Our study revealed that deficiencies existed in various aspects of COPD management in the primary care setting. These were particularly apparent in the process criteria such as smoking cessation service referral, uptake rate of SIV or PCV, and under-utilization of spirometry test. Through the audit process, COPD management at primary care level had been greatly enhanced, with most audit criteria being markedly improved and target audit standard achieved. The outcome criteria, AECOPD rate leading to hospital admission, was also significantly reduced in Phase 2.
In Phase 1, loopholes were identified in various aspects of COPD management. About 20% of COPD patients were found not to have a prescheduled FU for regular assessment at the beginning of the audit. FU care is essential as it allows further discussion on the management plans and future monitoring. To resolve this issue, the audit team had gone through the CMS record of this group of patients to review whether they had been arranged to have any FUs with private doctors or respiratory specialists. All of them were called up individually by nursing staff to enquire about their symptom control. For those without any proper assessment in the recent one year, an appointment for doctor’s consultation in their respective GOPC within 6 months would be offered. With such effort, many lost-to-FU COPD cases returned to GOPC for spirometry and clinical assessment, with 87.6% of all COPD cases having regular FU in GOPCs in Phase 2 (P<0.0001).
A combination of behavioral and pharmaceutical interventions has been provided at the SCCS in our department since 2010. Although we encouraged all smoker COPD patients to attend the SCCS during their routine doctor consultation, only about half of them were referred and even fewer (43.9%) actually attended in Phase 1. Despite our proactive promulgation, the situation during Phase 2 had not significantly improved although a rising trend was observed and the target standard had been achieved. These findings were consistent with literature suggesting that COPD smokers are poorly motivated to quit smoking in general (9). Another possibility is the physician-related factor. For example, literature shows that some physicians do not routinely deal with smoking cessation during their consultations with smokers partly due to lack of cessation specific knowledge or skills and partly due to insufficient consultation time (21). This is particularly true in our local GOPCs where the average time allocated for each consultation is only 6 to 7 minutes. There is definitely a need for a more proactive approach to promote the smoking cessation among all health care workers and COPD patients.
For criteria 3 and 4 on the update rate of SIV and PCV, although our performance had significantly improved during the audit cycle, only about half of COPD patients were vaccinated against SIV (49.2%) and PCV (57.1%) in Phase 2. Indeed, influenza vaccination coverage rates among COPD patients remain low in many countries (12-13). In HK, all elderly patients aged over 65 years are entitled to receive SIV and PCV for free under the HK Government Vaccination Program. However, the breakdown figures of SIV coverage among those under age 65 were still far from satisfactory (7.6% in Phase 1 and 23.0% in Phase 2). Given the widely established evidence on the long-term benefits of SIV on COPD care, such as reduced number of exacerbations, hospitalizations and all-cause mortalities (6), we would like to propose that HK government should launch out free SIV to COPD patients of all ages to reduce the mortality.
It is disappointing to find that only 29.6% COPD patients had ever conducted spirometry test in Phase 1. The reasons accounting for this poor performance rate are multifactorial. At doctors’ level, some doctors often make the diagnosis of COPD based on clinical features alone. At clinic level, spirometry service was previously only available at hospital setting. Therefore, all suspected COPD patients had to be referred to Respiratory Specialist Clinic to perform lung function tests where the waiting time ranged from months to two years under HAHK. To plug this loophole, a series of education talks on the proper diagnosis and management of COPD, emphasizing on the importance of spirometry test, were delivered to all doctors. Furthermore, almost all GOPCs were equipped with spirometry machine during the implementation phase so that the spirometry test could be conveniently performed locally within 2-4 weeks. In addition, at least 1-2 designated nurses from each GOPC had been specially trained on how to perform the spirometry correctly based on the aligned standard. With such facilitations both on the skill set and tool set, it is not surprising that tremendous improvement was observed for this criteria in Phase 2 (72.7%, P<0.00001).
The last criteria 6, the rate of AECOPD leading to hospital admission, is the single most important outcome criteria of this audit. Mild to moderate AECOPD that had been well managed in GOPCs would not be included in this criteria. In Phase 1, we found it quite alarming that almost 1 in 5 of COPD patient (17.9%) had been admitted to hospital due to AECOPD during the audit year. This data was comparable to Canadian studies which showed that approximately 20% of COPD patients had experienced severe acute exacerbations annually (22). In order to decrease the burden of hospital admissions, prevention and prompt treatment of exacerbations are the key goals in COPD care. In view of this, a series of service enhancement strategies were executed. Firstly, early identification of COPD patients by spirometry and proper grading according to the GOLD guideline were done as mentioned above. Secondly, all COPD cases were managed according to their grading, hence providing the right level of care to the right patients. For example, stable Group A patients would continue regular FU at GOPCs, where only a limited pharmacological choices including short-acting bronchodilators are available. Group B patients would be managed at Family Medicine Specialist Clinics, where long acting antimuscarinic antagonist (LAMA) was newly introduced in 2018 to improve their symptom control. A more comprehensive assessment would also be provided by the experienced Family Medicine Specialists at the clinic. For more severe Group C or D patients that warrant advanced care, a timely referral to the respiratory specialists would be initiated. Lastly, relatively stable AECOPD patients could be successfully managed at outpatient settings with more frequent FU instead of being admitted to hospital, hence reducing the hospital burden. This is in line with findings in the literature which state that frequent outpatient visits prevent exacerbation of COPD (23). With all these proactive interventions and efforts, the AECOPD rate leading to hospital admission was significantly reduced to 13.5% in Phase 2.
Strength and Limitations of this study
COPD is one of the most important disease entity commonly encountered in primary care. Moreover, COPD patients are one of the most vulnerable group of population in the community. Therefore, clinical audit on this topic and the subsequent continuous quality improvement programs will likely to have tremendous impact on COPD care in the community. To our knowledge, this study is one of the biggest clinical audits on COPD management ever conducted both locally and internationally, and it has provided crucial information on COPD care in primary care setting. The sample size was quite large with more than 2000 cases included in both Phase 1 and 2. The broad spectrum of audit criteria evaluated in the study reflected the comprehensive nature of COPD management in primary care. In addition, all audit criteria were based on objective assessment parameters with data being retrieved from the computer system from HAHK, therefore minimizing recall basis or data entry error.
With that being said, this study has several limitations. Firstly, the study was carried out in one single cluster of HAHK, therefore selection bias might be present. These results from the public primary health care sector might not be applicable to the private sector or secondary care. Nevertheless, since COPD cases from all 13 GOPCs of KCC had participated in the clinic audit, these data may give a realistic representation of COPD care in the public primary care settings and had provided important background information for future service enhancement. Secondly, this clinical audit mainly focused on short-term outcome aspects of COPD management. Long-term outcomes such as lung function improvement, smoking cessation rate, or COPD-related mortality rate were not analyzed. In addition, some process indicators such as assessment on inhaler technique and drug adherence had not been included. This gap will need to be filled as evidence has revealed that inhaler technique education significantly reduced exacerbation rate (24), and is shown to be more cost-effective (25). Subsequent studies focusing on the long-term outcome criteria and inhaler technique may help provide a more comprehensive picture of COPD management. Lastly, the one-year intervention phase might not be long enough for some criteria to achieve the statistically significant change, although clear improvements were shown. Therefore, continuous effort to implement more audit cycles would be necessary to further improve the clinic outcome in COPD care.