Chronic Obstructive Pulmonary Disease Primary Care Trust Summary: NHS Sheffield

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Chronic Obstructive Pulmonary Disease Primary Care Trust Summary: NHS Sheffield Chronic Obstructive Pulmonary Disease (COPD) describes a group of conditions which include emphysema and chronic

1 Chronic Obstructive Pulmonary Disease Primary Care Trust Summary: NHS Sheffield Chronic Obstructive Pulmonary Disease (COPD) describes a group of conditions which include emphysema and chronic bronchitis., people in Yorkshire and the Humber, or.9% of the population, are diagnosed with COPD. However, there are an estimated 77, people with COPD, suggesting that 43% of people with the disease are not currently diagnosed. COPD is the fifth largest killer disease in England. In Yorkshire and the Humber more people die from COPD (3. per,) than from colorectal cancer (7.4 per,) or chronic liver disease (.4 per,). A progressive illness, COPD is disabling and the number of people dying as a result of COPD increases with age. The direct cost of COPD to the health system in Yorkshire and the Humber is 77m: or an average of 5m a year for every PCT. The broader economic cost of COPD has been put at 3.8 billion for lost productivity in the UK economy as a whole. 25% of people with COPD are prevented from working due to the disease with at least 2 million lost working days a year among men and 3.5 million lost days among women every year. A recent national audit showed that readmission rates in Yorkshire were 32% and that the average length of stay a day longer than the national average (Yorkshire 6 days, England 5 days). The information below summarises key indicators relating to the prevalence, care and outcomes for people with Chronic Obstructive Pulmonary Disease (COPD) within NHS Sheffield PCT. Each section of the report is designed to broadly follow a COPD clinical pathway. This information is designed to allow the identification of differences in service provision and the potentially related variation seen at primary care/ provider trust level in outcomes and service usage for those with COPD. It is hoped that this information will generate discussion as to the drivers of any variation reported and encourage identification and adoption of best practice. Many indicators provide links to more detailed sources of information which the user can follow in order to investigate both local and national comparisons A summary of key indicators across the Yorkshire and Humber region is available to accompany the profiles available for each Primary Care Trust. Identification & Finding the Missing Millions Chart : Prevalence of COPD, all ages, 29- Chart a: Prevalence of COPD, all ages, 26-7 to 29-2.% 2.%.8%.8%.6%.6%.4%.4% % Prevalence.2%.%.8%.8%.9%.6% % Prevalence.2%.%.8%.6%.6%.4%.4%.2%.2%.%.% Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Charts & a: Quality and Outcomes Framework (QOF) data records the number of patients known to primary care services with COPD. This data has been obtained from The Information Centre for Health and Social Care from the link below 5.% 4.5% 4.% Chart 2: Prevalence of COPD in those aged 6+ and the estimated additional undiagnosed prevalence, 29- The recorded prevalance of COPD as a proportion of the total population in NHS Sheffield on the QOF register is.8% (9,98 people). This is lower than the regional average of.9%. The 9,98 people is equivalent to 2.2% of the population who are aged 6+. It is estimated that there are an additional (,52 people) aged over 6 who are undiagnosed with COPD. % COPD Prevalence 3.5% 3.% 2.%.8%.7% The predicted prevalance of COPD (both diagnosed and undiagnosed) in those aged over 6 in NHS Sheffield is modelled to rise to 4.8% by 22, an increase of,938 cases..5%.% 2.2% 2.%.5%.% Estimated 6+ Diagnosed Prevalance Estimated Undiagnosed Prevalence Prevalence: Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights. Estimated Undiagnosed Prevalence: Eastern Region Public Health Observatory Chart 2: QOF prevalence estimated as a percentage of 6+ population with future projections of the prevalence of COPD including undiagnosed cases for those aged 6+, produced by Eastern Region Public Health Observatory. This work is based on 25 ONS populations and Health survey for England smoking prevalence rates for For a fuller methodology see July 2

2 Prevention Chart 3: Smoking prevalence, 29- Chart 4: Proportion of those setting a quit date, who are successful and who are verified as successful, 29-24% 6% 23% 5% % Smoking Prevalence 23% 22% 22% 23.2% 23.3% % Successful 4% 3% 55.2% 52.7% 49.4% 46.4% 2% 2% 38.9% 33.9% 2% % 2.% 2% 2% % Smoking Cessation - Proportion of Sucessful Quitters Smoking Cessation - Proportion of Varified Sucessful Quitters Source: Yorkshire & Humber Public Health Observatory Smoking prevalence as reported in the Integrated Household Survey for NHS Sheffield is 23.2%, which is lower than the regional average. The number of people within NHS Sheffield who set a quit date with NHS Stop Smoking Services during 29- was 5,94. Source: Lifestyle Statistics; The NHS Information Centre for Health and Social Care Copyright 2. The Health and Social Care Information Centre, Lifestyles Statistics. All rights. Chart 4: From NHS Stop Smoking Service, the proportion of those who set a quite date during 29- who are recorded as quitting successfully and the proportion who are verified as quitting by CO 2 validation. The statistics are available from the Information Centre for Health and Social Care on the link below: Chart 3: Prevalence of smoking as reported in the Integrated Household Survey, this information is sourced from a Yorkshire and Humber Public Health Observatory report and based on Office of National Statistics surveys Provision of High Quality Care and Support Table : Responses from the Yorkshire and the Humber SHA COPD Resources Questionnaire Is there an agreed care pathway for managing across your Primary Care Organisation (PCO)? Is a community pulmonary rehabilitation programme currently provided within your PCO? Table : Is a summary of responses from the recently undertaken Yorkshire and Humber SHA COPD Resource Questionnaire and highlights responses to questions about the provision of services (see Table 2 for information on the utilisation of these service) Do COPD patients within your PCO currently have access to an early discharge scheme? Do COPD patients within your PCO currently have access to an admissions avoidance scheme? Do you have access to an oxygen assessment service for Long Term Assessment Oxygen Therapy (LTOT)? Do you have access to an oxygen assessment service for ambulatory oxygen? Do you have access to an oxygen assessment service for short burst oxygen therapy/ intermittent oxygen therapy?? Are there formal arrangements for patients with COPD to receive palliative care in your area? In Development July 2

3 Use of High Quality Care and Support Services Chart 5: Admissions for COPD per, people on the COPD QOF register, 29- Chart 5a: Admissions for COPD per, population, 25-6 to Admissions Per, Admissions Per, Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights In 29- there were,365 admissions for COPD in NHS Sheffield (36.8 admissions per, people with COPD). The total admissions equate to a PbR tariff of 3.6 million for 29- (or 356,646 per, people with COPD). Chart 5: Total admissions in 29- per, people on the QOF COPD patient register, taken from NHS Comparators, for admissions which are for ICD- codes between J4-J44, which are ordinary admissions or day cases. Chart 5a: Total admissions in 25-6 to 29- per, population, taken from NHS Comparators, for admissions which are for spells in hospital under the programme budgeting category for COPD. These include all ordinary admissions and day cases. The denominator here varies from that used in chart 5, in order to negate the effect of a changing COPD QOF register over time. Chart 6: Standardised average length of stay for patients admitted with COPD, 26-7 to 29- Chart 7: Sum of PbR tariffs for admissions for COPD per, people on the COPD QOF register, 29-4, 35, Number of Nights 9 8 PbR Tariff per, 3, 25, 2, 7 356,646 5, 297,74 282,55 6, 5 5, Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Chart 6: The average length of inpatient stay for spells in hospital where the programme budgeting category of the spell was that of COPD (group A). Day cases are not included. Chart 7: The sum of PbR tariffs which are for ordinary or day case admissions under programme budgeting category A, COPD, per, people on the QOF COPD patient register, taken from NHS Comparators for 29-. July 2

4 Chart 8: Emergency readmission rates for those with COPD within 3 days of a previous admission Chart 9: Emergency readmission rates for those with COPD within 72 hours of a previous admission % Emergency Re-Admissions tbc % Emergency Re-Admissions tbc Chart 8: Chart 9: Chart : Admissions for COPD by hospital provider trust, Q3 28/9 to Q2 2/ Chart : Standardised average length of stay for patients admitted with COPD by hospital provider trust, Q3 28/9 to Q2 2/ Admissions Number of nights /8 Q3 27/8 Q4 28/9 Q 28/9 Q2 28/9 Q3 28/9 Q4 29/ Q 29/ Q2 29/ Q3 29/ Q4 2/ Q 2/ Q2 27/8 Q3 27/8 Q4 28/9 Q 28/9 Q2 28/9 Q3 28/9 Q4 29/ Q 29/ Q2 29/ Q3 29/ Q4 2/ Q 2/ Q2 Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Sheffield Teaching Hospitals FT 4 per. Mov. Avg. (Sheffield Teaching Hospitals FT) Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Sheffield Teaching Hospitals FT 4 per. Mov. Avg. (Sheffield Teaching Hospitals FT) Chart : The number of admissions for COPD during 29- for the main hospital provider trusts in the PCT region. Taken from NHS Comparators, provided by the NHS Information Centre for Health and Social Care. Chart : The standardised average number of nights spent in hospital per COPD admissions during 29- for the main hospital provider trusts in the PCT region. Taken from NHS Comparators, provided by the NHS Information Centre for Health and Social Care. July 2

5 Callouts Chart : Incidence of ambulance callouts for breathing difficulties by ward of address attended, July 28 - June 29 The information presented in Chart 2 has been derived from Yorkshire Ambulance Service data and shows the number of callouts for 'breathing difficulties' by the location of the callout (not necessarily the location of residence). These breathing difficulties may be due to a much wider range of conditions that just COPD but present a useful geographical guide to the pressures on ambulance services. No attempt to standardise the results by the size of the ward have been undertaken as the callouts do not relate to any resident population of the ward. Wards with under 5 callouts in the period have been omitted for data security. 2 Burngreave Central Darnall Firth Park Arbourthorne Gleadless Valley Shiregreen & Brightside Manor Castle Southey Woodhouse Beauchief & Greenhill Walkley Richmond Birley East Ecclesfield Hillsborough Stannington Nether Edge Stocksbridge & U. Don Mosborough West Ecclesfield Beighton Dore & Totley Broomhill Graves Park Crookes Fulwood Ecclesall Source: Yorkshire Ambulance Service Number of incidents PCT Average Chart 2: The incidence of ambulance callouts for 'breathing difficulties' by ward of address of callout location, July 28 to June 29. Data supplied by Yorkshire Ambulance Service. Table 2: Responses from the Yorkshire and the Humber SHA COPD Resources Questionnaire: Local Provision and Usage of Services Service in Place? Number of Places Available Referrals Made During 29- Completed Patients During 29- Follow-up Courses Available Community Pulmonary Rehabilitation: Service in Place? Number of Days the Service Operates Hours of Operation Number of Patients Accepted Saved Bed Days in 29- Early Discharge Schemes: pm Service in Place? Number of Days the Service Operates Number of Patients Accepted Number of Admissions Avoided Admission Avoidance Schemes: y Long Term Assessment Oxygen Therapy Service in Place? Ambulatory Oxygen Assessment Service in Place? Short Burst Oxygen Therapy/ Intermittent Oxygen Therapy Assessment Service in Place? Number of Patients on Oxygen Register Number of Patients on Oxygen Register as a Proportion of the COPD QOF Register Oxygen Services: 72 7% Table 2: Is a summary of responses from the recently undertaken Yorkshire and Humber SHA COPD resource questionnaire and highlights responses to questions about the provision and utilisation of services. July 2

6 Outcomes for those with COPD Chart 3: Proportion of those on the QOF register who fulfil outcome measures 29- Chart 4: Proportion of those on the QOF register who fulfil outcome measures 29-, including exceptions % % 9% 9% 8% 8% Percentage 7% 6% Percentage 7% 6% 5% 4% 3% 9.9% 92.6% 92.7% 85.9% 87.8% 88.5% 86.% 89.8% 9.3% 88.2% 89.% 89.9% 5% 4% 3% 8.9% 8.6% 8.5% 75.9% 77.7% 78.% 68.8% 74.% 76.% 78.7% 78.8% 2% 2% % % % COPD 8 COPD COPD 2 COPD 3 % COPD 8 COPD COPD 2 COPD 3 Source: Quality and Outcomes Framework, The Information Centre for Health and Social Care Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Source: Quality and Outcomes Framework, The Information Centre for Health and Social Care Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights 25% Chart 5: Exception rates for COPD QOF indicators, 29- Charts 3 & 4: These show the proportion of those on the 29- COPD QOF register who meet the criteria for the four COPD outcome measures detailed below: COPD 8: The percentage of patients with COPD who have had influenza immunisation in the preceding September to 3 March. Percentage 2% 5% COPD : The percentage of patients with COPD with a record of FeV in the previous 5 months. COPD 2: The percentage of all patients with COPD diagnosed after st April 28 in whom the diagnosis has been confirmed by post bronchodilator spirometry. % 5% 2.% 2.9% 3.%.6%.6%.8% 2.% 7.5% 5.8% 2.3%.6% COPD 3: The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 5 months. Further information for the percentage of patients who have an FeV reading in the last 5 months presented by practices within NHS Sheffield can be found on the final sheet of this Document. This information is again drawn the the QOF data published by the NHS Information Centre for Health and Social Care, 29-. % COPD 8 COPD COPD 2 COPD 3 Source: Quality and Outcomes Framework, The Information Centre for Health and Social Care Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Chart 5: The percentage of people with COPD who are potentially eligible for inclusion in each of the QOF indicators who have been registered as being 'exceptions', July 2

7 4 Chart 6: COPD mortality rates per, population, Chart 7: Years of life lost due to COPD in those aged under 75, directly standardised rate per, population, 27-9 with 95% confidence limits DSR per, DSR per, Source: National Centre for Health Outcomes Development, the NHS Information Centre for Health and Social Care Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Source: National Centre for Health Outcomes Development, the NHS Information Centre for Health and Social Care Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights Chart 6: This indicator is the directly standardised COPD mortality rate per, of the population. The standardisation allows a meaningful comparisons between regions with differing age profiles. This information is reproduced from information in the National Clinical and Health Outcomes Knowledge Base maintained by the NHS Information Centre for Health and Social Care: Chart 7: Directly age standardised years of life lost due to mortality from bronchitis, emphysema and other COPD (ICD J4-J44) for those aged less than 75 years, directly standardised rate per, population, This information is reproduced from information in the National Clinical and Health Outcomes Knowledge Base maintained by the NHS Information Centre for Health and Social Care: Expenditure on those with COPD.44 Chart 8: Programme budgeting spend on COPD per,, Chart 9: Primary care prescribing spend on antimuscarinic bronchodilators (including combinations), July-Sept million per, population NIC per, bronchodilator STAR(9)-PUs Ipratropium Ipratropium & Salbutamol Tiotropium NHS Sheffield Y&H SHA Source: Department of Health Source: NHS Prescription Services, NHS Business Services Authority. 2 NHS Business Services Authority 45 4 Chart 2: Average primary care prescribing net ingredient cost per item prescribed Chart 8: Programme budgeting data is collected by the Department of health and includes the majority of spend outside of primary care, grouped by condition. The Department produces a range of tools to allow more detailed analysis of expenditure and its comparisons to outcomes levels, the main tool are listed below: Average net ingredient cost per item Programme Budgeting Toolkit: PCT Spend and Outcomes Tool (SPOT): Programme Budgeting Atlas: NHS Comparators: These can all be accessed from the DH website: DH_75743 Charts 9 & 2: These are based on data available from NHS Prescription Services and cover primary care prescriptions for July to September 2. In Chart 9 the use of the STAR PU population allows a meaningful comparison between spend in regions with different demographics. Ipratropium Ipratropium & Salbutamol Tiotropium Source: NHS Prescription Services, NHS Business Services Authority. NHS Business Services Authority 2 July 2

8 Outcomes for those with COPD Table 3: 29- Quality and Outcomes Framework percentage of COPD patients with an FEV reading in the last 5 months for all practices within NHS Sheffield. Pr ac tic e C od C88ABBEY LANE SURGERY Name of Practice Percentage of Practice Registered Patients who are on the COPD Register (% COPD Prevalence).5% Percentage on COPD Register with an FeV Reading 85.3% Percentage on COPD Register Including Exceptions with an FeV Reading 7.7% C88BARNSLEY ROAD SURGERY 2.6% 9.3% 87.5% C88BASLOW ROAD AND SHOREHAM STREET SURGERIES C88BENTS GREEN SURGERY C88BLUEBELL MEDICAL CENTRE C88BROOMHILL SURGERY C88BUCHANAN ROAD SURGERY C88BURNCROSS SURGERY C88BURNGREAVE SURGERY C88CARRFIELD MEDICAL CENTRE C88CARTERKNOWLE & DORE MEDICAL PRACTICE C88CHARNOCK HEALTH PRIMARY CARE CENTRE C88CROOKES VALLEY MEDICAL CENTRE C88DARNALL COMMUNITY HEALTH C88DARNALL HEALTH CENTRE-DR MEHROTRA C88DARNALL HEALTH CENTRE-DR SWINDEN C88DEEPCAR MEDICAL CENTRE C88DEVONSHIRE GREEN MEDICAL CENTRE C88DOVERCOURT SURGERY C88DR. POYSER AND PARTNERS C88DUKE MEDICAL CENTRE C88DUNNINC ROAD SURGERY C88DYKES HALL MEDICAL CENTRE & DEER PARK SURGERY C88ECCLESFIELD GROUP PRACTICE C88ELM LANE SURGERY C88FALKLAND HOUSE C88FAR LANE MEDICAL CENTRE C88FIRTH PARK SURGERY C88FOXHILL MEDICAL CENTRE C88GLEADLESS MEDICAL CENTRE C88GREENHILL HEALTH CENTRE C88GRENOSIDE SURGERY C88GREYSTONES MEDICAL CENTRE C88HACKENTHORPE MEDICAL CENTRE C88HANDSWORTH MEDICAL PRACTICE C88HAROLD STREET C88HEELEY GREEN SURGERY C88JAUNTY SPRINGS HEALTH CENTRE YJORDANTHORPE HEALTH CENTRE C88LOWEDGES SURGERY C88MANCHESTER ROAD SURGERY C88MANOR PARK MEDICAL CENTRE C88MANOR TOP MC DR SAVANI C88MANOR TOP MC DR SS SHARMA C88MEERSBROOK MEDICAL CENTRE C88MILL ROAD SURGERY C88MOSBOROUGH HEALTH CENTRE C88NORTHERN AVENUE SURGERY C88NORWOOD MEDICAL CENTRE C88OLD SCHOOL MEDICAL CENTRE C88OUGHTIBRIDGE SURGERY C88OWLTHORPE MEDICAL CENTRE C88PAGE HALL MEDICAL CENTRE C88 PARK HEALTH CENTRE.4%.7%.7% 2.8%.6% 3.% 2.8%.9%.4%.% 3.2% 3.8%.9%.3% 3.3%.% 2.9%.7% 3.2% 2.2%.8%.5%.2% 2.2% 2.%.9%.6% 2.9%.9% 2.7% 2.6% 3.%.% 3.4% 2.9%.8%.2% 2.% 2.% 2.8% 2.8%.3%.5%.% 23% 2.3% 97.5% 87.5% 67.4% 95.6% 94.4% 93.3% 98.4% 28.9% 93.9% 95.5% 73.3% 75.5% 96.3% 98.8% 97.3% 86.3% 97.8% 93.8% 88.%.% 85.% 8.3% 79.8% 9.3% 92.7% 9.3% 93.% 72.9% 87.% 88.7% 88.9% 89.3% 9.5% 88.% 87.7% 75.8% 94.% 85.4% 85.% 83.5% 78.% 46.2% 85.% 88.9% 83.9% 77.7% 94.6% 97.5% 84.7% 92.% 86.%.% % 93.7% % 75.4% 8.4% 83.8% 94.2% 26.8% 78.% 86.3% 64.7% 62.6% 67.5% 65.9% 79.3% 8.2% 85.2% 76.2% 8.3% 75.8% 75.6% 75.5% 84.% 8.2% 8.6% 8.8% 7.2% 78.4% 84.2% 86.5% 79.3% 84.% 8.% 7.% 77.5% 57.7% 79.% 78.% 68.% 42.9% 78.4% 7.8% 72.7% 9.7% 95.% 79.2% 88.5% 72.% 67.5% C88PITSMOOR SURGERY.6% 78.7% 7 C88PORTERBROOK MEDICAL CENTRE.3% 75.8% 68.5% C88RICHMOND MEDICAL CENTRE - DR WALTON 96.7% 86.4% C88RUSTLINGS ROAD MEDICAL CENTRE.5%.% 59.% C88SELBORNE ROAD MEDICAL CENTRE.5% 86.8% 7.2% C88SHARROW LANE MEDICAL CENTRE.5% 85.7% 66.7% C88SHEFFIELD MEDICAL CENTRE.8% 5.6% 45.7% C88SHIREGREEN MEDICAL CENTRE.9% 92.6% 86.8% C88SOTHALL MEDICAL CENTRE 2.2% 77.5% 65.5% C88SOUTHEY GREEN MEDICAL CENTRE 2.3% 86.% 69.% C88STANNINGTON MEDICAL CENTRE.5% 95.% 84.4% C88STONECROFT MEDICAL CENTRE 2.% 85.3% 7.3% C88THE AVENUE MEDICAL CENTRE.% 85.9% 67.% C88THE BIRLEY HEALTH CENTRE 86.% 75.5% C88THE CROOKES PRACTICE.% 89.6% 68.2% C88THE HEALTH CARE SURGERY PALGRAVE ROAD 9.3% 88.7% C88THE HOLLIES MEDICAL CENTRE.% 95.9% 73.4% C88THE MATHEWS PRACTICE BELGRAVE.9% 88.% 73.4% C88THE MEDICAL CENTRE CRYSTAL PEAKS 2.% 78.9% 72.7% C88THE MEDICAL CENTRE DR OKORIE.5% 89.5% C88THE MULBERRY PRACTICE CENTRAL HEALTH CLINIC.%.% C88THE NORFOLK PARK MEDICAL PRACTICE 3.2% 87.6% 8.% Y2THE SHEFFIELD ACCESS CENTRE.6%.% 2.% C88THE SLOAN PRACTICE.3% 83.% 69.3% C88THE SURGERY HIGHGATE TINSLEY.2% 86.7% 66.7% C88THE SURGERY NETHERGREEN ROAD.6% 85.4% 58.3% C88THE WHITE HOUSE SURGERY 3.% 77.9% 77.4% C88TOTLEY RISE MEDICAL CENTRE.% 96.4% 79.4% C88TRAMWAYS MEDICAL CENTRE 2.% 87.3% 85.7% C88UNIVERSITY HEALTH SERVICE.%.% C88UPPERTHORPE MEDICAL CENTRE.9% 75.% 7.% C88UPWELL STREET SURGERY.4% 84.9% 72.6% C88VALLEY MEDICAL CENTRE.9% 77.7% 73.5% C88WALKLEY HOUSE MEDICAL CENTRE.7% 7.4% 64.4% C88WESTFIELD HEALTH CENTRE 4.4% 84.5% 74.7% C88WINCOBANK MEDICAL CENTRE 2.2% 93.7% 9.5% C88WOODHOUSE HEALTH CENTRE 3.5% 76.2% 67.9% C88WOODSEATS MEDICAL CENTRE.4% 77.6% 58.9% Source: Quality and Outcomes Framework, The Information Centre for Health and Social Care Copyright 2, Re-used with the permission of The Health and Social Care Information Centre. All rights July 2

Evaluation Tool* Clinical Standards ~ March 2010 Chronic Obstructive Pulmonary Disease** Services

Evaluation Tool* Clinical Standards ~ March 2010 Chronic Obstructive Pulmonary Disease** Services *Formerly known as Self-Assessment Framework ** Chronic Obstructive Pulmonary Disease (COPD) Standard 1: