Pragmatic evaluation of a quality improvement programme for people living with modifiable high-risk COPD (PREVAIL)

PREVAIL

Patient / Population Intervention / Exposure Comparison Outcome

In 5,631 patients with modifiable high-risk COPD in 175 English general practices, the CONQUEST quality improvement and clinical decision support programme reduced exacerbations over two years compared with usual care.

N

5,631patients

Design

Cluster randomised health-services trial (UK PREVAIL, ISRCTN15819828); English general practices allocated 1:1 to the CONQUEST quality improvement programme (identification of modifiable high-risk patients from electronic records with case-finding spirometry, clinical review with treatment optimisation, supported follow-up) or usual care, 85 intervention and 90 control practices contributing patients; outcomes from electronic health records over a mean 24 months, propensity score weighted

Endpoint

Annual rate of moderate or severe COPD exacerbations over the two-year outcome evaluation period, from electronic health records (major cardiac or respiratory events were co-primary until the registration was amended on 28 July 2026; the abstract also reports complicated exacerbations: hospitalisation, oral corticosteroids or antibiotics 8 to 28 days after initial treatment)

Relevance

2Important — one of several pillars.

ResultModerate or severe exacerbations reduced by 13% (propensity score weighted rate ratio 0.87, 95% CI 0.78-0.97; P = 0.011; unweighted 0.80, 95% CI 0.72-0.89) and complicated exacerbations (hospitalisation, oral corticosteroids or antibiotics 8 to 28 days after initial treatment) by 26% (rate ratio 0.74, 95% CI 0.59-0.92; P = 0.007) over a mean 24 months. In patients on monotherapy or less at baseline 21% and 45% (0.79, 0.70-0.91 and 0.55, 0.42-0.74); in newly diagnosed patients 21% and 40% (0.79, 0.67-0.94 and 0.60, 0.38-0.94). 85 intervention and 90 control practices contributed 5,631 patients; 2,892 events over 1,828 person-years vs 18,469 over 9,382.

Price D, Hurst JR, Kerr M, et al. Presented at ERS Congress 2026, ALERT 1, 6 September. Not yet published.

Discussion & critique

Finding the high-risk patients a practice already has, reviewing them and optimising treatment cut exacerbations by an eighth and the complicated ones by a quarter, most in those on the least therapy or newly diagnosed. The trial was powered for a 30% reduction and found 13%, from propensity score weighted models in which the control arm contributed five times the person-years of the intervention arm, an imbalance between 90 and 85 practices that the abstract does not explain. The primary outcome was amended in the registration on 28 July 2026, two weeks after the trial ended, dropping major cardiac or respiratory events to secondary. Funded by AstraZeneca and the programme's own provider; the paper will have to show the plain intention-to-treat comparison.