ASCOT project: Asthma and COPD Respiratory Transformation Project
Project overview, including who was involved in the project
This is a Health Innovation Network (HIN) coordinated Respiratory Transformation Partnership (RTP) project. Within Liverpool we identified a cohort of patients who have diagnostic uncertainty, frequently lack diagnostic tests and are coded in primary care as having both COPD and asthma. We know they are high users of Urgent and Emergency care. The dual diagnosis often results in lower use of guideline-based treatment and less access to pulmonary rehabilitation (PR), biologics and other therapies. In addition the project will increase the number of patients who access the Respiratory Virtual Ward as an alternative to hospital admission.This project targets this complex group in areas with the highest health inequality and social deprivation. The project involves 3 sequential steps:
1. Case record review to establish the most likely diagnosis (asthma, COPD or both) based on existing diagnostic evidence.
2. Delivery of missing quality assured diagnostics, including spirometry and FeNO, delivered locally within practices to confirm diagnoses where required.
3. Optimisation of care, delivering COPD optimisation using the OPTIMISE approach or asthma optimisation within practice, supported by specialist respiratory clinicians.
Throughout delivery, specialist respiratory clinicians work alongside practice staff, providing mentorship and training to upskill primary care teams, teams in order to provide enduring respiratory expertise once the project ends.
Patients are supported to access self management tools such as MyCOPD, referred to Citizens Advice on Prescription to address wider determinants of health, and supported to access pulmonary rehabilitation, smoking cessation services, biologics and the Respiratory Virtual Ward, where appropriate.
Project outcomes/impact
We established a project steering group including primary care representation, the Place Commissioner, Business Intelligence and IT support. As a six-month project commenced at short notice and delivered over winter, we seconded staff rather than employed for this project only.We created study documents including a Memorandum of Understanding (so all parties are aware of commitments), study flow chart, information leaflet for participating practices and site checklist. All documents were shared on SharePoint for easy access. We created a study database on EMIS GP system to facilitate data download (for analysis) but also to permit clear recording of outcomes in primary care. This was designed to provide data needed for annual quality and outcomes framework (QOF) submission. We employed a project manager, belatedly, a couple of months into the project.
The project is ongoing and we have delivered the project in a number of primary care practices to date. Outcomes so far:
- Screening and COPD and asthma reviews have been very useful for practice staff education and upskilling. It took some time for staff to reach 30 case screenings per session as they familiarised themselves with EMIS and other systems
- Uptake of diagnostic testing (spirometry, reversibility and FeNO) was unexpectedly high with c.70% attendance to date, despite a majority of attendees failing to attend previous community diagnostic appointments. Local practices communicated appointments.
- Reviews are ongoing with referrals for Advice on Prescription (CAB provided). At completion the practice received their own FeNO machine, training and some consumables, ensuring a lasting legacy beyond the project period.
If you were to run the project again, what would you do differently?
It became clear that a Project Manager was needed. This wasn’t initially budgeted, but funding was found for 1 day per week. This has transformed delivery and we would recommend to anyone.Even with an experienced project manager, coordinating specialist respiratory staff availability, practice staff availability and room availability is very challenging and has slowed the project significantly. We hoped for five full days per week of screening or reviews but are struggling to achieve that, even in month five, because of the challenge of getting everyone together at the same time when rooms are available.
Because of the short delivery timeline, we had to second people to post with no clear back up. We have been significantly slowed by illness or events impacting our first project manager, who we had to replace, our second project manager, the lead COPD specialist nurse and latterly the asthma clinical fellow. A project delivered over a longer time and not over winter would have likely mitigated some of these impacts.
The project highlighted challenges impacting diagnostic reporting and recording in the primary care record and we could have addressed this challenge earlier.
FeNO training for practices was easier to deliver by local physiology staff rather than the manufacturer (which was planned originally).
Advice you would have for others undertaking the same type of project.
A practice manager is essential to coordinate the study and optimise delivery. Having a longer ‘run in’ to the study, longer to deliver and a timeline not over winter would have mitigated some of the factors which have slowed delivery.The first three practices include staff who were steering group members. This helped tackle initial challenges and will help with key initial ‘learning’.
The study documentation was partly designed to ensure all parties were clear what was involved, what was asked of each and signing the Memorandum of Understanding confirmed commitments. This has reduced problems and much uncertainty about the project.
Delivering diagnostics in practice appears to have dramatically improved attendance (in a group where a majority had failed to attend for diagnostics previously).
Feedback from the practice members in the first few practices is universally positive citing genuine improvements in knowledge and understanding and clear upskilling.
The ability to provide a FeNO machine to participating practices ensures an ongoing legacy from the project as well as improving engagement.