COPD is a common disease in the UK. Our work, and that of others, has shown that it is frequently mis-diagnosed (around 20% of those on COPD registers do not actually have the condition). The impact of COPD on patients and indeed on the NHS in terms of financial pressures is enormous and we are currently missing opportunities to ensure that patients receive the best possible care. Whilst audit is an excellent tool for pointing out where we can all do better, it does not always provide solutions to improve practice and care. It is difficult for all clinicians to be trained in the management of a wide variety of conditions, to keep up to date with the latest guidelines and to remember to implement all relevant aspects of them in time-pressured daily clinical practice.
We thought that it would be optimal if audits were accompanied by a tool that healthcare professionals could use “out of the box” that helped compliance with all current guidelines and recommendations. It was this idea that prompted us to begin developing a guideline-based computer guided consultation. This all started around 10 years ago, with the efforts of a small group of consultant clinicians and an expert in the design and delivery of respiratory services, and today, this tool is a reality and being tested in several sites across the country.
The LungHealth guided consultation software was designed to ‘get behind the consulting room door’ with the aim of providing expert, guideline driven advice to healthcare professionals and patients during COPD reviews. The software guides practitioners through the review and provides algorithm-driven consultations in line with the most recent guidelines, which are checked for updates quarterly. We included disease management modules which cover initial diagnosis, annual reviews, interim reviews and exacerbation reviews. We also included educational material that can be printed or emailed directly to the patient, and that helps supporting patients to manage their COPD. Management decisions always remain with the clinician, but the software prompts to consider what the guidelines would suggest at every step of the patient review.
In addition to guiding the review, LungHealth interprets spirometry readings and assesses symptoms, pointing out other possible diagnoses when spirometry or symptoms are not in keeping with COPD. Once the users confirm a COPD diagnosis, the software then guides them to classify the severity of the disease. Then, the programme ensures that inhaler therapy is optimized, again, in keeping with guidelines and any local formulary recommendations, and guides through a check of inhaler technique. It also recommends the appropriate non-pharmacological interventions in particular referral for smoking cessation support and pulmonary rehabilitation. Lastly, it generates anonymised reports and collates data required for QOF, which enable practices and localities to visualise the number of patients assessed, local COPD disease severity, control of symptoms and admission rates.
To get to where we are, we undertook several years of development and validation with a rigorous process involving feedback from users (both health care workers and patients) to drive its development. The system is hosted within the NHS HSCN security system and meets all NHS information and governance GDPR requirements, and has proven to be secure.
Our guided consultation software has now been tested to review hundreds of COPD patients in multiple localities, most recently in Spring-Summer 2020 in NHS Bedfordshire. During the COVID -19 pandemic, we adapted the software to enable remote consultations so that even the most vulnerable patients could continue to access support and high-quality care. This was a great success with nurses working from home simultaneously accessing GP systems and the LungHealth software whilst undertaking video or telephone consultations with patients in their own homes.
In keeping with existing data, 18% of patients assessed using our software had spirometry readings that were not consistent with COPD. These are all people that had potentially been put on wrong medication or treatment regime. This comes at a cost to both the patient’s health, and to the purse of the health service.
As these patients did not need inhalers to manage the condition, this resulted in a significant cost saving, and more importantly they could be reassessed to see what is really causing their symptoms and have that treated. Of those with COPD, at baseline, almost a quarter of patients with both mild and moderate COPD reported hospital admissions and ongoing breathlessness revealing definite room for improvement in care.
Where the LungHealth system was trialled, we saw inhaler technique improving from 68% to 95% and those with severe disease were frequently changed to triple inhalers which are cost effective as well as providing good symptom control and convenience for patients. Inhaler medications were ‘stepped down’ in some patients with milder disease and few symptoms.
Another success was that, following the implementation of our software, 92% of patients had a written self-management plan in place compared to 44% before review and 12% were referred for smoking cessation support. There were also increases in pulmonary rehabilitation referrals.
Using the guided consultation software provides huge opportunities not just to improve care, but also to use valuable NHS resources more wisely. If we extended the results from our latest trial site in Bedfordshire to the whole CCG, we estimated this could bring saving of £587,000 in the first year, largely as a result of correct diagnosis and optimising therapy in line with NICE guidelines.
Healthcare professionals find the system easy to use and patients also like the reviews. Use of the guided consultation provides an effective safety net against misdiagnosis whilst prompting the user to consider other potential comorbidities. Patients with a confirmed diagnosis receive appropriate management - both pharmacological and non-pharmacological - to achieve optimum disease control and health related quality of life. High quality, consistent reviews are achieved and do not rely on previous COPD training for healthcare professionals. Patients receive tailored treatments depending upon the severity of their disease, taking into account spirometry, symptoms and exacerbation frequency.
The software solution is a ‘living’ product, constantly under review by a multidisciplinary team of respiratory specialists to ensure its recommendations remain in line with the most recent guidelines.
The results of the software trials we conducted have led to a paper and several abstracts being published over the past years.
Paper:
Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice. Angus RM, Thompson EB, Davies L, Trusdale A, Hodgson C, McKnight E, Davies A, Pearson MG. Prim Care Respir J. 2012 Dec;21(4):425-30.
Abstracts:
Outcome of Nurse Based Review Using a Computer-Guided Consultation in COPD. R.M. Angus, A. Trusdale, L. Davies, E. McKnight, C. Hodgson, E. Thompson, M.G. Pearson. Am J Respir Crit Care Med 183;2011:A1499
Benefits of a Computer Guided Review in COPD. L. Davies, R.M. Angus, A. Trusdale, C. Hodgson, E. McKnight, M.G. Pearson. Am J Respir Crit Care Med 185;2012:A373
Real Life use of a Computer-Guided Consultation in COPD. E. B. Thompson , M. G. Pearson , L. Davies , E. McKnight , A. Trusdale , K. Sargeant , R. M. Angus.. Am J Respir Crit Care Med 2013;187:A2829
Modeled Heath Economic Benefits of a “Real Life” Computer Guided Review In COPD. E.B. Thompson, M.G. Pearson, L. Davies, A. Trusdale, E. McKnight, K. Sergeant, R.M. Angus. Am J Respir Crit Care Med 2013;187:A4379
EB Thompson, MG Pearson, L Davies, E McKnight, A Trusdale, K Sargeant, RM Angus Computer-guided consultation in COPD practice. Thorax 2013; 68(Suppl 3): A38
A computer guided consultation in standardizing COPD care: observations in a real life setting. R.M. Angus, L. Davies, E. McKnight , K. Sergeant , M.G.Pearson. Am J Respir Crit Care Med 2017;195:A1736