Improving outcomes for people with COPD by developing networks of general practices: evaluation of a quality improvement project in east London

Abstract

Background:Structured care for people with chronic obstructive pulmonary disease (COPD) can improve outcomes. Delivering care in a deprived ethnically diverse area can prove challenging.Aims:Evaluation of a system change to enhance COPD care delivery in a primary care setting between 2010 and 2013 using observational data.Methods:All 36 practices in one inner London primary care trust were grouped geographically into eight networks of 4–5 practices, each supported by a network manager, clerical staff and an educational budget. A multidisciplinary group, including a respiratory specialist and the community respiratory team, developed a ‘care package’ for COPD management, with financial incentives based on network achievements of clinical targets and supported case management and education. Monthly electronic dashboards enabled networks to track and improve performance.Results:The size of network COPD registers increased by 10% in the first year. Between 2010 and 2013 completed care plans increased from 53 to 86.5%, pulmonary rehabilitation referrals rose from 45 to 70% and rates of flu immunisation from 81 to 83%, exceeding London and England figures. Hospital admissions decreased in Tower Hamlets from a historic high base.Conclusions:Investment of financial, organisational and educational resource into general practice networks was associated with clinically important improvements in COPD care in socially deprived, ethnically diverse communities. Key behaviour change included the following: collaborative working between practices driven by high-quality information to support performance review; shared financial incentives; and engagement between primary and secondary care clinicians.

The impact of new forms of large-scale general practice provider collaborations on England’s NHS: a systematic review

“…All four studies had a moderate risk of bias based on CASP checklists. [24][25][26][27] One qualitative study examined a multisite general practice organisation with central ownership of 50 nationally dispersed GP practices. It used interviews and ethnographic observations to examine quality and safety processes, and to provide staff members' views on job satisfaction and on patient experience (Table 2).…”

“…They demonstrated an improvement on most key performance indicators; with the average of the networks often doing better than other PCT, average London, or national trends. This included achieving targets on childhood and flu immunisation, 24,26 annual review and care planning, [25][26][27] screening, 25 and, for people with chronic obstructive pulmonary disease or cardiovascular disease, increasing the number of individuals on registers and numbers referred into community rehabilitation clinics. 26,27 There were also improvements in measures of health outcomes, such as achieving targets for blood pressure, cholesterol, and average glycated haemoglobin levels for patients with type 2 diabetes.…”

“…This included achieving targets on childhood and flu immunisation, 24,26 annual review and care planning, [25][26][27] screening, 25 and, for people with chronic obstructive pulmonary disease or cardiovascular disease, increasing the number of individuals on registers and numbers referred into community rehabilitation clinics. 26,27 There were also improvements in measures of health outcomes, such as achieving targets for blood pressure, cholesterol, and average glycated haemoglobin levels for patients with type 2 diabetes. 25 One study compared performance in two local PCTs, which had a similar intervention package as the networks in Tower Hamlets, including the dissemination of clinical guidelines to all staff that were reinforced at central educational meetings and by standard data entry templates.…”

Rate of, and barriers and enablers to, pulmonary rehabilitation referral in COPD: A systematic scoping review

“…Thirty-five studies reported on referral rates [3,7,; 28 of these were observational studies [3,7,[12][13][14][16][17][18][19][20][21][22][23][25][26][27][28][29][30][31][34][35][36][37][40][41][42]44], while the remaining seven assessed the effect of an intervention on COPD care (and measured referral rates at baseline and post-intervention) [15,24,32,33,38,39,43]. Nine studies reported on HCP perceived barriers to PR referral [23,26,[45][46][47][48][49][50][51], and seven of these also reported on enablers [23,26,45,…”

“…Seven studies included an intervention designed to improve COPD care, with rate of referral to PR included as an outcome measure [15,24,32,33,38,39,43]. All 7 studies saw an improvement in referral rates post-intervention [15,24,32,33,38,39,43], although one included conference abstract did not explicitly state the actual improvement in referral rate post-intervention [15]. Four of the interventions involved HCP education [15,32,33,43], one introduced a discharge care bundle [39], and the other introduced a care package with financial incentives for the network of hospitals involved [24].…”