Abstract

Title:
A Primary Care Network (PCN) Pilot to Implement Optimisation Reviews Following Moderate or Severe COPD Exacerbations

Background:
Living Well Partnership, a large PCN in Southampton, supports over 900 patients with Chronic Obstructive Pulmonary Disease (COPD). Exacerbations of COPD are significant clinical events associated with permanent lung function decline, heightened cardiopulmonary risk, and reduced quality of life. This pilot aimed to prioritise post-exacerbation patients for a structured optimisation review with a respiratory nurse specialist, using the “SCOPES” template developed by the Act on COPD South East forum.

Method:
Patients with a moderate or severe exacerbation between 1st September 2024 and 31st January 2025 were identified and referred by practice staff. Reviews were conducted 2–4 weeks post-exacerbation by respiratory nurse specialists. The SCOPES template structured the review across six domains: smoking cessation, co-morbidity review, optimisation of therapy, pulmonary rehabilitation referral, exacerbation history review, and self-management support.

Results:
Of 204 patients coded as having had an exacerbation, 82 (40.2%) received a SCOPES review. An additional 176 COPD annual reviews (usual care) were completed during the pilot timeframe.

Compared with usual care, SCOPES reviews resulted in:
• 13.2% more pulmonary rehabilitation referrals
• 3.5% more smoking cessation referrals
• 100% more referrals to respiratory physicians
• 8.2% more medication/inhaler changes
• 60.1% more patients had a QRISK3 score completed
• 64.9% more patients received a personalised self-management plan

Conclusions:
Although less than half of exacerbating patients received a SCOPES review, the pilot demonstrated the value of structured, post-exacerbation assessments. SCOPES improved the identification and referral of patients needing further support, including pulmonary rehabilitation, smoking cessation, and secondary care. It also facilitated more frequent optimisation of inhaled therapies and cardiovascular risk assessment. Importantly, the timing of the review—shortly after an exacerbation—may have increased patient receptiveness to intervention. Future work should focus on improving case-finding mechanisms, possibly using risk stratification tools, to ensure timely reviews for all high-risk patients. Embedding SCOPES into routine post-exacerbation care may enhance outcomes and reduce future exacerbation risk in primary care COPD populations.