This study was the largest clinical audit on COPD management ever conducted in Hong Kong and describes the current practice on COPD care in public primary care settings.
In phase 1, marked deficiencies were identified in various aspects of COPD care. According to NICE guideline, COPD cases should be assessed at least twice per year (15), depending on its severity. Despite the recommendation, 20% COPD patients were found not to have a prescheduled FU for regular assessment in phase 1. To overcome this, we went through their CMS record to see whether they had been FU by other health care workers such as private doctors or respiratory specialists. All of them were called up by nursing staff enquiring about their symptom control. For those without being assessed by any doctor in the recent one year, an appointment for doctor’s consultation within 6 months had been offered. With such effort, many lost-to-FU COPD cases came back to GOPCs for spirometry and clinical assessment, with 87.6% of all COPD cases having regular FU in GOPCs in phase 2 (P < 0.0001).
Cigarette smoking is a major cause of COPD and smoking cessation is the most effective intervention to slow down its disease progression. Therefore, all professionals should, at every opportunity, advise and encourage the smokers to stop the smoking. Having said so, smoking cessation can be very difficult for patients with COPD, and there is no single factor that predict the long-term success. (16) A combination of behavioral and pharmaceutical interventions has been provided at the SCCS in our department since 2010. Although we encouraged all smoker COPD patients to attend the SCCS during their routine consultation, only about half of them were referred and even fewer (43.9%) actually attended in phase 1. More disappointing is that, despite our proactive promulgation, the condition in phase 2 was not significantly improved although the trend was positive. These findings were consistent with literature that COPD smokers are poorly motived to quit smoking (9). Another possibility is the physicians related factor. For example, literature shows that some physicians do not routinely deal with smoking cessation during their consultations with smokers, partly due to the lack of cessation specific knowledge and skills and partly due to insufficient consultation time. (8) This is particularly true in the GOPCs of HA where averagely 6 minutes is allocated for each consultation. Definitely a more proactive approach is needed to promote the smoking cessation among all health care workers and COPD patients.
For criteria 3 and 4 on SIV and PCV vaccination rate, although our performance was significantly improved during the audit cycle, only about half of COPD patients were vaccinated against SIV (49.2%) and PCV (57.1%) in phase 2. Indeed, influenza vaccination coverage rates among COPD patients remain low in many countries (10–11). In HK, all elderly patients aged 65 years or older are entitled to receive the SIV and PCV for free under Government Vaccination Program (GVP). However, the breakdown figure of SIV coverage among those under 65 yrs were still far from satisfactory (7.6% in phase 1 and 23.0% in phase 2). Given the widely established evidence on the long-term benefits of SIV on COPD care, such as reduced number of exacerbations, hospitalizations and decreased all-cause mortalities (6), we would like to propose that government should launch out free SIV to COPD patients of all ages to reduce the mortality.
It is disappointing to find that only 29.6% COPD patients were found to have conducted spirometry test before in phase 1. The reasons accounting for this poor performance is multifactorial. At doctors’ level, some doctors often make the diagnosis of COPD based on clinical features only. At clinic level, spirometry service was previously only available at hospital setting. Therefore, all suspected patients had to be referred to Respiratory Specialist Clinic to do the lung function test with a waiting time ranging from months to 2 years in HA. To plug this loophole, a series of education talks on the proper diagnosis and management of COPD were delivered, with importance of spirometry test emphasized. Furthermore, almost all GOPCs were equipped with spirometry machine during the implementation phase so that the spirometry test could be conveniently performed locally within 2–4 weeks. In addition, at least 1–2 designated nurses from each GOPC have been trained on how to perform the spirometry correctly and the standard of practice was aligned and audited. With such facilitations both on the skill set and tool set, it is not surprising that a tremendous improvement was observed for this criteria in phase 2 (72.7%, P < 0.00001).
The last criteria 6, the rate of AECOPD leading to hospital admission, is the only outcome criteria of this audit as well as the most important one. In phase 1, we found it quite alarming that almost 1 in 5 of COPD patient had been admitted to hospital due to AECOPD in the preceding year (17.9%). This data was similar with Canada studies which showed that approximately 20% of COPD patients had experienced severe acute exacerbations annually. (17) Indeed, acute exacerbations lead to accelerated decline in lung function, worse health status and increased health care utilization, and are the main cause of COPD-related hospitalizations and mortality.(18) In order to decrease the burden of exacerbations, prevention and prompt treatment of exacerbations are important goals in COPD care. In view of this, a series of service enhancement strategies were executed. Firstly, early identification of COPD patients with spirometry and proper staging according to the GOLD guideline was done as mentioned above. Secondly, all COPD cases were managed according to their severity, putting right patients at the right level of care. Stable group A patient would continue regular FU at GOPCs where only short acting bronchodilators are available. Group B patients would be managed at Family Medicine Specialist Clinic (FMSC), where Long Acting Antimuscarinic Antagonist (LAMA) was newly introduced in 2018 to improve the symptom control. For more severe group C/D patients that warrant advanced care, a timely referral to the specialist care would be initiated. Lastly, relatively stable AECOPD patients were advised to FU at GOPC more closely instead of being admitted to hospital. With all these proactive interventions and efforts, the AECOPD rate was significantly reduced to 13.5% in phase 2.
Strength and Limitations of this study
To our knowledge, this study was the first clinical audit on COPD management ever conducted locally and has provided important information on current COPD care in public primary care settings. The sample size was quite large with more than 2000 cases included in both phase 1 and 2. In addition, all audit criteria are based on objective assessment parameters with data being retrieved from the computer system from HA, therefore recall basis or data entry error had been minimized.
That said, this study has several limitations. First, the study was carried out in one single cluster of HA and therefore selection bias might exist. These results from the public primary health care sector might not be applicable to the private sector or secondary care. Never the less, since COPD cases from all 13 GOPCs of KCC have participated in the clinic audit, these data are well representative of COPD care in the public primary care settings and have provided important background information for future improvement strategies. Second, this clinical audit mainly focused on some short-term outcome aspects of COPD management. Long-term outcomes such as lung function improvement, smoking cessation rate or COPD mortality rate were not compared. In addition, some process indicators such as assessment on bronchodilator use had not been included. Subsequent studies focusing on the long-term outcome criteria may provide a better guide for the evaluation of COPD care. lastly, the one-year intervention phase might not be long enough for some criteria to achieve the targeted standard, although marked improvements were shown. Therefore, continuous effort in more audit cycles would be needed to further improve the clinic outcome in COPD care.