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Has the Quality and Outcomes Framework resulted in more timely diagnosis of COPD in primary care?

Has the Quality and Outcomes Framework resulted in more timely diagnosis of COPD in primary care?. LC Hunter, CM Fischbacher, N Hewitt, D McAllister, S Wild, RM Hardie. Lothian COPD data linkage project. COPD cohort study to identify risk factors in primary care for emergency hospital admission

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Has the Quality and Outcomes Framework resulted in more timely diagnosis of COPD in primary care?

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  1. Has the Quality and Outcomes Framework resulted in more timely diagnosis of COPD in primary care? LC Hunter, CM Fischbacher, N Hewitt, D McAllister, S Wild, RM Hardie

  2. Lothian COPD data linkage project • COPD cohort study to identify risk factors in primary care for emergency hospital admission • Data linkage - primary care data linked to secondary care admissions data and death data. • Eligible patients = diagnostic Read code for COPD in primary care record recorded between 1st April 2000 and 31st March 2008. • Date of COPD diagnostic code proxy for date of diagnosis in primary care. • Use as time zero in analysis of time to first admission.

  3. Patient presents to GP with symptoms of COPD Intervention pre-diagnosis ? Patient coded as COPD =date of diagnosis Date of COPD diagnostic coding Patient becomes symptomatic - acute exacerbation (treated in primary care) - Respiratory drug Cohort=7002 patients from 72 practices Read codes for COPD 1st April 2000- 31st March 2008.

  4. Intervention pre-diagnosismedian time 3 yrs (IQR: 0.1-6.2) n=3504 (50%) n=3498 (50%) Intervention pre-diagnosis of COPD Patient presents to GP with symptoms of COPD (n=7002) Patient becomes symptomatic Patient coded as COPD =date of diagnosis

  5. Intervention pre-diagnosis and gender 52% 48% 57% 43% p<0.001 (Chi square)

  6. Females: median time 3.6yrs (IQR:1-6.6) p<0.001 (Mann Whitney) Males:median time 2.7yrs (IQR: 0.9-5.6) Intervention pre-diagnosis of COPD - gender Patient presents to GP with symptoms of COPD (n=7002) Intervention pre-diagnosis Patient becomes symptomatic Patient coded as COPD =date of diagnosis

  7. Intervention pre-diagnosis by SIMD quintile 54% 52% 46% 48% 48% 52% 49% 51% 50% 50% p<0.05 (Chi square)

  8. Q1 (most deprived): median time 3.1yrs (IQR:1.1-6.2) Q5 (least deprived):median time 2.5yrs (IQR: 0.7-6.0) p<0.05 (Mann Whitney) Intervention pre-diagnosis of COPD - deprivation Patient presents to GP with symptoms of COPD (n=7002) Intervention pre-diagnosis Patient becomes symptomatic Patient coded as COPD =date of diagnosis

  9. Summary • Interventions pre-diagnosis • Higher proportion of females • Higher proportion of patients in more deprived quintiles • Longer time from intervention to diagnosis in these groups • Differences in gender and deprivation? • Females and patients in more deprived areas present earlier with milder COPD symptoms? • And/or delay in recognising/confirming COPD in these patients?

  10. Diagnostic code Intervention Diagnostic code Intervention ? Cohort start 01/04/2000 Cohort end 31/03/2008 ? 01/04/2004 = start of QOF QOF and date of diagnostic coding? Pre-start of QOF Post-start of QOF

  11. Intervention Diagnostic code Intervention Diagnostic code Median time 2.7yrs (IQR 1-5.3)** • Median time 3.4yrs (IQR 0.9-7.2)** Interventions pre-diagnosis n=1578 (47%)* Interventions pre-diagnosis n=1920 (53%)* *p<0.001 Chi square **p<0.0001 Mann Whitney QOF and date of diagnostic coding? Pre-start of QOF Post-start of QOF Cohort start 01/04/2000 Cohort end 31/03/2008 01/04/2004 = start of QOF

  12. Patients with interventions pre-diagnosis before and after QOF by gender Median time from intervention to diagnosis*** Pre-QOF= 2.8yrs (1-5.4) Post-QOF= 4.3yrs (1.1-7.8) 53% 47% 44% 56% ** * * p<0.05 (Chi square) **p<0.0001 (Chi square) ***p<0.0001 (Mann Whitney)

  13. Patients with interventions pre-diagnosis before and after QOF by deprivation quintile 54% 54% 46% 46% 55% 45% 49% 58% 42% 45% 55%

  14. Has QOF resulted in more timely diagnosis of COPD? • After start of QOF: • Higher proportion of male and female patients across all quintiles have interventions pre-diagnosis • Longer time from intervention to diagnosis for females. • Reasons? • Improved quality of coding post-QOF? • Patient not coded until fulfils disease register criteria. • Retrospective case finding with contemporary date of coding? • Differences in gender? • More retrospective case finding in females? • Presenting earlier with disease and taking longer to fulfil QOF disease register criteria

  15. Limitations and conclusions Limitations • Data not adjusted for severity at presentation/diagnosis. • Only patients diagnosed in first four years of QOF analysed. Conclusions • Date of diagnostic coding frequently does not reflect date a patient first treated for COPD in primary care. • Varies by sex, deprivation and time (in relation to QOF) • Researchers need to be aware of these potential issues when using date of diagnostic coding in analysis.

  16. Acknowledgements • ISD data linkage team • Lothian GP practices that participated in Lothian COPD cohort study • Dr John Steyn NHS Lothian eHealth clinical adviser

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