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

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

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

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

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

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

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

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

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

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

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