Abstract
Most clinical contacts with chronic obstructive pulmonary disease (COPD) patients take place in primary care, presenting opportunity for proactive clinical management. Electronic health records could be used to risk stratify diagnosed patients in this setting, but may be limited by poor data quality or completeness. We developed a risk stratification database algorithm using the DOSE index (Dyspnoea, Obstruction, Smoking and Exacerbation) with routinely collected primary care data, aiming to calculate up to three repeated risk scores per patient over five years, each separated by at least one year. Among 10,393 patients with diagnosed COPD, sufficient primary care data were present to calculate at least one risk score for 77.4%, and the maximum of three risk scores for 50.6%. Linked secondary care data revealed primary care under-recording of hospital exacerbations, which translated to a slight, non-significant cohort average risk score reduction, and an understated risk group allocation for less than 1% of patients. Algorithmic calculation of the DOSE index is possible using primary care data, and appears robust to the absence of linked secondary care data, if unavailable. The DOSE index appears a simple and practical means of incorporating risk stratification into the routine primary care of COPD patients, but further research is needed to evaluate its clinical utility in this setting. Although secondary analysis of routinely collected primary care data could benefit clinicians, patients and the health system, standardised data collection and improved data quality and completeness are also needed.
Highlights
The diagnosed prevalence of chronic obstructive pulmonary disease (COPD) was recently placed at around one million people in England,[1] there may be an estimated two million more without formal diagnosis.[2]
Under the hypothesis that linkage to secondary care data would reveal exacerbations that were absent from the primary care electronic health record (EHR), we aimed to describe and compare their incidence using stand-alone primary care (SaPC) data and primary care/secondary care (PC/SC) data, and the extent to which algorithmically calculated DOSE scores varied by data type
The proportion of patients with a non-zero Exacerbation score was found to differ by data type; PC/SC data generated an excess across all instances, to a maximum of an additional 157 patients gaining a non-zero score at the second instance
Summary
The diagnosed prevalence of chronic obstructive pulmonary disease (COPD) was recently placed at around one million people in England,[1] there may be an estimated two million more without formal diagnosis.[2] It is the second most common reason for emergency National Health Service (NHS) hospital admission, representing a significant cost.[2] Recognising the growing burden of long-term conditions on the health system, current NHS policy emphasises a need to move away from the traditional model of care, arguing instead for greater focus on the delivery of preventative care out of hospital, and concomitant shift in investment from secondary care to primary care and community services.[3,4,5] a sudden and rapid worsening of symptoms (known as COPD exacerbation) may sometimes necessitate hospital attendance, most clinical contacts with diagnosed patients take place in the primary care setting,[6] presenting opportunities to proactively manage the condition and reduce the risk of hospitalisation. Limited resources in primary care, dictate a need for methods to identify and target those patients at greatest risk. Progressive condition with multiple phenotypes,[7] arguments for a range of predictors being more powerful than any single clinical marker alone have motivated the development of several multicomponent indices for prognosis and risk stratification in COPD.[8,9]
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