Healthier South Wirral PCN COPD project

A project to identify and optimise care for patients with mild or moderate chronic obstructive pulmonary disease (COPD) across Healthier South Wirral Primary Care Network (HSW PCN) has been enabled through the use of PRIMIS’ GRASP-COPD. This joint working initiative between Healthier South Wirral PCN, Boehringer Ingelheim and PRIMIS took place between June 2021 and December 2022.  

Aims 

The project aimed to improve patient outcomes and reduce unscheduled COPD-related healthcare resource use through achievement of the following:  

1. Accurate identification of patients within the mild and moderate COPD cohort, based upon patients’ latest spirometry results 
2. Identification of patients with
   1. multiple respiratory diagnoses including those who may have been incorrectly diagnosed i.e., asthma and COPD 
   2. potential undiagnosed COPD (no recorded respiratory disease of any type but multiple SABA inhaler issues) 
   3. uncontrolled COPD
3. Optimisation of respiratory treatments in line with local and national guidelines and environmental targets for the above populations 
4. Empowerment of diagnosed COPD patients in HSW PCN to better self-manage their disease with appropriate and accessible support from local primary care services  
5. Empowerment of the patient, HCP and care provider communities to better identify and manage COPD patients through a full, comprehensive COPD education programme 

Tool

After consultation with clinical staff within the PCN, PRIMIS created a bespoke version of the GRASP-COPD tool to incorporate specifics required for the project such as FeNO testing, multiple SABA inhaler issues and design of a tailored summary data view for each practice. This bespoke version of GRASP-COPD was installed at each of the six participating practices within the PCN and lists of patients requiring targeted review by the clinical staff were generated. 

As part of the project, the clinical pathway for mild to moderate COPD patients was reviewed and improved and its implementation was supported by a comprehensive education programme for clinical staff involved in chronic disease management of COPD patients.  

Outcomes

Aggregate baseline data was collected from all six participating GP practices in June 2021. The same data items were extracted over a year later (December 2022) from a sample of practices in order to assess the impact of the programme.  

• COPD prevalence fell by 0.27% making it more comparable with the national QOF average of 1.9%. This may be due, in part, to the project aim of targeting patients with dual/multiple respiratory diagnoses and ensuring accurate recording 

• Decrease in the number of COPD patients reported as never having had spirometry (down from 15.4% to 12.3%) 

• Increase of 11% in the number of COPD patients with a recorded spirometry result within diagnostic range (FEV1/FVC ratio <70%) 

• 8% decrease in the percentage of COPD patients whose last smoking status denotes a smoker 

• increase in the percentage of patients (diagnosed and undiagnosed) having had a FeNO test 

• increase in the number of undiagnosed patients having a lung function test (to confirm or reject potential diagnosis) 

PRIMIS was delighted to be a supporting partner of this valuable joint working initiative to improve the health and care of patients with COPD within South Wirral.  

For further info please see the Publications page.