Introduction

This quality standard covers the assessment, diagnosis and management of chronic obstructive pulmonary disease (COPD). It does not cover prevention, screening or case finding. For more information see the COPD topic overview.

This quality standard should be considered alongside quality statement 2 in the NICE quality standard on smoking: supporting people to stop, which sets out the high‑quality requirements for referring people who smoke to an evidence‑based smoking cessation service. Smoking is one of the main causes of COPD and encouraging people with COPD to stop smoking is one of the most important components in managing COPD.

This quality standard should also be considered alongside the NICE quality standard on end of life care for adults, which sets out the high‑quality requirements for adults approaching the end of their life.

Why this quality standard is needed

COPD is a long‑term respiratory condition characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months and is usually progressive. COPD is predominantly caused by smoking. Other factors, particularly occupational exposures, such as harmful dust and chemicals, may also contribute to developing COPD. People with COPD often have exacerbations, when there is rapid and sustained worsening of symptoms beyond their usual day‑to‑day variation.

In the UK, it is estimated that 3 million people have COPD, of whom 2 million are undiagnosed. Prevalence increases with age and most people are not diagnosed until they are in their 50s. There are significant geographic variations in the prevalence of COPD, and it is closely associated with levels of deprivation. Unlike many other common chronic diseases, the prevalence of COPD has not declined in recent years.

There is no single diagnostic test for COPD. Making a diagnosis relies on clinical judgement based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry.

COPD is treatable but not curable, and early diagnosis and treatment can help to slow the decline in lung function and increase the amount of time that people with COPD have to enjoy an active life. Pharmacological and other therapies can help to manage symptoms and disability caused by COPD, and improve the person's quality of life, despite having only limited or no impact on the airflow obstruction.

The quality standard is expected to contribute to improvements in the following outcomes:

  • COPD diagnosis

  • morbidity

  • mortality

  • acute exacerbations

  • hospital admissions

  • A&E attendance

  • quality of life

  • change in breathlessness

  • exercise capacity

  • inappropriate non‑invasive ventilation.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1 to 3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Improvement areas

Reducing premature mortality from the major causes of death

1.2 Under 75 mortality rate from respiratory disease*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition**

Reducing time spent in hospital by people with long‑term conditions

2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

Improving quality of life for people with multiple long‑term conditions

2.7 Health‑related quality of life for people with three or more long‑term conditions**

3 Helping people to recover from episodes of ill health or following injury

Improvement areas

Helping older people to recover their independence after illness or injury

3.6 i Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation service*

3.6 ii Proportion offered rehabilitation following discharge from acute or community hospital*

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i. GP services

ii. GP out‑of‑hours services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

i. Primary care

ii. Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving the experience of care for people at the end of their lives

4.6 Bereaved carers' views on the quality of care in the last 3 months of life

Alignment across the health and social care system

* Indicator is shared

** Indicator is complementary

Table 2 Public health outcomes framework for England 2013–16

Domain

Objectives and indicators

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.14 Smoking prevalence – adults (over 18s)

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.7 Mortality rate from respiratory diseases*

4.11 Emergency readmissions within 30 days of discharge from hospital*

4.13 Health‑related quality of life for older people

Alignment across the health and social care system

* Indicator shared with the NHS Outcomes Framework

Table 3 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2B Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services*

Aligning across the health and care system

* Indicator shared

** Indicator complementary

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to COPD.

A patient safety alert on risk of severe harm and death from unintentional interruption of non-invasive ventilation has been issued by NHS England to raise awareness of patient safety incidents. Non‑invasive ventilation is used for some people with COPD who have acute exacerbations that do not respond to medical therapy.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE Pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and are supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for COPD specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole COPD care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with COPD in secondary, primary and community services.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality COPD service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating people with COPD should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people with COPD. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.