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Chronic obstructive pulmonary disease

About

What is covered

This pathway covers the management of COPD in adults (aged over 16 years) in primary and secondary care.
An estimated 3 million people have COPD in the UKHealthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission.. Most people are not diagnosed until they are in their fifties.
COPD is predominantly caused by smoking and is characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months but is usually progressive in the long term. Exacerbations often occur, when there is a rapid and sustained worsening of the patient's symptoms beyond normal day-to-day variations.
There is no single diagnostic test for COPD. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry.

Updates

Updates to this pathway

17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
6 August 2015 Smoking cessation: supporting people to stop smoking quality standard added to this pathway.
24 March 2015 Insertion of endobronchial nitinol coils to improve lung function in emphysema (NICE interventional procedure guidance 517) added to breathlessness and exacerbations.
11 March 2015 Minor maintenance update.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
24 February 2015 Minor maintenance update.
2 December 2014 Minor maintenance update.
1 October 2014 Minor maintenance update.
11 August 2014 Minor maintenance update.
20 March 2014 Minor maintenance updates.
24 September 2013 Insertion of endobronchial valves for lung volume reduction in emphysema (NICE interventional procedure guidance 465) added to breathlessness and exacerbations.
11 January 2013 Minor maintenance updates.
4 December 2012 Minor maintenance updates.
7 August 2012 Minor maintenance updates.
29 May 2012 Minor maintenance updates.
23 March 2012 Roflumilast for the management of severe chronic obstructive pulmonary disease (NICE technology appraisal guidance 244) added to the treating stable COPD path.
16 January 2012 Services for people with COPD (NICE commissioning guide) added to resources dropdown list.
25 October 2011 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Management of chronic obstructive pulmonary disease in adults (aged over 16 years) in primary and secondary care

What is covered

This pathway covers the management of COPD in adults (aged over 16 years) in primary and secondary care.
An estimated 3 million people have COPD in the UKHealthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission.. Most people are not diagnosed until they are in their fifties.
COPD is predominantly caused by smoking and is characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months but is usually progressive in the long term. Exacerbations often occur, when there is a rapid and sustained worsening of the patient's symptoms beyond normal day-to-day variations.
There is no single diagnostic test for COPD. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry.

Updates

Updates to this pathway

17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
6 August 2015 Smoking cessation: supporting people to stop smoking quality standard added to this pathway.
24 March 2015 Insertion of endobronchial nitinol coils to improve lung function in emphysema (NICE interventional procedure guidance 517) added to breathlessness and exacerbations.
11 March 2015 Minor maintenance update.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
24 February 2015 Minor maintenance update.
2 December 2014 Minor maintenance update.
1 October 2014 Minor maintenance update.
11 August 2014 Minor maintenance update.
20 March 2014 Minor maintenance updates.
24 September 2013 Insertion of endobronchial valves for lung volume reduction in emphysema (NICE interventional procedure guidance 465) added to breathlessness and exacerbations.
11 January 2013 Minor maintenance updates.
4 December 2012 Minor maintenance updates.
7 August 2012 Minor maintenance updates.
29 May 2012 Minor maintenance updates.
23 March 2012 Roflumilast for the management of severe chronic obstructive pulmonary disease (NICE technology appraisal guidance 244) added to the treating stable COPD path.
16 January 2012 Services for people with COPD (NICE commissioning guide) added to resources dropdown list.
25 October 2011 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Chronic obstructive pulmonary disease (2010) NICE guideline CG101
Chronic obstructive pulmonary disease - roflumilast (2012) NICE technology appraisal guidance 244
Varenicline for smoking cessation (2007) NICE technology appraisal 123
Insertion of endobronchial valves for lung volume reduction in emphysema (2013) NICE interventional procedures guidance 465
Living-donor lung transplantation for end-stage lung disease (2006) NICE interventional procedures guidance 170
Lung volume reduction surgery for advanced emphysema (2005) NICE interventional procedures guidance 114

Quality standards

Smoking cessation: supporting people to stop smoking

These quality statements are taken from the smoking cessation: supporting people to stop smoking quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statements

Diagnosis

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by post bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation

Quality measure

Structure
a) Evidence of local arrangements to ensure that clinical diagnoses of COPD include a record of one or more indicative symptoms.
b) Evidence of local arrangements to ensure that people diagnosed with COPD have the diagnosis confirmed by post-bronchodilator spirometry.
c) Evidence of local arrangements to ensure that post bronchodilator spirometry is carried out on correctly calibrated equipment.
d) Evidence of local arrangements to ensure that those carrying out post bronchodilator spirometry are competent in its performance and interpretation.
Process
a) Proportion of people with COPD who have one or more indicative symptoms recorded.
Numerator – the number of people in the denominator with one or more indicative symptoms recorded.
Denominator – the number of people with COPD.
b) Proportion of people with COPD who have the diagnosis confirmed by post bronchodilator spirometry.
Numerator – the number of people in the denominator who have confirmatory post bronchodilator spirometry.
Denominator – the number of people with COPD.

Description of what the quality statement means for each audience

Service providers ensure diagnoses of COPD include a record of one or more indicative symptoms, and are confirmed by post bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation.
Healthcare professionals ensure that people diagnosed with COPD have a record of one or more indicative symptoms and confirmatory post bronchodilator spirometry. Those carrying out spirometry ensure that the equipment is calibrated and that they are competent in its performance and interpretation.
Commissioners ensure they commission services that record one or more indicative symptoms when diagnosing COPD, and confirm diagnoses of COPD with post bronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation.
People with COPD are identified by having at least one symptom of COPD (such as breathlessness, long-lasting cough or often coughing up phlegm) and have their diagnosis confirmed by a trained healthcare professional using specialist equipment to test how well the lungs work.

Source clinical guideline references

NICE clinical guideline 101 recommendations 1.1.1.1 (key priority for implementation), 1.1.1.2, 1.1.2.2 and 1.1.2.4 (key priority for implementation).H2. Data source

Data source

Structure
a) to d) Local data collection.
Process:
a) Local data collection.
b) The percentage of all patients with COPD diagnosed after 1 April 2008 in whom the diagnosis has been confirmed by post-bronchodilator spirometry. Available from Quality and Outcomes Framework indicator COPD 12.

Definitions

Indicative symptoms include but are not limited to:
  • exertional breathlessness
  • chronic cough
  • regular sputum production
  • frequent winter 'bronchitis'.

Management planning

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease.

Quality measure

Structure
Evidence of local arrangements to provide people with COPD an individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease.
Process
Proportion of people with COPD who have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease.
Numerator – the number of people in the denominator who have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease.
Denominator – the number of people with COPD.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to provide people with COPD individualised comprehensive management plans, and ensure that information and educational material about the condition and its management is of high quality.
Healthcare professionals ensure that people with COPD have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease.
Commissioners ensure services are commissioned that provide people with COPD with individualised comprehensive management plans, which include high-quality information and educational material about the condition and its management, relevant to the stage of disease.
People with COPD have an up-to-date, individually tailored care plan, which includes information and advice about their condition and how it will be managed, relevant to their stage of the disease.

Source clinical guideline references

NICE clinical guideline 101 recommendation 1.2.12.19.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Appendix C of the full National Clinical Guideline Centre COPD clinical guideline suggests the following topics for inclusion in educational packages:
  • disease education (anatomy, physiology, pathology and pharmacology, including oxygen therapy and vaccination)
  • dyspnoea/symptom management, including chest clearance techniques
  • smoking cessation
  • energy conservation/pacing
  • nutritional advice
  • managing travel
  • benefits system and disabled parking badges
  • advance directives (living wills)
  • making a change plan
  • anxiety management
  • goal setting and rewards
  • relaxation
  • identifying and changing beliefs about exercise and health-related behaviours
  • loving relationships/sexuality
  • exacerbation management (including when to seek help, self-management and decision making, coping with setbacks and relapses)
  • home care support
  • managing surgery (non thoracic)
  • the benefits of physical exercise
  • support groups – such as the British Lung Foundation Breathe Easy groups, which operate throughout the UK.

Inhaled and oral therapies

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan.

Quality measure

Structure:
a) Evidence of local arrangements to ensure that healthcare professionals prescribing inhaled and oral therapies follow NICE guidance.
b) Evidence of local arrangements to ensure that inhaled and oral therapies are prescribed as part of an individualised comprehensive management plan.
Process:
a) Proportion of people with COPD who are offered inhaled and oral therapies in accordance with NICE guidance.
Numerator – the number of people in the denominator offered inhaled and oral therapies in accordance with NICE guidance.
Denominator – the number of people with COPD.
b) Proportion of people with COPD who receive their inhaled and oral therapies as part of an individualised comprehensive management plan.
Numerator – the number of people in the denominator receiving their inhaled and oral therapies as part of an individualised comprehensive plan.
Denominator – the number of people with COPD receiving inhaled and oral therapies.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to ensure inhaled and oral therapies are offered in accordance with NICE guidance as part of an individualised comprehensive management plan.
Healthcare professionals ensure they offer inhaled and oral therapies in accordance with NICE guidance as part of an individualised comprehensive management plan.
Commissioners ensure they commission services that offer inhaled and oral therapies in accordance with NICE guidance as part of an individualised comprehensive management plan.
People with COPD are offered medicines taken through the mouth (oral) or breathed in (inhaled) as part of an individually tailored care plan.

Source clinical guideline references

NICE clinical guideline 101 sections 1.2.2, 1.2.3 and 1.2.4 (includes two key priorities for implementation, 1.2.2.6 and 1.2.2.8.)

Data source

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection.

Definitions

Offers of inhaled and oral therapies will be in accordance with NICE guidance, if they follow the sequence of therapies as described in NICE clinical guideline 101 sections 1.2.2 to 1.2.4. The guideline also provides this sequence in a diagram form in Appendix C algorithm 2a.

Annual comprehensive assessment

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with COPD have a comprehensive clinical and psychosocial assessment at least once a year, or more frequently if indicated.
b) Evidence of local arrangements to ensure that clinical and psychosocial assessments include degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.
Process
Proportion of people with COPD who had a comprehensive clinical and psychosocial assessment in the previous 12 months which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.
Numerator – the number of people in the denominator who had a comprehensive clinical and psychosocial assessment in the previous 12 months which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.
Denominator – the number of people with COPD.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for the comprehensive clinical and psychosocial assessment of people with COPD at least once a year, or more frequently if indicated. The assessment should include the degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.
Healthcare professionals ensure that clinical and psychosocial assessments of people with COPD include degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.
Commissioners ensure they commission services that provide clinical and psychosocial assessments at least once a year, or more frequently if indicated, for people with COPD that include degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.
People with COPD have a full assessment at least once a year, or more frequently if necessary, which includes measuring breathlessness, frequency of flare-ups, checking current health and predicting future problems, and checking for other related conditions.

Source clinical guideline references

NICE clinical guideline 101 recommendations 1.1.5.1, 1.2.14.2 and 1.2.14.4.

Data source

Structure
a) and b) Local data collection.
Process
Local data collection. GP practices can analyse data collected for Quality and Outcomes Framework indicator COPD13: the percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council (MRC) dyspnoea scale in the preceding 15 months.

Definitions

People with very severe COPD reviewed in primary care should be reviewed at least twice a year.
A comprehensive clinical and psychosocial assessment should include, but is not limited to, the following:
  • body mass index
  • degree of breathlessness (using for example, MRC dyspnoea score)
  • frequency and severity of exacerbations
  • health status (using for example, the COPD assessment tool [CAT] or St George's respiratory questionnaire [SGRQ])
  • prognosis (using for example, the BODE index, DOSE or ADO index)
  • presence of hypoxaemia and possible need for oxygen therapy
  • presence of comorbidities
  • psychological assessment for anxiety and depression (using for example the Hospital Anxiety and Depression Score [HADS])
  • need for pulmonary rehabilitation
  • need for referral to specialist and therapy services
  • inhaler technique
  • smoking status and desire to quit
  • post-bronchodilator spirometry.

Smoking cessation support

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support.
Quality measure
Structure
a) Evidence of local arrangements to ensure that people with COPD who smoke are regularly encouraged to stop.
b) Evidence of local arrangements to provide the full range of evidence-based smoking cessation support.
Process: Proportion of people with COPD who smoke who are offered the full range of evidence-based smoking cessation support.
Numerator – the number of people in the denominator offered the full range of evidence-based smoking cessation support.
Denominator – the number of people with COPD who smoke.
Outcome
Smoking quit-rate for people with COPD attending NHS stop-smoking services.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to regularly encourage people with COPD who smoke to stop smoking, and that the full range of evidence-based smoking cessation support is available.
Healthcare professionals ensure they regularly encourage people with COPD who smoke to stop smoking, and offer the full range of evidence-based smoking cessation support.
Commissioners ensure they commission services to provide the full range of evidence-based smoking cessation support.
People with COPD who smoke are regularly encouraged to stop and offered support to stop smoking.

Source clinical guideline references

NICE clinical guideline 101 recommendation 1.2.1.2 (key priority for implementation).

Data source

Structure
a) and b) Local data collection.
Process
Local data collection. GP practices can analyse data collected for Quality and Outcomes Framework indicator SMOKING4. This is the percentage of patients with any (or any combination of) the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses, who smoke and whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months.
Outcome
Local data collection. Information on 4-week smoking quit-rates for all people attending NHS smoking cessation services is collected in Vital Signs as VSB05 (also included in National Indicator Set NI123).

Definitions

Local services should agree the time periods to monitor quit rates, for example 4-week or 12-month. NICE public health guidance 10 recommends auditing 4-week quit rates.

Pulmonary rehabilitation

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme.

Quality measure

Structure
a) Evidence of local arrangements to provide multidisciplinary pulmonary rehabilitation programmes.
b) Evidence of local arrangements to ensure effectiveness of multidisciplinary pulmonary rehabilitation programmes, by collection and audit of health outcome data.
c) Evidence of local arrangements to ensure multidisciplinary pulmonary rehabilitation programmes can be accessed in a timely manner.
d) Evidence of local arrangements to ensure multidisciplinary pulmonary rehabilitation programmes are geographically accessible.
Process
Proportion of people with COPD meeting appropriate criteria who receive an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme.
Numerator – the number of people in the denominator receiving an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme.
Denominator – the number of people with COPD meeting appropriate criteria for pulmonary rehabilitation.
Outcome
a) Improvements in exercise capacity as measured by a validated field exercise test, for example the 6-minute walk test or the incremental shuttle walking test.
b) Improvements in health-related quality of life measured by a validated questionnaire, for example St George's Respiratory Questionnaire (SGRQ).

Description of what the quality statement means for each audience

Service providers ensure multidisciplinary pulmonary rehabilitation programmes are timely and accessible, and that health outcomes are monitored to ensure their effectiveness.
Healthcare professionals ensure they offer pulmonary rehabilitation to appropriate people with COPD.
Commissioners ensure they commission timely and accessible multidisciplinary pulmonary rehabilitation programmes, and that health outcomes are monitored to ensure their effectiveness.
People with COPD are offered a programme of care, called pulmonary rehabilitation, that is designed for the person with their full involvement to help restore health, if they are likely to benefit from it.

Source clinical guideline references

NICE clinical guideline 101 recommendations 1.2.8.1 (key priority for implementation) and 1.2.8.2 to 1.2.8.4

Data source

Structure
a) The national COPD audit of 'acute care resources and organisation of care' examines access to a formal pulmonary rehabilitation programme and whether it is delivered by a multidisciplinary team. The national COPD audit of 'primary care resources and organisation of care' examines, at an organisation level, access to community pulmonary rehabilitation services.
b) The national COPD audit of 'acute care resources and organisation of care' examines whether pulmonary rehabilitation programmes measure health status before and after pulmonary rehabilitation.
c) and d) Local data collection.
Process
Local data collection.
Outcome
a) and d) Local data collection.

Definitions

NICE clinical guideline 101 states that pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually MRC grade 3 and above). This includes those who have had a recent hospitalisation for an acute exacerbation. Pulmonary rehabilitation is not suitable for those who are unable to walk, have unstable angina or who have had a recent myocardial infarction.

Management of exacerbations

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.

Quality measure

Structure
Evidence of local arrangements to provide people who have had an exacerbation of COPD with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.
Process
Proportion of people who have had an exacerbation of COPD who are given individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.
Numerator – the number of people in the denominator given individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.
Denominator – the number of people who have had an exacerbation of COPD.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to make sure people who have had an exacerbation of COPD are given individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.
Healthcare professionals ensure people who have had an exacerbation of COPD are given individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.
Commissioners ensure they commission services that provide individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact to people who have had an exacerbation of COPD.
People who have had a flare-up of COPD are given written advice, tailored to the individual, to help them recognise future flare-ups early; a plan for managing flare-ups at home (including having antibiotics and corticosteroids to use at home if appropriate); and the name and details of a healthcare professional to contact.

Source clinical guideline references

NICE clinical guideline 101 recommendations 1.2.12.21 to 1.2.12.25 (key priorities for implementation).

Data source

Structure

Local data collection.
Process
Local data collection. The national COPD audit patient survey examines, at a patient level, whether they have been provided with a written plan for when their chest gets bad.
The national COPD audit GP survey examines, at a patient level, the provision of antibiotic rescue packs.

Definitions

Not all people will be eligible or appropriate for provision of antibiotics and corticosteroids for self-treatment at home. NICE clinical guideline 101 recommendation 1.2.12.24 states that appropriate use of antibiotic and corticosteroids should be monitored.

Initial assessment for long-term oxygen therapy

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service.

Quality measure

Structure
Evidence of local arrangements, to ensure that people with COPD potentially requiring long-term oxygen therapy (LTOT) are assessed in accordance with NICE guidance by a specialist oxygen service.
Process
Proportion of people with COPD with oxygen saturation less than or equal to 92% when stable, who are assessed for LTOT in accordance with NICE guidance by a specialist oxygen service.
Numerator – the number of people in the denominator assessed for LTOT in accordance with NICE guidance by a specialist oxygen service.
Denominator – the number of people with COPD with oxygen saturation less than or equal to 92% when stable.
It is noted that an assessment for long-term oxygen therapy should be considered in a range of clinical circumstances and not only for people with less than or equal to 92% oxygen saturation when stable (please see definitions section). However, to aid measurability, the specific population of those with less than or equal to 92% oxygen saturation when stable has been chosen.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for a specialist oxygen service to assess all people with COPD potentially requiring LTOT in accordance with NICE guidance.
Healthcare professionals ensure people with COPD potentially requiring LTOT are referred to a specialist oxygen service for assessment in accordance with NICE guidance.
Commissioners ensure they commission a specialist oxygen service to assess people with COPD who potentially require LTOT, in accordance with NICE guidance.
People with COPD potentially requiring long-term oxygen therapy are assessed by a specialist oxygen service.

Source clinical guideline references

Data source

Structure
Local data collection. The national COPD audit of 'acute care resources and organisation of care' examines, at unit level, the provision of LTOT services.
Process
Local data collection.

Definitions

NICE clinical guideline 101 section 1.2.5 contains criteria for the appropriate assessment for and provision of long-term oxygen therapy.
Recommendation 1.2.5.4 states people potentially requiring long-term oxygen therapy are:
  • all patients with very severe airflow obstruction (FEV1 < 30% predicted)
  • patients with cyanosis
  • patients with polycythaemia
  • patients with peripheral oedema
  • patients with a raised jugular venous pressure
  • patients with oxygen saturations ≤ 92% breathing air.
Assessment should also be considered in patients with severe airflow obstruction (FEV1 30-49% predicted)

Review of long-term oxygen therapy

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD.

Quality measure

Structure
Evidence of local arrangements to ensure that people with COPD receiving long-term oxygen therapy (LTOT) are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD.
Process
Proportion of people with COPD receiving LTOT, who have had a review in the previous 12 months by a specialist oxygen service in accordance with NICE guidance, as part of the integrated clinical management of their COPD.
Numerator – the number of people in the denominator reviewed in the previous 12 months by a specialist oxygen service in accordance with NICE guidance, as part of the integrated clinical management of their COPD.
Denominator – the number of people with COPD receiving LTOT.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for a specialist oxygen service to annually review people with COPD receiving LTOT in accordance with NICE guidance and as part of integrated clinical management.
Healthcare professionals ensure people with COPD receiving LTOT are reviewed by a specialist oxygen service in accordance with NICE guidance, at least annually, as part of the integrated clinical management of their COPD.
Commissioners ensure they commission specialist oxygen services to annually review people with COPD receiving LTOT in accordance with NICE guidance, and as part of the integrated clinical management of their COPD.
People with COPD who are receiving long-term oxygen therapy have this reviewed at least once a year by a specialist oxygen service.

Source clinical guideline references

NICE clinical guideline 101 recommendation 1.2.5.7.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

NICE clinical guideline 101 section 1.2.5 contains recommendations on reviewing people receiving LTOT.

Care in hospital

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support.

Quality measure

Structure
a) Evidence of local arrangements to ensure people with COPD admitted to hospital with an exacerbation are cared for by a respiratory team.
b) Evidence of local arrangements to provide a specialist early supported discharge scheme, with appropriate community support, for people with COPD admitted to hospital with an exacerbation.
Process
a) Proportion of people with COPD admitted to hospital with an exacerbation who are cared for by a respiratory team.
Numerator – the number of people in the denominator cared for by a respiratory team.
Denominator – the number of people with COPD admitted to hospital with an exacerbation.
b) Proportion of people with COPD admitted to hospital with an exacerbation, and who meet the criteria for early supported discharge, who are placed on a specialist early supported discharge scheme with appropriate community support.
Numerator – the number of people in the denominator placed on a specialist early supported discharge scheme with appropriate community support.
Denominator – the number of people with COPD admitted to hospital with an exacerbation and meeting the criteria for early supported discharge.
Outcome
Reduction in mean length of stay of people admitted to hospital with an exacerbation of COPD.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to make sure people admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported discharge scheme with appropriate community support.
Healthcare professionals ensure that people admitted to hospital with an exacerbation of COPD are cared for by a respiratory team and, if they meet appropriate criteria, are placed on a specialist early supported discharge scheme with appropriate community support.
Commissioners ensure they commission services to make sure people admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and that there is access to a specialist early supported discharge scheme with appropriate community support.
People admitted to hospital with a flare-up of COPD are cared for by a respiratory team and are considered for a scheme involving a shorter stay in hospital with extra support at home.

Source clinical guideline references

NICE clinical guideline 101 recommendations 1.3.4.1 (key priority for implementation) and 1.3.4.3

Data source

Structure
a) Local data collection.
b) The national COPD audit of 'acute care resources and organisation of care' examines, at a unit level, the provision of an early discharge scheme and the healthcare professionals directly involved with scheme.
Process
a) The national COPD audit of 'admitted exacerbations' examines, at a patient level, the number of patients seen by a respiratory specialist during admission.
b) The national COPD audit of 'admitted exacerbations' examines, at a patient level, the number of patients accepted onto an early discharge scheme.
Outcome
Local data collection. The admitted patient care commissioning datasets contain the data needed for calculating length of stay for people admitted to hospital with an exacerbation of COPD. Data available via HES Online.

Definitions

National quality guidance for early supported discharge is contained within the NICE commissioning guide on services for people with COPD.

Non-invasive ventilation in hospital

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, non invasive ventilation delivered by appropriately trained staff in a dedicated setting.

Quality measure

Structure
a) Evidence of local arrangements for the prompt assessment and delivery of non-invasive ventilation (NIV) to people admitted to hospital with an exacerbation of COPD and persistent acidotic ventilatory failure.
b) Evidence of local arrangements to ensure that people admitted to hospital and receiving NIV for an exacerbation of COPD and persistent acidotic ventilatory failure, have NIV delivered by appropriately trained staff in a dedicated setting.
Process
a) Proportion of people admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure, who are promptly assessed for NIV, and for whom any subsequent delivery is promptly undertaken.
Numerator – the number of people in the denominator promptly assessed for NIV, and for whom any subsequent delivery is promptly undertaken.
Denominator – the number of people admitted to hospital with an exacerbation of COPD and persistent acidotic ventilatory failure.
b) Proportion of people admitted to hospital and receiving NIV for an exacerbation of COPD and persistent acidotic ventilatory failure, who have it delivered by appropriately trained staff in a dedicated setting.
Numerator – the number of people in the denominator having NIV delivered by appropriately trained staff in a dedicated setting.
Denominator – the number of people admitted to hospital receiving NIV for an exacerbation of COPD and persistent acidotic ventilatory failure.
Outcome
a) Reduction in hospital mortality rate of patients admitted with an exacerbation of COPD.
b) Reduction in median length of stay of patients admitted with an exacerbation of COPD.
c) Reduction in complications, specifically ventilator-associated pneumonia.
d) Reduction in the need for intubation.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for the prompt assessment and delivery of NIV to people admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure. Ensure systems are in place for delivering NIV in a dedicated setting by appropriately trained staff.
Healthcare professionals ensure that people admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed, and receive NIV delivered by appropriately trained staff in a dedicated setting.
Commissioners ensure they commission services to promptly assess people admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure for NIV, and deliver it through appropriately trained staff in a dedicated setting.
People admitted to hospital with a flare-up of COPD, who are not getting enough oxygen into their blood and not breathing deeply enough despite having the right type of medicines, are promptly assessed for a treatment called 'non-invasive ventilation'. This is an emergency treatment given by trained staff in hospital that involves wearing a mask connected to a machine that pumps oxygen into the lungs.

Source clinical guideline references

NICE clinical guideline 101 recommendations 1.3.7.1 and 1.3.7.2 (key priorities for implementation).

Data source

Structure
a) Local data collection.
b) The national COPD audit of 'acute care resources and organisation of care' examines, at a unit level, the provision of NIV services within dedicated settings and the training of staff delivering NIV.
Process
a) Local data collection. The national COPD audit of 'admitted exacerbations' examines, at a patient level, whether NIV was given and the reasons for not ventilating.
b) Local data collection.
Outcome
The admitted patient care commissioning datasets contain the data needed for calculating (in patients admitted with exacerbations of COPD) the number receiving NIV, the number of deaths in hospital, the number receiving intubation and the median length of stay.
The office of populations, censuses and surveys classification of surgical operations and procedures (OPCS-4) code for NIV is E85.2. The OPCS-4 code for invasive ventilation is E85.1. The ICD-10 code for COPD with acute exacerbation is J44.1.
Data available via HES Online.

Definitions

A designated setting is one where staff have been specifically trained in NIV. For example intensive care units, high-dependency units, emergency admissions units or dedicated respiratory wards.
Prompt assessment and receipt of NIV should be defined as:
  • assessment and receipt of NIV within 3 hours of presentation, and
  • receipt of NIV within 1 hour of the decision being made to administer NIV.

Review within 2 weeks of discharge

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge.

Quality measure

Structure
Evidence of local arrangements to ensure that people admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge.
Process
Proportion of people discharged from hospital following an admission with an exacerbation of COPD, who are reviewed within 2 weeks of discharge.
Numerator – the number of people in the denominator reviewed within 2 weeks of discharge.
Denominator – the number of people discharged from hospital following admission with an exacerbation of COPD.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to make sure that people admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge.
Healthcare professionals ensure that people being discharged from hospital following admission, with an exacerbation of COPD, have arrangements for a review within 2 weeks.
Commissioners ensure they commission services to review people admitted to hospital with an exacerbation of COPD within 2 weeks of discharge.
People admitted to hospital with a flare-up of COPD are checked within 2 weeks of leaving hospital.

Source clinical guideline references

NICE clinical guideline 101 recommendation 1.3.10.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Local services and commissioners should agree the specific service arrangements for reviewing patients within 2 weeks of discharge, following an admission with an exacerbation of COPD. This review may take place in primary or secondary care depending on local agreement.

Palliative care

This quality statement is taken from the COPD quality standard. The quality standard defines clinical best practice in COPD care and should be read in full.

Quality statement

People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with advanced COPD, and their carers, are identified and offered palliative care.
b) Evidence of local arrangements to ensure that palliative care is provided for people with advanced COPD and their carers, and addresses physical, social and emotional needs.
Process
Proportion of people with advanced COPD, and their carers, who receive palliative care that addresses physical, social and emotional needs.
Numerator – the number of people in the denominator receiving palliative care that addresses physical, social and emotional needs.
Denominator – the number of people with advanced COPD, and their carers, identified as needing palliative care.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to identify people with advanced COPD and their carers, and offer palliative care that addresses physical, social and emotional needs.
Healthcare professionals ensure they identify people with advanced COPD and their carers, through prognostic indicators and offer palliative care that addresses physical, social and emotional needs.
Commissioners ensure they commission services to provide palliative care to people with advance COPD that addresses physical, social and emotional needs.
People with advanced COPD and their carers are offered palliative care (which is care in the later stages of the disease to make the person as comfortable as possible) that addresses their physical, social and emotional needs.

Source clinical guideline references

NICE clinical guideline 101 recommendation 1.2.12.10.

Data source

Structure
a) The national COPD audit of 'acute care resources and organisation of care' examines, at a unit level, the provision of palliative care services and information on end-of-life care for people with advanced COPD. The national COPD audit of 'primary care resources and organisation of care' examines, at an organisational level, access to palliative care services.
b) Local data collection. GP practices collect data on the completeness of a palliative care register for QOF PC3 – 'the practice has a complete register available of all patients in need of palliative care/support irrespective of age'.
Process
Local data collection. GP practices collect data on case review meetings for Quality and Outcomes Framework indicator PC2: the practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed.

Definitions

Indicative markers for people who are likely to benefit from palliative care include but are not limited to:
  • severe airflow obstruction (FEV1 <30% predicted)
  • respiratory failure
  • low BMI (less than 19)
  • house bound (MRC dyspnoea score 5)
  • history of two or more admissions for exacerbations during the previous year
  • need for non-invasive ventilation for an acute exacerbation
  • eligibility for long-term home oxygen therapy.

Identifying people who smoke

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.

Rationale

There is evidence that people who smoke are receptive to smoking cessation advice in all healthcare settings. It is therefore important that healthcare practitioners proactively ask people if they smoke, and offer advice on how to stop.

Quality measures

Structure
Evidence of local arrangements to ensure that people are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.
Data source: Local data collection.
Process
a) Proportion of people who are asked if they smoke by their healthcare practitioner.
Numerator – the number of people in the denominator who are asked if they smoke by their healthcare practitioner.
Denominator – the number of people who have face-to-face contact with a healthcare practitioner.
Data source: a) Local data collection. The quality and outcomes framework (QOF) contains indicators related to identifying and supporting people who smoke in primary care.
b) Proportion of people who smoke who receive advice on how to stop.
Numerator – the number of people in the denominator who receive advice on how to stop.
Denominator – the number of people who report that they smoke during face-to-face contact with a healthcare practitioner.
Data source: b) Local data collection. NICE public health guidance 10: audit support – criterion 3i. The QOF contains indicators related to identifying and supporting people who smoke in primary care.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people to be asked if they smoke by their healthcare practitioner, and for those who smoke to be offered advice on how to stop.
Healthcare practitioners ask their patients if they smoke, and offer those who smoke advice on how to stop.
Commissioners ensure that they commission services where healthcare practitioners ask their patients if they smoke, and that they offer those who smoke advice on how to stop.

What the quality statement means for patients, service users and carers

People are asked if they smoke by their healthcare practitioners, and those who smoke are offered advice on how to stop.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Advice can vary by healthcare setting. In the context of primary care settings, this would involve evidence-based, opportunistic advice offered to people who smoke about the options and support available to help them stop smoking. In the context of secondary care settings, advice may involve the practitioner providing people who smoke with information and referring them to an evidence-based smoking cessation service.
The National Centre for Smoking Cessation and Training offers a training module on the delivery of evidence-based smoking cessation interventions, to ensure that this is done in a sensitive way within the brief time available with the patient.
This statement is linked to statement 2, because advice on how to stop may include a referral to an evidence-based smoking cessation service.

Equality and diversity considerations

Advice should be culturally appropriate and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.
Advice may include referral to an evidence-based smoking cessation service. NICE public health guidance 10 states that such services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use local evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Referral to smoking cessation services

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered a referral to an evidence-based smoking cessation service.

Rationale

Smoking cessation services provide the most effective route to stopping smoking, but many people who smoke do not use these services when they try to stop. It is therefore important that practitioners are aware of and make use of the opportunities to refer people who smoke to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care sets out the high-quality requirements for ensuring that pregnant women who smoke are referred to an evidence-based smoking cessation service.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered a referral to an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who smoke who are referred to an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who are referred to an evidence-based smoking cessation service.
Denominator – the number of people identified as smokers in any healthcare setting.
Data source: Local data collection. The quality and outcomes framework (QOF) contains indicators related to support in primary care for people who smoke.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered a referral to an evidence-based smoking cessation service.
Healthcare practitioners offer people who smoke a referral to an evidence-based smoking cessation service.
Commissioners ensure that they commission services that offer people who smoke a referral to an evidence-based smoking cessation service.

What the quality statement means for patients, service users and carers

People who smoke are offered a referral to an evidence-based smoking cessation service to help them stop smoking.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Evidence-based smoking cessation services are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.
The National Centre for Smoking Cessation and Training offers training modules for people delivering smoking cessation interventions.
This statement is linked to statement 1, because advice on how to stop may include a referral to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care states that 'Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment' and the appropriate referral criteria are defined. The supporting information also states that the midwife may provide the pregnant woman with information (in a variety of formats, for example, a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to secondhand smoke for both mother and baby.

Equality and diversity considerations

NICE public health guidance 10 states that evidence-based smoking cessation services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Behavioural support with pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.

Rationale

People who smoke are more likely to stop smoking if they are offered a combination of interventions, with combined behavioural support and pharmacotherapy the most likely to be successful.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Denominator – the number of people referred to an evidence-based smoking cessation service.
Data source: Local data collection. Contained in NICE public health guidance 10: audit support – criterion 7; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Healthcare practitioners offer behavioural support with pharmacotherapy to people who have been referred to an evidence-based smoking cessation service.
Commissioners ensure that they commission evidence-based smoking cessation services that offer people who smoke behavioural support with pharmacotherapy.

What the quality statement means for patients, service users and carers

People who have been referred to an evidence-based smoking cessation service are offered behavioural support (which may be either individual or group counselling) together with drug treatment.

Source guidance

Definition of terms used in this quality statement

Behavioural support
This can be individual behavioural therapy or group behaviour therapy.
NICE public health guidance 10 states that individual behavioural therapy involves scheduled face-to-face meetings between someone who smokes and a practitioner from the smoking cessation service trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.
NICE public health guidance 10 states that group behaviour therapy involves scheduled meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). It is normally combined with pharmacotherapy.
Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
A summary of further considerations relating to pharmacotherapy is provided in quality statement 4.
Evidence-based stop smoking services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.

Rationale

Pharmacotherapy interventions act as an aid to help people to stop smoking, and it is important that people who seek support to stop smoking receive the full course of their chosen pharmacotherapy to increase the chances of success.

Quality measures

Structure
Evidence of local arrangements to ensure that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Data source: Local data collection.
Process
Proportion of people who seek support to stop smoking and who agree to take pharmacotherapy who receive a full course.
Numerator – the number of people in the denominator who receive a full course of pharmacotherapy.
Denominator – the number of people who seek support to stop smoking and who agree to take pharmacotherapy.
Data source: Local data collection. Contained in NICE public health guidance 1: audit – criterion 5 and NICE public health guidance 10: audit support – criteria 5–8; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Healthcare practitioners offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.
Commissioners ensure that they commission services that offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.

What the quality statement means for patients, service users and carers

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course of drug treatment.

Source guidance

Definition of terms used in this quality statement

Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that healthcare professionals who prescribe nicotine replacement therapy (NRT), varenicline or bupropion should offer advice, encouragement and support including referral to an evidence-based smoking cessation service. Pharmacotherapy should normally be prescribed as part of an abstinent contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date. NICE technology appraisal guidance 123 states that varenicline should normally be prescribed only as part of a programme of behavioural support.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
It is important that people who smoke who receive pharmacotherapy receive a full course, which will vary depending on the individual smoker. A full course for NRT is at least 8 weeks, for varenicline it is at least 12 weeks and for bupropion it is at least 8 weeks. NICE public health guidance 10 outlines that the prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date with subsequent prescriptions given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.
Drugs with a metabolism that is affected by smoking (or stopping smoking) should be monitored, and the dosage adjusted if appropriate.

Equality and diversity considerations

There should be a discussion about risks and benefits of using NRT with young people aged 12–17 and pregnant or breastfeeding women.

Outcome measurement

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Rationale

Recording smoking status using carbon monoxide testing after 4 weeks provides an incentive for people who are attempting to stop, and is an objective way to measure individual and service level outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Data source: Local data collection.
Process
Proportion of people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Numerator – the number of people in the denominator who are assessed for carbon monoxide levels 4 weeks after the quit date.
Denominator – the number of people who smoke who have set a quit date with an evidence-based smoking cessation service.
Data source: Local data collection. The Health and Social Care Information Centre's Indicator Portal collects data on the number of people who smoke who successfully quit at the 4-week follow-up per 100,000 population.
Outcome
4-week quit rates.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Healthcare practitioners ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Commissioners ensure that they commission services for people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

What the quality statement means for patients, service users and carers

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Source guidance

Definition of terms used in this quality statement

NICE public health guidance 10 states that success should be validated by a carbon monoxide monitor reading of less than 10 ppm at the 4-week point. This does not imply that treatment should stop at 4 weeks.
Evidence-based smoking cessation services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Glossary

American Society of Anesthesiologists
American Thoracic Society
Body mass index
Body mass index, airflow obstruction, dyspnoea and exercise capacity
Chronic obstructive pulmonary disease
European Respiratory Society
Forced expiratory volume in 1 second
Forced vital capacity
Global Initiative for Chronic Obstructive Lung Disease
Inhaled corticosteroid
Long-acting beta2 agonist
Long-acting muscarinic antagonist
Long-term oxygen therapy
Medical Research Council
Non-invasive ventilation
Partial pressure of oxygen in arterial blood
Short-acting beta2 agonist
Short-acting muscarinic antagonist
Oxygen saturation of arterial blood
Carbon monoxide lung transfer factor

Paths in this pathway

Pathway created: May 2011 Last updated: August 2015

© NICE 2015

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