GP Referral Audit

A community based specialist respiratory centre in Rotherham helps to drive forward improvements in quality of care for COPD – an audit of Primary Care outpatient COPD referrals to BreathingSpace.

Current UK guidelines (NICE) highlight the importance of accurate diagnosis in respiratory disease through a combination of history taking, examination and spirometry but despite this several studies in the literature show that misdiagnosis and under diagnosis of Chronic Obstructive Pulmonary Disease (COPD) are common in clinical practice. From the UK literature, it is estimated that that 30% of COPD patients have a misdiagnosis. There is a large volume of literature providing evidence of the consequences of inaccurate diagnosis in COPD including financial, ethical and safety issues. One issue frequently discussed is that of inappropriately prescribed inhaler therapy because of the huge expense of some of these recommended drugs.

In 2006, an audit was undertaken within Rotherham primary care community which assessed quality and accuracy of COPD diagnosis of patients listed on GP registers compared to the current guidelines and standards (NICE, 2004 and BTS spirometry). This audit highlighted that at that time there was still much work to be done to achieve the recommended standards of care for COPD.

In May 2007 BreathingSpace in Rotherham was opened to provide specialist nurse-lead community based respiratory services for patients with COPD. A wide range of services are provided by respiratory specialist healthcare professionals including diagnosis, medication optimisation, and pulmonary rehabilitation. BreathingSpace is also a hub for the regional delivery of comprehensive respiratory related education for healthcare professionals by Rotherham Respiratory Group.

The evaluation work of BreathingSpace completed in 2010 highlighted the benefits for those patients undertaking comprehensive assessment and pulmonary rehabilitation services but there was insufficient information available to determine any wider impacts on the community of this bespoke model of care for COPD.

With the publication of the Strategy for COPD and Asthma in England (July 2011) and quality standards it is an important time for providers and commissioners to gain a better understanding of how community respiratory services (such as BreathingSpace) can help to improve quality of diagnosis and care within the primary care setting.

Aim of the Audit
The primary aim was to review COPD referrals from Rotherham GPs and practice nurses between May 2007 and Sept 2010 with regards to reliability of recorded COPD diagnosis, severity of airflow obstruction and reasons for referral, with reference to the appropriate NICE guidelines (2004). A total number of 1534 outpatient referrals were reviewed

The audit protocol, data collection progress and findings were regularly discussed with the COPD Theme steering group which included senior respiratory clinicians, GP representative and two patient representatives.

Summary, recommendations and outputs
The audit findings indicate that the reliability of primary care COPD diagnosis recorded on outpatient referral in Rotherham is good with approximately 4 out of 5 COPD diagnoses confirmed by the respiratory specialists. This result is better than in published primary care audits from elsewhere in the UK, where suggested accuracy of diagnosis ranges from 50 -70%. During 2007 and 2010, 894 Rotherham based healthcare professionals completed respiratory and spirometry training courses at BreathingSpace which may have contributed to improved use and quality of spirometry undertaken in primary care. This positive finding could be considered as evidence of the wider impact of BreathingSpace and a positive message to share with both Rotherham primary care community and others interested in developing specialist respiratory community services.

GPs and practice nurses in Rotherham are doing well at following NICE (2004) COPD Guideline recommendations on referring patients to specialist services including pulmonary rehabilitation. However, these guidelines do not include specific recommendations about when to refer to community specialist services as opposed to hospital based specialist services. In line with Rotherham strategic work on reducing outpatient hospital referrals, a bitesize document has been created to give community staff clarity on when to refer COPD patients to BreathingSpace services as opposed to hospital based services. The impact of this document will be evaluated within the ongoing Rotherham COPD pathway development work.

In March 2012, Dr Gurnam Basran, a consultant physician and CLAHRC’s COPD Theme Lead gave a keynote presentation to 344 Rotherham primary care professionals (including 135 GPs and 76 other practice based professionals). This presentation, part of the protected learning time programme, was focused specifically on COPD diagnosis and management. Dr Basran highlighted the difficulties with accurate recording of the severity of airflow obstruction in COPD and gave clear updated information on how the updated NICE guidelines (June 2010) have changed this classification.

Feedback provided so far indicates that Rotherham primary care community is engaged in supporting the development and quality improvements required for a seamless respiratory pathway for COPD in Rotherham. COPD care in Rotherham is now clearly everybody’s business not just for the specialists.

For further information contact:
Angela Green - Respiratory Researcher (Project Manager for COPD Theme) 
Tel: 01709 426066

This project involved The Rotherham NHS Foundation Trust, which includes BreathingSpace, NHS Rotherham, and a member of the GP commissioning group (NHS Rotherham).