1. GRASP-COPD Hannah Wall, Programme Delivery Manager hannah.wall@nhsiq.nhs.ukhannah.wall@nhsiq.nhs.uk 07920845437 Ian Robson, Senior Analyst Ian.robson@nhsiq.nhs.ukIan.robson@nhsiq.nhs.uk 007554111067 A practical tool to help you and your respiratory patients

2. Aims of the presentation To introduce GRASP-COPD To demonstrate how to use the tool at practice level to support patients with COPD Highlight an example of a CCG who have successfully used GRASP-COPD

3. Set up on 1 April 2013 and part of NHS England Combines six previous improvement bodies including the Institute and NHS Improvement Several arms, including improvement programmes across the five domains and capacity and capability to support frontline professionals become agents for change Measurement and evaluation intrinsic to all national transformational change programmes NHS Improving Quality

4. What is GRASP? GRASP was originally created for stroke prevention in Atrial Fibrillation as a practice risk stratification/ case finder tool (GRASP-AF) Initially developed by the West Yorkshire Cardiovascular Network, the Leeds Arrhythmia team and PRIMIS, as part of the NHS Improvement AF in primary care national priority

5. How GRASP-AF works MIQUEST queries to identify patients with a diagnosis of AF Stroke risk calculated using CHADS 2 Highlights patients with a CHADS 2 score of 2 or more not receiving warfarin who would benefit from review to assess anti-coagulation need Does not assess contraindications to warfarin, the decision whether or not to start warfarin remains a clinical one

6. Snapshot of the tool - dashboard

7. Snapshot of the tool – case finder

8. Evolution of GRASP-AF GRASP-AF is now in use in more than 2600 practices in England It is estimated that around 170 strokes have been avoided as a result of using this tool GRASP-AF is still available and is free to download In 2012 the success of GRASP prompted the creation of two new stratification tools – GRASP- HF (heart failure) and GRASP-COPD

9. Why GRASP for COPD? 1 person dies from COPD every 20 minutes 1 in 8 people over 35 has COPD that has not been properly identified or diagnosed, and over 15% are only diagnosed when they present to hospital as an emergency COPD is the second most common cause of emergency admissions to hospital Over 50% of people currently diagnosed with COPD are under 65 years of age

10. Key priorities for primary care Public awareness - undiagnosed Prevention – lung health Smoking cessation Early/accurate/differential diagnosis Quality assured spirometry Disease registers and risk stratification Medicines optimisation and self-management

11. GRASP can help with these: Public awareness - undiagnosed Prevention – lung health Smoking cessation Early/accurate/differential diagnosis Quality assured spirometry Disease registers and risk stratification Medicines optimisation and self-management

12. Audit 1 Patients already diagnosed with COPD The results will enable you to: –Audit your management of patients with COPD against current NICE guidance –Identify patients who may be inaccurately diagnosed and therefore not being treated according to the NICE guidance –Review patients who have a diagnosis of both asthma and COPD –Easily assess and visualise clinical data about your patients with COPD

13. GRASP-COPD dashboard

14. GRASP-COPD datasheet

15. Audit 2 Patients not yet diagnosed with COPD The results will enable you to: –Identify patients potentially missing a COPD diagnosis code –Identifying patients at risk of developing COPD –Providing several pre-set filters to prioritise those patients most likely to need a review

16. GRASP-COPD case finder

18. GRASP-COPD – the benefits Free to download and use Easy to interpret Uploading anonymous data back to PRIMIS gives access to benchmarking data for CCGs at local regional and national level Provides a case finder and a ready-made disease register with the ability to select/ examine different patient groups

19. Who is using GRASP-COPD? No of practicesAF%COPD% East of England SCN NHS Luton CCG3129 93.55%00.0% NHS West Suffolk CCG2516 64.00%00.0% NHS Mid Essex CCG5022 44.00%00.0% NHS Great Yarmouth And Waveney CCG2710 37.04%00.0% NHS Herts Valleys CCG7013 18.57%00.0% NHS North East Essex CCG457 15.56%00.0% NHS Bedfordshire CCG557 12.73%00.0% NHS Castle Point And Rochford CCG283 10.71%00.0% NHS West Norfolk CCG232 8.70%00.0% NHS South Norfolk CCG252 8.00%14.00% NHS Ipswich And East Suffolk CCG423 7.14%00.0% NHS Cambridgeshire And Peterborough CCG1077 6.54%00.0% NHS Norwich CCG241 4.17% 2 8.33% NHS Basildon And Brentwood CCG450 0.00%00.0% NHS East And North Hertfordshire CCG590 0.00%00.0% NHS North Norfolk CCG200 0.00%00.0% NHS Southend CCG360 0.00%00.0% NHS Thurrock CCG340 0.00%00.0% NHS West Essex CCG390 0.00%00.0%

20. Who is using GRASP-COPD? Data at 30.06.2014: –Number of practices uploading data: 85 –Number of CCGs 21 –Number of patients with COPD: 12,912 –Prevalence of COPD: 2.48%

21. How to Access GRASP-COPD Need to register with the PRIMIS Hub - http://www.primis.nottingham.ac.uk/hub/login/index.php http://www.primis.nottingham.ac.uk/hub/login/index.php Download the CHART software CHART – Excel based system for preparing MIQUEST queries / viewing results, compatible with all major clinical systems If you are practice based can access GRASP-COPD straight away Non-practice based has to request access from within PRIMIS Hub

22. Setting-up CHART Download CHART software from PRIMIS Hub Lower Macro Security, and “trust access to Visual Basic” – Developer tab Set-up your practice details Download the GRASP Suite audits using the in-system function User Guides available from PRIMIS and NHS IQ

23. Running GRASP-COPD Export queries from CHART (2 minutes) Run queries through clinical system’s MIQUEST facility (5 mins to overnight) Load results into CHART (2 minutes)

24. Understanding the Results COPD Casefinder

25. Understanding the Results COPD Casefinder

26. Understanding the Results GRASP-COPD

27. Understanding the Results GRASP-COPD

28. CHART Online Can anonymously upload a copy of your practice’s results Compare your practice / CCG to others in the country Track your improvements Aids the national picture

29. Improving Early Diagnosis of COPD

30. What are the targets for improvement? The focus of the improvement for this measure is the NHS Outcomes Indicator Set (OIS) ‘Unplanned hospitalisation for chronic ambulatory care sensitive conditions’ and to target patients with a primary diagnosis of COPD as this is the most prevalent condition for patients being admitted with chronic ambulatory conditions. The approach implemented was to seek a reduction in the number of these patients by linking this target measure to a Local Improvement Scheme (L.I.S.) based on each individual practice position at the end of 2013/14.

31. How to begin To initiate the project, a programme was devised that follows several distinct phases: Introducing developing tools for GPs Designing and producing local training guides Developing the engagement & long-term support Changing attitudes to appropriate diagnosis Increase the diagnosis rate by utilising a number of strategies.

32. Key staff - Working collaboratively Primary Care Development team: 1 st Phase -Leading on implementing the LIS Primary Care Informatics team: 2 nd Phase - Supporting GP practice staff in using the technology Medicines Management team: 3 rd Phase - Practice Pharmacists supporting data analysis

33. Local Incentive Scheme The development of the L.I.S. rewards practices for ensuring COPD patients receive or are offered the best care possible in line with NICE quality standards. The embedded 3 components within the service specification are as follows: Component 1: A GP representative actively takes part in the CCG’s commissioning agenda and priorities by attending monthly locality meetings Component 2: Each practice is required to run the PRIMIS COPD GRASP tool which is free of charge and provides the CCG with results of the quality audits on a quarterly basis Component 3: Practices will be required to demonstrate improvement in patient care in line with individual practice action plans e.g. classify and record the severity of COPD, increased diagnosis rates, a reduction in the number of unplanned hospitalisations and evidences the care given to patients

34. Technology & tools As all practices in Walsall use the same clinical system a number of tools were designed by the Primary Care Informatics Team to support the practice: Supporting practices in running the GRASP-COPD query library via a training methodology to up-skill the practice managers The audit results require a need for analysis and interpretation by the practice which can be complex and confusing. The team have developed an interpretation and analysis document that demonstrates how to utilise the dashboard audits and drill down to cohorts of specific patients to target optimisation of treatment and care e.g. to ensure all patients on the COPD register have a validated diagnosis, for example, some patients may be added to the register following a provisional diagnosis in hospital without any validated calculated spirometry FEV scores

35. Technology & tools (cont’d) To support practices further in data capture a clinical template has been designed to replicate all of the COPD GRASP data set to ensure data is captured during the face-to-face consultation and also ensures a consistent approach in data recording and data quality across the CCG To support practice staff who may experience difficulty in running the audits, the team has the added functionality of using an IT remote assistance tool that allows a connection to the practices computer and can be used as a training aide to demonstrate to the practice how to perform the tasks required All of the data captured at practice level has been captured into detailed comprehensive graphs and the data has been manipulated to display all of the components of the GRASP COPD into a whole Walsall CCG dashboard

36. 3rd Phase: Further support Practice pharmacists work alongside practice managers The practice manager takes responsibility for running the quarterly COPD GRASP audits and shares the reports with the pharmacist who is able to support the analysis and interpretation of data They in turn share the data results with the clinicians and administrative staff to significantly identify patients who need medicines optimisation to improve treatment regimens

37. Data analysis What do need to capture for the organisation? What does the PRIMIS GRASP COPD tool give us to address the Outcomes Indicator Set? How can we collate all of the information? Will we see outcomes and benchmarking measures? Can we demonstrate progress?

40. Results Walsall CCG’s prevalence rate for COPD was 2.1%. At the end of 2013-2014 year prevalence has risen to 2.4%. From the practice actions plans there has been significant improvements in the classification of severity due to patients having a generic coded entry of COPD but do not have their level of severity recorded determined by FEV ₁ or FEV ₁ % predicted. Admissions data: at the end of 2013/14 shows a reduction of 1.2% overall which is a reduction of 3 hospital spells at the CCG expected average of 12.99%. The focus of the 2014/15 L.I.S. is that GP practices will be provided with a dashboard and summary sheet detailing the results of the 2013/14 data quality audits, highlighting areas for the practice to address and this will form the baseline for measuring improvement at the end of financial year 2014/15.

41. Finally To further this project work other clinical target areas are being identified where engagement with practices and the use of software tools are in development to support practice staff, CCG Commissioners and improve patient care. A consideration is utilisation i.e. this approach could be replicated at scale across other practices and commissioning organisations.

42. Thank you Hannah.wall@nhsiq.nhs.uk ian.robson@nhsiq.nhs.uk barbara.yates@walsallhealthcare.nhs.uk Hannah.wall@nhsiq.nhs.uk ian.robson@nhsiq.nhs.uk barbara.yates@walsallhealthcare.nhs.uk