As GPs working for the London Respiratory Team, we were extremely pleased to see the high profile given to COPD in February's BJGP1–4 since we believe that primary care, as part of an integrated pathway, has a major role both in earlier diagnosis and continued management of this condition. We would like to highlight two concepts from our workstreams:5 first that COPD is as important as lung cancer (or TB or other serious illness) and second to view high quality stopping smoking support as the treatment for COPD. We are keen to promote straightforward techniques such as very brief advice on smoking6 and simple case-finding techniques7 that can be used even in time-limited consultations to provide systematic and opportunistic earlier diagnosis of COPD and maximally effective intervention.
Opportunities to signpost patients in primary care range from receptionists noticing insidiously increasing breathlessness in patients they may have known for years, through to practice nurses who are ideally placed to offer case-finding spirometry to patients at risk of COPD. Increasing fragmentation of care within the NHS often means that the patient's registered GP may be the only healthcare professional in a position to spot recurrent chest infections, for instance, diagnosed out-of-hours or at walk-in centres, or to offer follow-up following an emergency department attendance. Earlier and accurate diagnosis in turn leads to proven interventions such as stopping smoking as a treatment and pulmonary rehabilitation. Per quality-adjusted life year, these treatments are highly cost effective at around £2092 and £2000–8000 per quality adjusted life year respectively.8–9
Within London, we're making the case for change in respiratory services by advocating a value-based approach to COPD health care. Work is needed across the UK to get the best value from the respiratory programme spend. The coming months will be a key time for clinicians and commissioners to debate where there could be improvements within the existing respiratory budget by maximising the outcomes that people with COPD want through the use of therapies that have proven cost-effectiveness.
REFERENCES
- 1.Broekhuizen B, Sachs APE, Verheij TJM. COPD in primary care: from episodic to continual management. Br J Gen Pract. 2012;62(595):60–61. doi: 10.3399/bjgp12X625003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Miravitlles M, Andreu I, Romero Y, et al. Difficulties in differential diagnosis of COPD and asthma in primary care. Br J Gen Pract. 2012 doi: 10.3399/bjgp12X625111. DOI: 10.3399/bjgp12X625111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Martin A, Badrick E, Mathur R, Hull S. Effect of ethnicity on the prevalence, severity, and management of COPD in general practice. Br J Gen Pract. 2012 doi: 10.3399/bjgp12X625120. DOI: 10.3399/bjgp12X625120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Tsiligianni JG, van der Molen T, Siafakas NM, Tzanakis NE. Air travel for patients with chronic obstructive pulmonary disease: a case report. Br J Gen Pract. 2012;62(595):107–108. doi: 10.3399/bjgp12X625328. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.The London Respiratory Team. Workstreams. London: NHS; http://www.london.nhs.uk/what-we-do/our-current-projects/london-respiratory-team/workstreams (accessed 8 May 2012) [Google Scholar]
- 6.NHS Centre for Smoking Cessation & Training. Very brief advice on smoking. London: NCSCT; 2012. http://www.ncsct.co.uk/vba (accessed 8 May 2012) [Google Scholar]
- 7.Price D, Crockett A, Arne M, et al. Spirometry in Primary Care case-identification, diagnosis and management of COPD. Prim Care Respir J. 2009;18(3):216–223. doi: 10.4104/pcrj.2009.00055. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hoogendorn M, Feenstra TL, Hoogenveen TR, Rutten-van Mölken MP. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax. 2010;65(8):711–718. doi: 10.1136/thx.2009.131631. [DOI] [PubMed] [Google Scholar]
- 9.Griffiths TL, Phillips CJ, Davies S, et al. Cost-effectiveness of an outpatient multidisciplinary pulmonary rehabilitation program. Thorax. 2001;56(10):779–784. doi: 10.1136/thorax.56.10.779. [DOI] [PMC free article] [PubMed] [Google Scholar]