Identification of key opportunities for optimising the management of high-risk COPD patients in the UK using the CONQUEST quality standards: an observational longitudinal study

David M G Halpin; Andrew P Dickens; Derek Skinner; Ruth Murray; Mukesh Singh; Katherine Hickman; Victoria Carter; Amy Couper; Alexander Evans; Rachel Pullen; Shruti Menon; Tamsin Morris; Hana Muellerova; Mona Bafadhel; James Chalmers; Graham Devereux; Martin Gibson; John R Hurst; Rupert Jones; Konstantinos Kostikas; Jennifer Quint; Dave Singh; Marije van Melle; Tom Wilkinson; David Price

doi:10.1016/j.lanepe.2023.100619

Identification of key opportunities for optimising the management of high-risk COPD patients in the UK using the CONQUEST quality standards: an observational longitudinal study

Lancet Reg Health Eur. 2023 Apr 21:29:100619. doi: 10.1016/j.lanepe.2023.100619. eCollection 2023 Jun.

Authors

David M G Halpin^{1

2}, Andrew P Dickens², Derek Skinner³, Ruth Murray³, Mukesh Singh^{4

5

6}, Katherine Hickman^{7

8

9}, Victoria Carter³, Amy Couper², Alexander Evans³, Rachel Pullen², Shruti Menon¹⁰, Tamsin Morris¹⁰, Hana Muellerova¹¹, Mona Bafadhel¹², James Chalmers¹³, Graham Devereux¹⁴, Martin Gibson¹⁵, John R Hurst¹⁶, Rupert Jones¹⁷, Konstantinos Kostikas¹⁸, Jennifer Quint¹⁹, Dave Singh²⁰, Marije van Melle^{2

21

22}, Tom Wilkinson^{23

24}, David Price^{2

3

25}

Affiliations

¹ University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK.
² Observational and Pragmatic Research Institute, Singapore.
³ Optimum Patient Care, UK.
⁴ General Practice, Horse Fair Practice Group, Rugeley, Staffordshire, UK.
⁵ Keele University Medical School, Keele, UK.
⁶ Staffordshire Integrated Care System, UK.
⁷ National Asthma and COPD Audit Programme, Care Quality Improvement Department (CQID), RCP, London, UK.
⁸ Low Moor Medical Practice, Bradford, UK.
⁹ Leeds and Bradford Clinical Commissioning Groups, UK.
¹⁰ Medical and Scientific Affairs, AstraZeneca, London, UK.
¹¹ BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK.
¹² School of Immunology & Microbial Science, King's College, London, UK.
¹³ Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
¹⁴ Liverpool School of Tropical Medicine, Liverpool, UK.
¹⁵ Salford Royal NHS Foundation Trust & Chief Executive Officer of NorthWest EHealth, UK.
¹⁶ UCL Respiratory, University College London, London, UK.
¹⁷ Plymouth Marjon University, Plymouth, UK.
¹⁸ Respiratory Medicine Department, University of Ioannina, Greece.
¹⁹ Respiratory Epidemiology, Faculty of Medicine, National Heart & Lung Institute, London, UK.
²⁰ Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK.
²¹ Connecting Medical Dots BV, Utrecht, the Netherlands.
²² ORTEC, Zoetermeer, the Netherlands.
²³ University of Southampton Faculty of Medicine, Southampton, UK.
²⁴ National Institute for Health and Care Research Southampton Biomedical Research Centre, Southampton, UK.
²⁵ Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.

Abstract

Background: This study compared management of high-risk COPD patients in the UK to national and international management recommendations and quality standards, including the COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST). The primary comparison was in 2019, but trends from 2000 to 2019 were also examined.

Methods: Patients identified in the Optimum Patient Care Research Database were categorised as newly diagnosed (≤12 months after diagnosis), already diagnosed, and potential COPD (smokers having exacerbation-like events). High-risk patients had a history of ≥2 moderate or ≥1 severe exacerbations in the previous 12 months.

Findings: For diagnosed patients, the median time between diagnosis and first meeting the high-risk criteria was 617 days (Q1-Q3: 3246). The use of spirometry for diagnosis increased dramatically after 2004 before plateauing and falling in recent years. In 2019, 41% (95% CI 39-44%; n = 550/1343) of newly diagnosed patients had no record of spirometry in the previous year, and 45% (95% CI 43-48%; n = 352/783) had no record of a COPD medication review within 6 months of treatment initiation or change. In 2019, 39% (n = 6893/17,858) of already diagnosed patients had no consideration of exacerbation rates, 46% (95% CI 45-47%; n = 4942/10,725) were not offered or referred for pulmonary rehabilitation, and 41% (95% CI 40-42%; n = 3026/7361) had not had a COPD review within 6 weeks of respiratory hospitalization.

Interpretation: Opportunities for early diagnosis of COPD patients at high risk of exacerbations are being missed. Newly and already diagnosed patients at high-risk are not being assessed or treated promptly. There is substantial scope to improve the assessment and treatment optimisation of these patients.

Funding: This study is conducted by the Observational & Pragmatic Research International Ltd and was co-funded by Optimum Patient Care and AstraZeneca. No funding was received by the Observational & Pragmatic Research Institute Pte Ltd (OPRI) for its contribution.

Keywords: COPD; Diagnosis; Exacerbations; Pulmonary rehabilitation; Spirometry; Treatment.