Improving the diagnostic certainty and treatment optimisation of patients on the COPD register - COPD Optimisation Project Pilot (COPE) (ID 437)
none
Funding: None
Abstract
The problemCOPD is fifth most common cause of death in UK
Stats following exacerbation are particularly chilling
COPD is underdiagnosed, often misdiagnosed, until the disease has progressed leading to reduced QoL and early morbidity
At risk patients are not commonly identified early and proactively managed
Good practice missed by audit due to incorrect readcodes
A solution – COPD Optimisation Pilot ProjEct (COPE)
Aims
Improve the diagnostic certainty and treatment optimisation of patients on COPD register
Move to proactive rather than reactive management
Intervene early in disease to educate and empower patient to self-manage their condition in order to keep well
Ensure correct readcodes for accurate recording and audit
Method
Identify and target patients at higher risk of exacerbation in pilot sites in Hywel Dda UHB
Review the patient concentrating on high-value interventions
- Confirm or correct the diagnosis
• spirometry
- Optimise non-pharmacological management
• Smoking cessation
• Vaccinations
• Refer eligible patients to Pulmonary Rehabilitation or local COPD+ expert patient programme
- Optimise pharmacological management
• Phenotype the patient according to All Wales COPD guidelines
• Prescribe according to these guidelines
• Consider the Green Agenda
• Ensure patients have a written or digital management plan. Either a written management plan or the NHS Wales COPDHub app.
• Refer appropriate patients to secondary care
Results
Increased diagnostic certainty
Increased referral rate to smoking cessation services
Increased referral rate pulmonary rehabilitation and COPD+ programmes
Increased numbers of patients treated accorded to All Wales COPD guidelines
Increased number of patients having written/digital management plans
Increased downloads of NHS Wales COPD app
Supported by NHS Wales COPD lead
Next Steps
Development of digital templates for EMIS/VISION with NACAP approved readcodes is in hand
Trial in identified pilot sites across three Health Boards
Rollout across Wales alongside a support educational package
Conflicts of interest: None
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