Comparison of COPD primary care in England, Scotland, Wales, and Northern Ireland

While it was already clear from the COPD primary care audit that there is shortfall in delivering key aspects of COPD care, it appears that there is some variability between the UK nations, with Scottish practices often performing less well, while English and Northern Irish practices perform similarly to Welsh ones. This could be due to the quality of event recording, quality of care given, or a combination of the two, perhaps driven by participation in the Quality and Outcomes Framework (QOF) pay-for-performance scheme, which Scotland stopped participating in 201610. For example, different national priorities, levels of funding/incentivisation, and therefore availability of programmes may explain differences in the proportion of patients being referred to pulmonary rehabilitation.

Recording of post-bronchodilator spirometry was poor in all nations, and this is likely due to GPs using generic rather than specific post-bronchodilator codes to record the results of spirometry8,11. However, even with this poor UK-wide recording of post-bronchodilator spirometry, Welsh primary care practices were still significantly better than other UK practices at confirming, or at least coding confirmation of, airway obstruction. Welsh primary care practices were also significantly better at referring patients to pulmonary rehabilitation than practices in other UK nations. The reason for Welsh practices’ greater performance in confirmation of airway obstruction and referral to pulmonary rehabilitation could perhaps be that participation in the primary care audit has led to an increased awareness of the importance of these interventions and how to accurately code them in the patient’s electronic health record. This is after all the second primary care audit that Wales has participated, with the previous being in 201512. Further supporting this possible explanation, greater referral to pulmonary rehabilitation in Wales is largely driven by greater exception reporting, which requires extra coding in the patient record to exclude patients from the denominator of their QOF payment calculations. Of note, spirometry recording was highly correlated within practices and recording of spirometry varied from 0% to 95% at the practice level. This is a substantial variation in the quality of data recording across practices and recording here could perhaps be improved by increasing GP awareness of the most accurate way to code spirometry results in their GP software package. Additionally, accurate coding of lung function is easier with the Vision software than other packages and this could explain why the recording of spirometry was slightly better in our CPRD GOLD cohort, which comprises practices using Vision, than the audit cohort which comprised almost all practices in Wales. Alternatively, the increased recording of spirometry in Welsh practices could be explained by the Welsh government making it a strategic objective in 2016 which has resulted in the provision of all practices with a standard spirometer and certified training to practice nurses for its use.

QOF may also be a factor in explaining our results. Post-bronchodilator spirometry is financially incentivised through the QOF in Wales13, England14, and Northern Ireland15, and had also been in Scotland until the previous year16 (Scotland left QOF in 201610 and the audit was in 2017). With no other differences in QOF incentivisation between the countries, the audit could explain why Welsh practices were significantly better at recording post-bronchodilator spirometry. It’s also interesting to note that Wales was the only country that incentivised referral to pulmonary rehabilitation through the QOF13,14,15,16 and therefore this financial incentivisation combined with the audit could have helped deliver the substantially better pulmonary rehabilitation referrals in Welsh practices than in practices in the other countries. And in the case of influenza immunisation, which was not financially incentivised through the QOF in Wales13, unlike in England14 and Northern Ireland15 (and in Scotland until the previous year16), performance was worse in Welsh practices than in the other countries, which further suggests that the QOF is a factor in the performance of each of the countries.

There are likely other factors at play too, such as the ease of completing a specific element of care, or national or practice focuses. If the audit is leading to improvements in just the coding of care, rather than the care itself, this could perhaps explain why the improvements seen in Wales do seem to be for those areas of care where improved coding could lead to the appearance of better results (such as post-bronchodilator spirometry and pulmonary rehabilitation referral), whereas those areas that are unlikely to be affected by coding issues, such as seasonal influenza immunisation did not see improvement in Wales. Differences in the locations used for key components of healthcare may also explain some of the differences between the countries. For example, if tests are undertaken in hospital, it is possible that the data are not input into the GP computer system. Equally outcomes such as influenza vaccination may be undertaken in a number of settings, and it is possible that although it occurs, it does not get coded in the primary care record. This may also be true for smoking cessation services.

Since devolution in 1999, there have been numerous reports into the impact of divergences of health policy on outcomes in the four UK countries. However, one overarching theme in these reports is that comparisons between the countries is difficult due to inconsistent recording of data in each country17,18. Analyses of the QOF have found that patients from all countries generally received best practice care, but Scotland and Northern Ireland performed better at delivering evidence-based care than England and Wales17,19. However, these studies used data from 2008/0919 and 2010/1117 so changes in care quality in each nation over the past 10 years could explain contrasting findings in this study, where Scotland generally performed worst.

The major strength of this study is its size; 56,764 patients from 305 GP practices were included. However, this study is not without limitations; it would have been desirable to adjust for socioeconomic status or deprivation as the UK countries have differing levels of deprivation20. Each country has its own measure of multiple deprivations, however, these measures are not comparable between nations20,21,22,23,24, and CPRD only provides additional linked data for England. A further limitation is that when making assessments of treatment provided using electronic health records, we only see what has been recorded, which may not always reflect reality. It may be that essential details have been recorded in free text or recorded using different codes than would be expected, and therefore levels of care received may be higher than it appears for items of care that are more complex for GPs to code accurately. There is also a risk that the practices included in our study are slightly larger than the average practice in the UK25 and therefore our results may only be generalisable to larger practices rather than all UK practices.

England, Scotland, and Northern Ireland had significantly fewer patients with COPD than Wales that received coded documented confirmation of airways obstruction and referrals to pulmonary rehabilitation. It is possible that national audit in Wales has led to improvements in the delivery of, or at the very least, improvements in the recording of care, that are not being seen in the UK countries without national audits. This highlights the importance of audits such as the NACAP primary care audit for improving quality of care and the recording of that care for benchmarking and future improvement.

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