Dear Sirs,

Adherence to recommended standards of management (such as NICE guidelines in the UK) differs widely in clinical practice. Programmes of management appear to drive improved patient outcomes, and there have been several reports in this journal recently of the benefits that follow formalised COPD disease management programmes.1–3 In the most recent paper by Zakrission et al. in the December 2011 issue,3 there was a significant reduction in exacerbation frequency in those patients in the intervention group.

We therefore wish to report the findings of an audit and targeted education programme on the management of COPD patients in Dartford, Gravesham and Swanley (DG&S) in West Kent, UK, focussed on the 2004 UK COPD NICE guidelines.4 A proprietary general practice data audit tool (POINTS) (identical to the tool used by Roberts et al.2 previously) was integrated into 30 practices, and data were collected from patients on the COPD registers. An education programme was incorporated to underpin the launch and implementation of the programme, and there were additional COPD clinic hours provided. The programme also incorporated qualitative interviews with practice members to determine attitudes and to learn from the process.

The programme was successful in improving the management of COPD patients in DG&S according to NICE guidelines over a 12-month period. Key improvements included statistically significant improvements to the categorisation of patients by COPD severity (42% up to 60%; p<0.001) and the recording of patient-centric measures (FVC, exacerbations, and MRC dyspnoea scores; p<0.001. Inhaler technique measurement; p<0.01).

The level of participation in the education programme and the number of additional clinic hours appeared to drive improved interest, knowledge and care of patients with COPD. Practices involved in less than 25 hours education and additional clinic hours had significantly more patients categorised to severity at baseline than those undertaking 25 – 49 and ≥50 hours education and additional clinic hours (p<0.001). At 12 months, however, there were no significant differences between the level of categorisation between the three groups. These improvements were validated by the qualitative analysis which showed that highly engaged practices accepted, implemented and valued the programme and saw the advantage of the better patient care it created.

Even in its infancy, the impact of the programme of audit and targeted education is impressive; the rate of increase in unscheduled hospital admissions for the year following the programme in the DG&S locality was 2%, compared to 55% in the remainder of the Primary Care Trust, and 12% in England — a trend replicated in the cost of admissions data.

A central feature in the success of this programme was the use of the POINTS audit tool which served two important purposes. It provided a patient-linked reminder of the key elements of NICE guidance at each consultation, and it provided detailed data on the COPD patient population in primary care. POINTS provided reliable data on current management practices which facilitated the identification of gaps in service provision and unmet patient needs and allowed targeted training programmes to be undertaken. This would not be feasible without such a database. To use the information in the audit tool reports, practitioners need to want to access it. Practitioners with high engagement and an understanding of the programme thrived on comparison of performance with their peers, and across practices.

The management programme was successful in improving the management of COPD patients in DG&S to NICE guidelines. Continued improvement in the adherence of practices to NICE standards through targeted educational initiatives directed by centrally analysed outcomes data could further improve patient outcomes, and reduce unscheduled admissions and the related cost of treating COPD. The lessons from this study could be used to create and implement guidelines for other chronic diseases to the benefit of patients and health care budgets.