Respiratory Quality Improvement ProgrammeBreathlessness Project

Vanessa BrownRachel DomineyJayne Longstaff

Professor Anoop Chauhan

Breathlessness project

A Respiratory Quality Improvement Project

“Breathlessness is a common symptom which can be caused by a number of different conditions. Early diagnosis of the cause of breathlessness can improve outcomes for patients.

The aim of this pilot breathlessness project is to test new models of care to facilitate access to diagnostics and accurate diagnosis in an efficient and effective way.”

Three Test Sites

Grange

Bordon

Wickham

Surgery Location (semi-rural) Patient list size(1) Wickham West Hampshire 12,113(2) Badgerswood South East Hampshire 12,540(3) The Grange South East Hampshire 6,500

Ken’s Journey• Age 57 years• Breathless with wheeze

(MRC 2)• Worse at work (a life long

welder)• Ex-smoker; 10 pack year• Time off work, poor QOL

• Spirometry fixed moderate obstruction

• Normal cardiac assessment

• FeNO 50 ppb• +ve skin prick testing

grass, tree and HDM

GRASP Inclusion Criteria

Exacerbations

2 or more respiratory exacerbation in previous 3 years

WheezeNocturnal wheezeWheeze ever

CoughDry coughChronic cough ever

SputumNocturnal SOBExertional SOB ever

107COPD case-finding search

Symptoms relating to asthma

History of wheezeDyspnoea code

Latest chest antibiotic treatment

e.g. amoxicillin

Oral steroid treatment

Pred. tablets

SABA

Saba inhalers

Asthma case-finding search

MRC Breathlessness Grade

Grade 1, 2, 3, 4Earliest Shortness of Breath Term

DyspnoeaBreathlessness mild exertionBreathlessness on moderate exertion

Excluded diagnosed conditions related to breathlessness e.g. COPD, heart failure

Heart failure case-findingsearch

972

130

357

Practice records search - case finding

COPD914

HF52

Asthma180

COPD58

HF78

Asthma177

68

6

13

GRASP 87 Patients

Manual filter 34 patients

Patient attendance 19

Surgery 1&2

20

Surgery 3

GRASP 313 Patients

Manual filter35 patients

Patient attendance 23

Patient Journey

Full Physiological assessment

Clinical Review

Self-management and follow-up

Follow-up mentorship

clinic

TESTSPFTsFeNOBMISkin TestsCardiac BNP

HistoryExamCXRECGBloodsMRCRCP

Inhaler techniqueSmoking cessationSelf Management PlanEducation

Education

Practice Education/Certification

QUESTIONNAIRESEpworthGERDSNOTCATNijmegenACQ

Results - examples

PATIENT 1 3 5 9

Gender M F M F

Age (yrs) 77 75 83 86

BMI (Kg/m2) 28 27 28 29

FeNO (ppb) 65 9 18 47

MRC 1 2 1 2

CAT 13 23 15 11

ACQ 1.28 3.4 1.14 1.43

FEV1 % pred 62% 69% 92% 96%

O2 Sats 97% 94% 93% 96%

Diagnosis ACOS, Nasal Polyps

ACOS, Allergic Rhinitis

Asbestosis Hypertension

Asthma

Results - Diagnosis

ACOSCOPD

Asthma

GORD

Sino-N

asal Dise

ase

Asbesto

sis

Hyperventilati

on

Workplace asth

ma

Cardiac

Other0123456789

10111213141516

6 month evaluationPatients 12 months

Pre clinic6 months post clinic(Aug – Feb 2016 )

GP non-elective/OOH visits1 > exacerbations

46 3

1> ED Visits 5 0

1> Hospitalisations 3 0

Deaths - 0

Moved from area - 2

Improved Compliance - 16

Initial Health Economics

• Cost per patient of clinic attendance £142– Includes GRASP identification, manual search, medical,

nursing and admin staff for clinic

• National tariff for new patient outpatient appointment – Respiratory multi professional £241 – Cardiology multi professional £189

» excluding market forces factor and additional investigations

• Reduction in:– GP (£45) and OOH visits (£114), plus £41 per prescription– ED visit– Hospital admissions

Ken’s Journey Continued

“The team coming to the surgery was beneficial to me. It reassured me having all the tests done and I am so very pleased with what they have done. I am very satisfied and impressed. Thank you!”

• Further tests in secondary care

• PEFR diary, CT scan and lung function testing

• Diagnosed workplace asthma

• Bespoke treatment and self-management

• Improved quality of life

“This breathlessness

project was very well

organised and thorough

and could help a lot of

people"

"Very welcoming, friendly and professional! More information from this than the normal GP“

“A very helpful and useful clinic which

taught me things about my self I didn't

know; I would definitely recommend it to

other people”

Patient Feedback“Everyone was very informative

and professional, I even had allergy testing which was

interesting. It was also useful having someone explain why I'm

taking inhalers, how it works properly and how to take it

correctly. Would recommend :)"

Summary

• Specialist secondary care case-finder breathlessness clinics in primary care can:• Identify at risk patients and accurately confirm diagnosis• Optimise treatment and improve management

• Specialists clinics allow for:• Tailored HCP education and mentorship clinic• Reduction in secondary care referrals• Early diagnosis and improved patient outcomes• ‘Joined up’ care

What next?

Modern Innovative Solutions Improving Outcomes in Asthma, Breathlessness and

COPD

Patient Journey

1 2 3 4 5 6 7 8 9 10 11 12 13 14

GP visitDiagnosisAssessment Drug treatments i.e. relievers/antibiotics

Practice Nurse Visit

Review 2 weeks after diagnosis

GP Visit

PFSpirometryDrug treatment

Chest X-ray at hospital

GP Visit

Review & Treat

PN Visit

Review & Treat

ED Visit

Review & Treat: Nebs Steroids

GP Visit

Within 7 days Step up treatment

Hospital Admission

MAULOS X-rayDrugs Tests i.e. BT/PF/etc

Outpatient visit (1)

Spir/LFT X-ray/BTRxs/Ass/ Sats/History/comorbidities/reflux

Outpatient visit (2)

Rx/Treatment escalated

GP Visit

1 or 2 visits to GP

Could have 2nd admission

GP or consultant referral to severe asthma clinic

Consultants and specialists X 7 visits

1GP Visit

(1st)

£

2PN Visit

(2nd)

£

3 GP Visit(3rd)

£

4 Chest X-Ray

£

5 GP Visit(3rd)

£

6PN Visit(4th)

£

ED Visit

7£

8

GP Visit

£

9Admission to hospital

£

10

£

11

Outpatient visit (2)

£

12GP Visit

£

13

Consultant /GP Referral

£xx

RespiratoryClinic

14

• There could be up to 14 steps in a 12 month patient journey prior to referral to a respiratory clinic.

• The patient may have had more than one admission into hospital (50% of all asthma admissions are severe asthmatics)

Factor in x 2 Admissions PBR Tariff

Outpatient visit (1)

Patient IdentificationPractice records

Asthma & COPD Breathless with no known

diagnosis

ASTHMA BREATHLESS

GRASP

MISSION ABC Clinics

COPD

Patient Education

Action Stations!

Self management Plans

Bespoke 1:1s

Skin Tests, FeNO

Teamwork

Working with Surgeries

QuestionnairesProtocol Assessments

Integration between primary and secondary care

Pilot MISSION Sites

Diagnosis Treatment Maintain Control

Flo-Tone

• Eclipse Live• GRASP

Pharmacists

Nurses

CommunityRespiratoryIntegratedServices

• Niox FENO• Thorasys

“Mini” MissionClinic

Rapid Mission Clinic

GP Practice

SpecialistConsultant

Primary CareClinic

Severe MissionClinic

Acute CareProvider

Airsonett

ESMENA

• Education/ Training

• BLF• Asthma UK

Innovator Core Respiratory Specialist Team ProviderLegend:

Comorbidity and Medicines Optimisation

myAsthma/myCOPD/CLINITOUCH

Message DynamicsmGAGE

Change ImprovementFellows

Innovators

5 Reasons

1. Improving the lives of patients with breathlessness2. High quality ‘breathlessness’ investigations in the

right place at the right time3. Innovative and integration approach of diagnostic

tools, clinical teams and digital platforms leading to exceptional health outcomes in patients with breathlessness

4. Flexible service personalised for each patient, empowering self-management

5. Leaving a legacy of education and strong networks

Winner of HSJ Value Award in Use of Diagnostics 2015!

“Our winner has a fantastic multidisciplinary team approach. The impact is excellent, well evaluated and it works with high risk patients, which in the longer term will reduce death rates.”