Authors (including presenting author) :
FY Man, CT Tse, Leung SH, Chen XRC, Li YC
Affiliation :
Dept. of Family Medicine (FM) and General Outpatient Clinics (GOPCs), Kowloon Central Cluster (KCC)
Introduction :
Chronic Obstructive Pulmonary Disease (COPD) is one of the common conditions encountered in in GOPC. Acute exacerbation of COPD (AECOPD) accounts for around 4% of all public hospital annual admissions locally over the past years.
Objectives :
This study tried to review the management of AECOPD in the primary care clinics of KCC and to work out improvement strategies to reduce the hospital admission due to AECOPD.
Methodology :
This is a service based clinical audit. All COPD patients who had been regularly FU at GOPCs of KCC FM&GOPC from 01/04/2017 to 31/03/2018 were included in first cycle data analysis. Secondary cycle data analysis was performed from 01/04/2018 to 31/03/2019. A series of service enhancement strategies were executed from 01/04/2018 to reduce the hospital admission for COPD patients, they are:
1. Early identification of COPD patients with spirometry and proper staging. All patients suspected to have COPD were assessed in Nurse and Allied Health Clinic-Respiratory program (NAHC-Resp). Patients were properly diagnosed and grouped according to the GOLD guideline.
2. Management of COPD according to different severity, putting right patients at the right level of care. We have collaborated with KH RMD to provide optimal care. Group A patients would continue FU at GOPCs, whereas Group B patients were managed in Family Medicine Specialist Clinic (FMSC), where LAMA was newly introduced in 2018. Patients of group C and D were referred to KH RMD for specialist care. All symptomatic COPD patients would receive brief pulmonary rehabilitation in the NAHC-Resp program.
3. Staff engagement: Promulgation to all doctors and nurses was arranged, e.g. revision of the GOLD guidelines. Training and alignment of CAT score and mMRC dyspnea score to nursing staff were also conducted.
Outcome assessment included CAT score of patients FU by FMSC before starting LAMA, 1 month after LAMA, and 6 months after LAMA were analyzed by repeated measure ANOVA. mMRC of patient before starting LAMA, 1 month after LAMA, and 6 months after LAMA were analyzed by Friedman test. The admission rate due to AECOPD from the two cycles was compared by the chi-square test.
Result & Outcome :
2358 COPD patients were found to have regular FU in our cluster during the first cycle. The hospital admission rate due to AECOPD during the first cycle was 17.9%. Among the 112 Group B patients FU at FMSC from 01/10/2018 to 30/09/2019, 58 cases (51.8%) were put on LAMA. 28 cases (25.0%) of them have been put on LAMA for more than 6 months and were recruited for analysis of symptom scores. They are all male, with the mean age of 72.7 (SD=8.97). Among the 28 subjects, 82.1% (n=23) did not experienced acute exacerbation within the study period and only 9 cases (32.1%) were referred to SOPD. In addition, there was statistically significant reduction in mMRC score from before treatment and 1 month after treatment (p=0.007), but there was no significant difference between 6 month and 1 month after treatment (p=0.378). Similarly, there was a statistically significant reduction of CAT score at 1 month (mean=10.32) compared to before treatment (mean= 13.79) (p=0.028), but the change was not significant at 1 month and 6 month (p=1.0). The hospital admission rate due to AECOPD during the second cycle was significantly reduced to 13.5% (p=0.000043).
In conclusion, via a team based approach, COPD patients of different severities could be effectively managed or triaged in the community, putting right patients at the right level of care. With these proactive strategies, the hospital admission rate due to AECOPD had been significantly reduced and hence relieved the burden to the acute hospital and secondary care.
