Getting a handle on breathlessness. Case finders and GRASP audit tools for COPD and heart failure - Dr Richard Healicon, Programme Delivery Lead, NHS Improving Quality Presentation from the Breathlessness Symposium held in London on 1 July 2014

1. Introducing GRASP-COPD and GRASP-HF
Dr Richard Healicon
Living Longer Lives
NHS IQ

2. • Free primary care audit tools
• Aligned to NICE/ ESC guidance
• Compatible with all GP systems in England
• Each has a case finder
• Care Audit (patient identifiable)
• CHART Online (anonymised data)
• AF, COPD and HF
Introducing the GRASP Suite

3. • Voluntary upload of data to CHART online
• Web based analysis tool with a variety of comparative
viewing options available:
• Secure and restricted access
• For both primary care staff and commissioners
CHART Online

4. GRASP-AF

5. GRASP-COPD

6. GRASP-HF

7. Good Health Subclinical
changes
Clinical
disease
Recovery
Death
Asymptomatic Increasing symptoms
Screening
GRASP
Case
Finders
GRASP Care
Toolkits
Diagnosis
Where does GRASP fit in?

8. GRASP-AF
The case finder audit includes patients who are currently
registered at the practice AND have a diagnosis of AF or atrial
flutter OR have read coded entries that suggest probable AF or
possible AF. Likelihood of AF is determined by the type of entry
found; factors are classified into possible or probable AF.
AF case finder

9. GRASP-COPD
COPD case finder
The diagnosis of COPD relies on a combination of history, physical examination and
confirmation of airflow obstruction using spirometry. The case finder summary sheet is
designed to give an indication of patients who may benefit from having their records
reviewed in case of a missing diagnosis.
A diagnosis of COPD should be considered in patients over the age of 35 who have a
risk factor (generally smoking) and who present with exertional breathlessness, chronic
cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze.

10. A table is then provided showing the number of patients over the age
of 35 recorded as being current smokers or ex-smokers within the
practice. As COPD is predominantly caused by smoking, inclusion of
smoking prevalence is useful.

11. The first part of the summary sheet provides useful preliminary information for
the audit including an up-to-date count of the practice population (currently
registered patients) and a table summarising the patients that could be targeted
for review. A list of the patients identified in each row can be found using the
pre-set filters available in the datasheet.

12. The next part of the summary sheet gives details of patients on medication that
might indicate the presence of COPD such as short and long acting beta2
agonist, short and long acting muscarinic antagonist and inhaled corticosteroid.

13. The next part of the summary sheet looks for evidence of frequent chest
problems such as frequent respiratory exacerbation. This, along with other
factors/symptoms, may indicate COPD.

14. The next section of the summary sheet looks for patients with key COPD
symptoms or evidence of a COPD monitoring Read code on their electronic
record. Patients who present with exertional breathlessness, chronic cough,
regular sputum production or wheeze (along with other symptoms) may need
reviewing for COPD. The presence of COPD related codes on a patient’s
record (such as history of COPD, at risk of COPD, suspected COPD) suggests
they should be reviewed for a diagnosis.

15. The presence of asthma symptoms on the summary sheet is designed
to give an indication of the number of patients who have classic asthma
symptoms. These patients are less likely to need reviewing to establish
whether their symptoms suggest COPD.
NICE guidance suggests you should consider a diagnosis of COPD in
patients over 35, who are smokers/ex-smokers who have symptoms of
COPD but do not have clinical features of asthma (such as those
listed above)6.

16. The lung function test table shows those patients who may have been reviewed
with spirometry in the past. These details can be viewed in the datasheet and
may help to determine whether the patient has COPD or should be assessed
for COPD.

17. GRASP-HF
HF case finder
The focus of the overall tool is on Heart Failure with LVSD, so the case finder
tool is designed to assist in looking for patients who should have this
combination of recorded information.

18. The first part of the summary sheet provides useful preliminary information for
the audit including an up-to-date count of the practice population (currently
registered patients) and, for reference, an up-to-date count of the number of
patients with both heart failure and LVSD diagnoses.
The next two rows summarise the number of patients that either have only
heart failure recorded or only LVSD recorded and therefore should be targeted
for review. A list of the patients identified in these two rows can be found using
the pre-set filters available in the datasheet.

19. The next two sections of the summary sheet show the number of indicative
terms (terms that might suggest the presence of heart failure) and supporting
information (supplementary data items that will help GPs assess the likelihood
of a missing diagnostic code) that have been recorded in the records of
patients who do not have both heart failure and LVSD. The presence of these
items in the datasheet is designed to signpost practices to groups of patients
most likely to have a missing diagnosis code.

21. The final two sections of the summary sheet show information about related heart
conditions the patient may have and relevant medication the patient may be taking,
which may also provide additional supporting information for case finding.

23. The three GRASP tools relate to conditions that can
cause breathlessness
All three GRASP tools have a case finder
Search for Read codes which suggest a diagnosis
Allows GPs to review these patients and facilitate earlier
diagnosis
Once diagnosed, GRASP care tools allows audit against
NICE guidelines
Summary