A Community of Practice for COPD risk stratification, lessons from Birmingham
Project overview, including who was involved in the project
•Early intervention to optimise care for patients with COPD is vital to prevent future exacerbations and deterioration.•Prior history of exacerbation is the strongest predictor of future exacerbations, but other demographic and disease characteristics are also important.(1)
•A pragmatic decision was taken in 2024/25 by NHS England to target those with rising ‘amber’ risk rather than 'high' risk patients, who may already be known to secondary/community care. However, there is a lack of evidence for individual search tools or templates, and uncertainty around the best approach.(2)
•BSol ICB was unsuccessful in an NHS England funding bid but made adaptions to continue the programme of work using a cluster-randomised study and mixed methods analysis.
•To test the different tools currently available, practices across East Birmingham and Solihull localities were allocated to usual care (usually run via the older Ardens high-risk COPD search tool) or the OPTIMISE search tool. Both then had access to specialist-led MDT to discuss patients identified through the searches to optimise care.
•OPTIMISE rising risk (intervention): Diagnosis of COPD + ≥ 2 exacerbations in last 12months defined by simultaneous antibiotics/steroids + medical research council (MRC) 2&3 + current/ex-smoker, excluding very frail (Rockwood 5,6,7)
•Ardens high risk (usual care): FEV1% predicted <50% or ratio <0.5 OR Home Oxygen OR MRC Score 4-5 OR Cor Pulmonale OR CAT Score 20+.
•Services involved:
o Birmingham and Solihull ICB
o East Locality PCN
o Solihull Community Respiratory Team
o University Hospitals Birmingham NHS Foundation Trust
o Birmingham Community Healthcare Respiratory Team
o University of Birmingham
Project outcomes/impact
•Two localities undertook this project. Patterns of learning were similar across areas despite different demographics of patients and service settings:•East Birmingham:
o 16 primary/secondary care MDTs were held March-December 2025 across 9 GP practices: 4 usual care, 5 intervention.
o 277 patient notes reviewed: 23% known to respiratory services, 48% received advice (medications 8%, non-pharmacological 15%, other advice 15%, locality hub appointment recommended 10%) 19% no changes, 9% not COPD/diagnostic uncertainty, 6% not suitable.
•Solihull:
o 113 patient notes reviewed virtually by community respiratory team: 20% required community appointment, 26% received advice for primary care, 18% already known to respiratory services, 17% no action, 14% not reviewed due to data sharing or inappropriate clinical status, 4% issues with coding/COPD not present.
•The impact on healthcare utilisation following the intervention is currently being analysed.
•High volumes of patients identified during searches (Ardens tool identified higher numbers than OPTIMISE tool) and funding limitations necessitated pragmatic changes in study design from face-to-face reviews to virtual case note MDTs. This enabled review of more records, but potentially reduced individual impact for patients who may have benefited more from holistic face-to-face reviews in place of their usual quality and outcomes framework (QOF) annual review.
•MDTs provided useful opportunities for discussion, troubleshooting and education with practice teams.
•Community of practice meetings held monthly via Teams supported learning across 5 localities at different stages of implementation of similar initiatives.
•Lack of additional funding, protected time for this work and competing clinical priorities limited attendance and speed of progression of the project.
If you were to run the project again, what would you do differently?
•Engage early with primary care networks, neighbourhood teams and wider social care to look at existing pathways and streamline referrals.•A tiered approach could work well, with an enhanced QOF review delivered in primary care and supported by integrated MDTs to discuss challenging cases and provide educational support.
Advice you would have for others undertaking the same type of project.
•Many of the items found within the OPTIMISE tool represent fundamental COPD care, and MDTs offer an opportunity to upskill and promote good practice across a wider area. To maximise impact, it would be beneficial to consider early who else can add value to the work: consider your tobacco dependency teams, social prescribers, mental health teams and council representatives to help tackle the wider determinants of health which can often drive healthcare contacts.•An initial desktop review is helpful to screen out those who may not be suitable for intervention e.g. frail/housebound or are under secondary care already and can be a useful way of reviewing coding errors and misdiagnosis.
•Speak with your information governance teams and investigate honorary contracts to facilitate data sharing across traditional organisational barriers.
•Consider your local population and its needs to identify targets for action that meet the needs of your local community – this could be high intensity users, those at rising risk of exacerbation or those yet to be diagnosed.
•Collect data to show your impact!
1. Hurst JR, Han MK, Singh B, Sharma S, Kaur G, de Nigris E, et al. Prognostic risk factors for moderate-to-severe exacerbations in patients with chronic obstructive pulmonary disease: a systematic literature review. Respiratory research. 2022;23(1):1-213.
2. Health Innovation South West. Lung Health @home. Impact and learning from the COPD Winter Planning Project. Exeter: Health Innovation South West; 2025.