Community Assessment of COPD Health Care (COACH) study: a clinical audit on primary care performance variability in COPD care

Abstract

Background: A thorough evaluation of the adequacy of clinical practice in a designated health care setting and temporal context is key for clinical care improvement. This study aimed to perform a clinical audit of primary care to evaluate clinical care delivered to patients with COPD in routine clinical practice.

Methods: The Community Assessment of COPD Health Care (COACH) study was an observational, multicenter, nationwide, non-interventional, retrospective, clinical audit of randomly selected primary care centers in Spain. Two different databases were built: the resources and organization database and the clinical database. From January 1, 2015 to December 31, 2016 consecutive clinical cases of COPD in each participating primary care center (PCC) were audited. For descriptive purposes, we collected data regarding the age at diagnosis of COPD and the age at audit, gender, the setting of the PCC (rural/urban), and comorbidities for each patient. Two guidelines widely and uniformly used in Spain were carefully reviewed to establish a benchmark of adequacy for the audited cases. Clinical performance was analyzed at the patient, center, and regional levels. The degree of adequacy was categorized as excellent (> 80%), good (60-80%), adequate (40-59%), inadequate (20-39%), and highly inadequate (< 20%).

Results: During the study 4307 cases from 63 primary care centers in 6 regions of the country were audited. Most evaluated parameters were judged to fall in the inadequate performance category. A correct diagnosis based on previous exposure plus spirometric obstruction was made in an average of 17.6% of cases, ranging from 9.8 to 23.3% depending on the region. During the audited visit, only 67 (1.6%) patients had current post-bronchodilator obstructive spirometry; 184 (4.3%) patients had current post-bronchodilator obstructive spirometry during either the audited or initial diagnostic visit. Evaluation of dyspnea was performed in 11.1% of cases. Regarding treatment, 33.6% received no maintenance inhaled therapies (ranging from 31.3% in GOLD A to 7.0% in GOLD D). The two most frequently registered items were exacerbations in the previous year (81.4%) and influenza vaccination (87.7%).

Conclusions: The results of this audit revealed a large variability in clinical performance across centers, which was not fully attributable to the severity of the disease.

Keywords: COPD; Clinical audit; Primary care; Quality of care; Variability.

Fig. 1

Distribution of audited cases throughout the country, Map obtained from http://d-maps.com/carte.php?num_car=2208&lang=es

Fig. 2

Distribution of maintenance inhaled therapies. ICS: inhaled corticosteroids; LABA: long-acting ß₂ agonist; LABD: long-acting bronchodilator; LAMA: long-acting muscarinic antagonist

Fig. 3

Distribution of maintenance inhaled therapies according to GOLD 2017 groups. Only in 436 cases out of the total 4307 cases audited (10.1%), GOLD classification could be assessed, based on exacerbation frequency and symptoms. ICS: inhaled corticosteroids; LABA: long-acting ß₂ agonist; LABD: long-acting bronchodilator; LAMA: long-acting muscarinic antagonist; CAT: COPD Assessment Test; mMRC: modified Medical Research Council