Finding the ‘missing millions’: do we need incentives to optimise COPD outcomes?

Under-diagnosis of COPD remains an international problem.^1,2 Less than one-third of the predicted three million people in the UK with COPD currently have a diagnosis.¹ Furthermore, there is wide and unwarranted variation in the proportion of those who have a diagnosis versus those who remain undiagnosed, with deprived populations having both the highest prevalence and the highest under-diagnosis of COPD.^1,2 This is important, since the diagnosis of COPD is often made late when significant lung function has been lost, when exacerbations and hospitalisations are more common, quality of life is notably affected, and the costs of managing the disease are significant.³

Given that awareness of COPD is low, both amongst primary care clinicians and patients,⁴ it is not surprising that the early identification of people with clinically relevant COPD is central to disease management guidelines and health policy.^5–8 In this issue of the PCRJ, Falzon et al. describe the use of a locally enhanced service (LES) in one particular Primary Care Trust (PCT) in the UK that uses financial incentives to drive up COPD diagnosis rates.⁹

Evidence to support the use of financial incentives to improve performance in healthcare is so far modest and inconsistent.¹⁰ Critics have even suggested that such incentives are controlling and may undermine and even worsen performance, especially when intrinsic motivation is high to begin with.¹¹ Yet, finding ways to motivate and engage over-burdened primary care clinicians in the management of chronic diseases remains challenging. In the UK National Health Service (NHS), the new Clinical Commissioning Groups (CCGs), led by primary care clinicians, will have the remit to drive improvement by setting priorities and influencing the provision of care in order to obtain positive health outcomes in their localities. Improvements in COPD care should be high on their agenda; CCGs are specifically tasked with reducing mortality in respiratory disease as well as reducing the time people with long-term conditions spend in hospital, both of which are more likely to be achieved if people are diagnosed early and treated appropriately.⁸

Critics of early diagnosis initiatives rightly highlight that smoking is the major cause of COPD and that almost all cases could be prevented, or disease progression lessened, by patients quitting.¹² Furthermore, the ability of primary care to perform and interpret spirometry accurately has been questioned. However, although all smokers should be advised to quit, utilising lung function measures can enhance quit rates in those with COPD, and it is entirely possible to assure the quality of spirometry in primary care settings.^13,14

Therefore, financial incentives for COPD case-finding should at least be tied to the provision of smoking cessation support and quality assured spirometry. But there is also opportunity to enhance care through other high value interventions, such as influenza vaccination and pulmonary rehabilitation.¹⁵ Falzon et al. are to be commended for incentivising these measures as part of their LES. It has been shown that use of a financial incentive in a hospital to drive implementation of a discharge care bundle for COPD led to improved compliance with best practice interventions and reduced readmission rates.¹⁶ It will be interesting to see if Falzon et al., as a consequence of the LES, can show improved outcomes in other aspects of primary care COPD management over and above diagnosis prevalence rates.

Finding the missing millions is an essential aspect of the COPD care pathway, and primary care is well placed to identify the undiagnosed population. However, care needs be taken when designing financial incentives in order to avoid “tick-box” exercises and fragmentation of care. The individual parts of the management pathway for COPD are in place: we know who to look for, how to investigate them, what interventions provide the best value and outcomes, how to manage stable patients, and how to treat them when things go wrong. The importance of integrated, collaborative efforts between different parts of the healthcare system has been discussed in this journal and others. With the high burden of COPD and the current financial situation in many countries around the world, we suggest that the time is right for an integrated incentive and reward system to optimise COPD outcomes with primary care clinicians taking the lead.