A Study Into Airways Disease Case Finding and Management (ASSIST)

Background Chronic Obstructive Pulmonary Disease (COPD) COPD is a disease of the lungs characterised by airway inflammation leading to airflow obstruction. It is a progressive and largely preventable disease caused by the inhalation of noxious gases generally through cigarette smoking. Patients experience persistent symptoms including breathlessness, reduced exercise tolerance and an increase in the production of mucus in the airways. The impact of the disease to the individual is substantial in terms of physical disability and psycho-social issues.

Patients with COPD can experience an exacerbation of their disease, defined as a sudden worsening of symptoms above and beyond the individual's normal daily variation. COPD exacerbations are the second most common cause of emergency hospital admissions in the UK, with an estimated 94,000 admissions per annum. Indeed, COPD is one of the most expensive inpatient conditions in the UK, costing the National Health Service (NHS) over £800 million in direct healthcare costs. COPD is also set to become the third leading cause of death worldwide by the year 2030, surpassed only by heart disease and stroke. Despite this high level of mortality, public awareness of COPD is low in the United Kingdom (UK): around 89% of the general public have never heard of COPD.

Under-diagnosis of COPD Evidence suggests that 13% of people over 35 have COPD but many are diagnosed late and most are currently undiagnosed. Almost a third of patients admitted to hospital with a COPD exacerbation had not been diagnosed. Opportunities for early diagnosis of COPD are missed in primary care: a recent study demonstrated that 85% of patients had consulted primary care with lower respiratory symptoms in the five years immediately before their diagnosis of COPD. The insidious onset of COPD means undiagnosed patients may unconsciously modify their way of life, and only present to primary care in the later stages of disease. Furthermore, smokers, who constitute a substantial portion of the target population for case finding, have been shown to hold self-exempting beliefs and thus may be less likely to present to primary care. In addition, many patients visit their GP for problems related to COPD, such as chest infections and breathlessness, but the correct diagnosis is not made.

The importance of early diagnosis of COPD National health policy initiatives in the UK underscore improved diagnosis as a priority Early diagnosis of COPD followed by optimisation of treatment has potential cost savings for the NHS of more than £1 billion over 10 years . Prevention strategies (smoking cessation, dietary, exercise promotion, self-management and vaccination) can be targeted on this group of patients to maintain and improve health, and appropriate pharmacologic therapies (that can improve symptoms, exercise tolerance and quality of life and reduce the risk of exacerbations) commenced in newly identified people if appropriate. A recent systematic review of the literature concluded that a combination of a screening questionnaire and micro-spirometry seems to demonstrate the best overall screening test accuracy, but there has been little uptake of this strategy in UK primary care and doubts remain as to its feasibility and cost-effectiveness. However, whilst a variety of approaches to case finding have been trialled world-wide published studies have been variable in quality and the most effective, economical method of screening has yet to be identified. The National Institute for Health and Clinical Excellence (NICE) and the Department of Health (DoH) in the UK have recommended both systematic and opportunistic case finding to diagnose symptomatic patients . The UK National Screening Committee concurs, explicitly recommending case finding (defined as targeting patients with symptoms suggestive of COPD) rather than screening (defined as identifying apparently healthy people who may be at increased risk of COPD). A recent All Party Parliamentary Group report on Respiratory Deaths (APPG RD) concluded that tools to aid health care professionals to case find for COPD need to be developed in order to prioritise for use at national level.

Case-finding: identifying symptomatic but not yet diagnosed patients 'TargetCOPD' is an ongoing NIHR funded randomised controlled trial comparing the cost-effectiveness of two alternative case-finding approaches for identifying undiagnosed COPD. Both approaches rely on patient self-reported questionnaires to identify symptoms; one opportunistically administered, the other systematically administered. 'TargetCOPD' should provide some useful information on case-finding using questionnaires. However, evidence suggests that alternative approaches to case finding such as electronic searches based on routine primary care data may be a valuable tool for identifying symptomatic patients with as yet undiagnosed COPD. However, further validation of electronic case-finding strategies is required.

In early 2015 the Wessex CLAHRC, WAHSN and West Hampshire CCG ran a service development project in two surgeries in West Hampshire using notes review and a different electronic case finding instrument, GRASP-COPD. The project identified a need for further investigation into the efficiency of case-finding strategies.

The investigators propose to use an electronic case-finding algorithm developed and validated in Birmingham, UK as part of a NIHR funded programme grant centred on case finding for COPD.

'Complex' patients: identification and management Over the past two decades, there has been a shift in the locus of care for the majority of patients with chronic respiratory diseases in the UK towards the community. Respiratory diseases are amongst the most common causes of primary care consultations, accounting for 24 million consultations annually. Increasing numbers of complex respiratory patients are being managed in the primary care setting by generalist teams, with a focus on avoidance of admissions to hospital. Specialist secondary care is restricted to those patients admitted to hospital in a crisis or referred because of uncontrolled disease.

There is evidence of significant and unwarranted variability in the standards of respiratory management in both the primary and secondary care sectors. Marked variations in outcomes for patients with respiratory disease have also been shown, both regionally and between individual General Practitioner (GP) practices. There is evidence linking the quality of care provided in general practice with unplanned admissions to secondary care , and decreased admission rates have been reported in a number of long-term conditions (including COPD and asthma) where GPs were financially incentivised to provide high-quality care . Moreover, higher levels of professional education, nurse staffing and clinical recording in primary care are all associated with an improvement in the quality of clinical care for patients with COPD. However, a 'skills gap' may exist in some primary care settings, where GPs and other health care professionals lack advanced training in the management of these common conditions, particularly in the case of patients with multi-morbidity, uncertain diagnosis or complex problems .

The investigators have performed pilot studies which have identified widespread variability in practice level competencies for the diagnosis and management of respiratory conditions in primary care; in particular quality assured spirometry is only performed in a minority. No practices currently deliver FeNO measurements central to draft NICE Asthma guidelines. Knowledge of inhaled therapy options and techniques is highly variable. Patients with more severe or complicated disease may receive suboptimal care, which may in turn lead to poor outcomes. Such patients may fail to reach a specialist assessment that could potentially improve outcomes, either because they are not offered referral to a specialist clinic or because they decline going to a hospital clinic for such an assessment. Therefore, a community-based integrated care approach with joint specialist-generalist "mentorship" clinics in the community which utilise both specialist skills and the overall holistic perspective of the generalist primary care teams may be a promising solution. We have piloted a series of such 'mentorship' clinics as part of a service improvement programme of work with West Hampshire Clinical Commissioning Group (WHCCG) and the Wessex Academic Health Sciences Network (WAHSN). Pilot data suggest significant impacts on suboptimal outcomes including a reduction in inappropriate inhaled medication, exacerbations, unscheduled visits to primary care and attendance and admission to hospital. Furthermore, attendance rates and feedback from patients and care-givers suggest such clinics have high levels of acceptability to patients and their families.

Further potential benefits of 'mentorship' clinics in the community include not only improvement in quality of care for each of the individual patients seen, but also on-site education for the primary care teams, leaving a legacy of improved skills and greater confidence in managing complex disease. Such clinics have the potential to increase patient and staff satisfaction, reduce secondary care use and consequently reduce the financial burden of respiratory disease on the local health economy.

Up to 20 GP practices throughout Wessex will be recruited to the intervention arm. Practices in the intervention arm will be recruited pragmatically through the relevant CCG or local clinical and academic networks. Practices will be supported by the clinical research team from study set up to study end. The study team will directly engage with each practice in order to ensure that study processes align with administrative and clinical arrangements in each specific practice. A briefing/debriefing session will be held with each practice prior to the study commencing and at study conclusion.

Practices in the control arm will be matched if possible by size, demographic profile, socio-economic status profile and rural/urban setting. Control practices will be identified through the Hampshire Health Record Analytic Database (HHRA). The HHRA is a separate electronic database created for research, analysis and commissioning support within the local NHS. It currently includes data from 133 practices across Hampshire which is linked to the GP patient database system. The Governance body is the Hampshire Health Record Advisory Group (HHRAG), which ensures the security and confidentiality of the HHRA and HHR (Hampshire Health Records) and considers issues of data integration, data sharing and data extraction/analysis. The HHRA receives data monthly from the HHR, but in a pseudonymised format,. Although the HHRA can be viewed in a pseudonymised format by analysts working directly with the database, all data used for research purposes is extracted in an anonymised format.