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Assessing competence in practice: Quality Assured Diagnostic Spirometry

Monica Fletcher

Chief Executive Education for Health Chair European Lung Foundation

Most COPD is undiagnosed

3.2 million people have COPD but 2.2 million remain undiagnosed Shahab L, Jarvis MJ, Britton J et al. Thorax 2006;61:1043-1047.

70% with moderate

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www.rightcare.nhs.uk/index.php/atlas/respiratorydisease/2012

• 20% GP consultations are for respiratory problems

• GPs manage the majority of patients with airways disease

• Nationally about 25% on primary care COPD registers not meeting diagnostic criteria

• West London study verifying diagnosis of COPD using a centralised diagnostic service for primary care found 36% misdiagnosed & therefore on inappropriate treatment 1

• Several studies have also demonstrated that asthma is also frequently over diagnosed or misdiagnosed2,3,1

1. Starren et al (2011) PCRJ 2. Linden Smith et al (2004) CanRJ 3.Aaron et al (2008) CMAJ

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Does late diagnosis matter in COPD?

• Lung function declines progressively, but evidence this is more rapid than we thought in early stages of the disease,1,2

• Exacerbations are common even in moderate disease (22% GOLD stage 2 )3

• Quality of life, physical & social function are significantly reduced in all stages of disease from mild to severe4

• 44% of people with COPD in the UK are of working age: over half are prevented from working at all and a quarter limited in their ability to work – lost personal & societal income

Decramer M, et al (2009) Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT):

DOI:10.1016/S0140-6736(09)61298-8 Lancet , (2009)2 Jenkins CR, et al. TORCH study. Respir Res 2009;10:59 3. Hu rst J, et al. Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease. NEJM 2010;363(12):1128-38. 4;Miravitlles M, et al. Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities. Thorax 2009;64:863-8.

How late is “late” diagnosis?

• A recent Canadian study found that 21% of those with undiagnosed COPD had severe or very severe disease1

• NCROP audit 2008 – Nationally 10% of emergency COPD admissions were undiagnosed 2

• London study 2011 - 34% admissions were undiagnosed and one fifth of the undiagnosed patients were in respiratory failure 3

1Hill K, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care CMAJ 2010;182:673-8 2. Royal College of Physicians, BTS, BLF. Report on the National Clinical COPD resources outcomes Project RCP 2008 3. Bastin A, et al. High prevalence of undiagnosed and severe chronic obstructive pulmonary disease at first hospital admission with acute exacerbation. Chronic Respiratory Disease 2010;7(2)91-7. http://dx.doi.org/10.1177/1479972310364587

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Missed opportunities in primary care

• Over half (56%) had two or more consultations for lower respiratory tract complaints

• 27% had four or more consultations for lower respiratory tract infections

• One third of these received two or more prescriptions for steroids and or antibiotics

Price D, Halpin D, Winter D et al. Missed opportunities to diagnose COPD. Oral Presentation European Respiratory Society Conference. 2011

38,000 patients, 2 years prior to diagnosis:

Impact of Inaccurate Spirometry results: Costs to the individual

• Diagnosis : be it wrong, inaccurate and correct diagnosis (COPD, asthma, other diagnosis)

• Psychological impact on individual and family

• Disability and/or work issues

• Life insurance

• Inappropriate and expensive ongoing treatments (with potential side effects)

• Further tests or investigations

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Inaccurate spirometry results: Healthcare costs • Under or over treatment or no treatment including inappropriate, expensive therapies

• Inappropriate referrals

• Further unnecessary investigations

• Wrong labeling on practice registers / QOF: Follow up and recall

An estimation of cost of misdiagnosis (Based on a rate of 25%) Approx £28.5m

Total misdiagnosed (COPD pts)

Stage % total

number Cost of annual medication per patient

Total cost per year

835,000 known 25%=208,750

mild 53% 110,637 £80 £8,850,960

moderate

39% 81,412 £137 £11,153,444

severe 8% 16,700 £514 £8,583,800

TOTAL £28,588,204

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• The diagnosis and assessment of respiratory disease requires accurate measurement of lung function (along with clinical history taking and physical examination)

• The most widely used test of lung function is SPIROMETRY

• Many options which are: affordable, easy to use, reliable, portable desktop hand held options providing reference values & computer generated interpretation

“Yet high quality spirometry continues to prove difficult to implement in primary care” (and other settings!)

Jenkins C (2009) Editorial Primary Care Respiratory Journal 18(3)128-129

The UK Quality & Outcomes Framework (QOF) pay for performance scheme & spirometry Strong M et al (2009) BMC Health Services Research

• QOF Introduced in 2003 to improve Quality in general practice

• In 2006/07 practices in Rotherham achieved 94.5% indicators (national average 96%)

• 3217 patients randomly selected from 5,649 patients with COPD from 38 GP practices in Rotherham

• Only 31% met BTS standards (3 consistent readings 2 within 100mls) and 12% not consistent with COPD diagnosis

Quality Outcomes Framework is rewarding the QUANTITY not QUALITY of spirometry Substantial variation in performance and interpretation

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How can we ensure earlier diagnosis?

Opportunistic assessment:

• Smoker or ex smoker over 35 • Symptoms such as breathlessness, chronic cough, regular

sputum production, frequent winter “bronchitis” and wheeze

Systematic case finding by audit of GP register

• Symptomatic patients with airflow obstruction • E.g. smokers or ex-smokers not known to have COPD or

asthma with history of recurrent respiratory symptoms or infections or treatment with inhalers

Quality assured diagnostic spirometry

• Ensuring the diagnosis is correct

What can go wrong with spirometry in the community setting?

Patient • Ill prepared

• Poor technique, effort

• Posture ….

Operator • Competence, training, motivated, lack of time,

conscientious, poor instructions…….

Equipment • Fully functioning, calibration, regular

serviced…..

Environment • Temperature, privacy, distraction,

hygiene…..

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Misbelief

Simple test Minimum skill

required

Clinical Experience : A definition Making the same mistakes with increasing confidence over an impressive number of years

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A Guide to Performing

Quality Assured Diagnostic Spirometry

In publication by DH

Assessing Quality Assured Spirometry

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A Guide to Performing

Quality Assured Diagnostic Spirometry

1. Calibration and cleaning 2. Preparation of the patient 3. Performance of the test 4. Interpretation of results 5. Reporting – top ten tips 6. Common technical errors 7. Quality assurance 8. Ensuring competency

Performing Quality Assured Diagnostic Spirometry in clinical practice: Assessing competence in those performing and interpreting the test*

*currently being formalised

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Who should diagnose respiratory conditions

Diagnosis should be made by a qualified medical practitioner or an appropriately trained nurse or AHP

The diagnosis of most common respiratory disorders is based on

– comprehensive clinical history

– physical examination

– relevant additional tests e.g. FBC, CXR

– Diagnostic spirometry

Who should perform quality assured diagnostic spirometry

• Spirometry may be performed by a range of practitioners who may not be qualified HCPs BUT the interpretation should only be carried out by a qualified HCP or clinical physiologist

• Because spirometry is a practical procedure, assessment of competence is critical

• Quality Assured Diagnostic Spirometry should only be performed in a clinical setting by individuals who have been assessed to the standards established by the ARTP otherwise the accuracy of the diagnosis cannot be relied upon

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Delegation of tasks

• Professionals responsible for Quality assured diagnostic spirometry have a duty to ensure that they and the staff they manage have the necessary skills and competence to undertake the procedure in accordance with the nationally agreed standards.

• This includes GPs delegating to practice nurses and practice nurses delegating to HCAs

So what is the plan?

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• Inexperienced staff will attend an approved training programme and on successful completion will be entered onto a register

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• Practitioners undertaking a current ARTP approved training programme will be entered on to a register on successful completion of the course

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• Practitioners already on a register will remain on the register for 3 years and will then be reassessed

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• Experienced staff may have direct entry to a register by submitting a portfolio of tests to a recognised assessment centre and upon meeting the qualifying criteria will be entered on to the register

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• Very experienced staff may be able to access the register directly through an equivalence process * To be determined

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Evidence for the need for training

– ‘good quality spirometry from trained and experienced staff provides more robust and reliable results than office testing’ (Lange et al. Respir Med 2009)

– Nurses who have undertaken a COPD diploma module were more confident in interpreting spirometry than those who had not undertaken the training 53% v 12% (p<0.001) (Davison BTS abstract 2012)

• Spirometry in Primary Care Practice

– 30 primary care clinics, Comparison 3.4% in usual group v 13.5% in trained group (15 of each) met ATS acceptability and reproducibility criteria (Eaton et al, Chest 1999; 116:416-423)

– Only 12% of nurses performing spirometry had received accredited training. (Upton et al. PCRJ 2007)

Existing training programmes

• Need to explore opportunities to broaden certification opportunities for all HCP including doctors, during their training programmes both GPs and Specialist Registrars.

• Practice nursing programmes and other nursing courses

• Pharmacists

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Improving primary care Spirometry

• QOF & local enhanced services

• Cost savings to be had

• Satisfaction

• Professionalism

• Excellence in care: PCRS Quality Award

• Improving Quality In Physiological diagnostic Services: IQIPs

Francis Report :

‘ there needs to be a clear set of fundamental standards of care which are backed by evidence,

clinically informed and enforced by a clear regulatory regime’

Care Quality Commission

Commissioning processes

Certification courses and individuals Registration of

individuals

LIFE AND BREATH FOR THOUSANDS OF PATIENTS!

During the first half of2013 will draw up detailed plans and processes. So we can start to implement and roll out Later in the year