients are receiving.”

PCRS resources you can use to improve care provided by your practices or teams:

• Asthma Guidelines in practice – a PCRS consensus
• All that glitters is not GOLD, nor is it even NICE is a consensus-based article that sets out a simple treatment pathway distilled from current guidelines.
• The PCRS Tobacco Dependency Guide