Responsible respiratory prescribing
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Responsible Respiratory Prescribing. Dr Vince Mak London Respiratory Team Clinical Lead Medicines Management Workstream May 2012. NHS London Respiratory Team Who are we?. Aim is to improve the experience of Londoners with COPD and reduce the impact of the disease.

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Responsible respiratory prescribing

Responsible Respiratory Prescribing

Dr Vince Mak

London Respiratory Team Clinical Lead

Medicines Management Workstream

May 2012


Responsible respiratory prescribing

NHS London Respiratory Team

Who are we?

Aim is to improve the experience of Londoners with COPD and reduce the impact of the disease


Responsible respiratory prescribing

What is the London Respiratory Team?

Clinically-led multi-disciplinary team (Team Leader – Dr Louise Restrick, Consultant Physician Whittington)

Community and hospital health professionals

Patient/carer voice

Project manager

Funded by Department of Health

NHS London Team


Responsible respiratory prescribing

London Respiratory team approach:

Strategy

RIGHT CARE APPROACH

  • Doing the Right Thing

  • Doing the Right Things Right

    Identify priorities in delivering COPD Right Care in London

    Quality, innovation, performance, productivity and safety framework - QIPP


Responsible respiratory prescribing

Value Framework

Health Outcomes

Patient defined

bundle of care

Value

=

Health Outcomes

Cost of delivering Outcomes

Cost

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483


Right care for copd

RIGHT CARE for COPD

  • Doing the Right Thing – what is cost effective?

    • Encourage Responsible Prescribing


Responsible respiratory prescribing

Cost of Respiratory Medication

by BNF Chapters

~£1 billion on respiratory medication not including antibiotics…

Source: NHS Information Centre


Responsible respiratory prescribing

Volume of Respiratory Medication

but a relatively low volume of respiratory prescriptions ...

Source: NHS Information Centre


Responsible respiratory prescribing

Item cost of Respiratory Medication

Respiratory items are the most expensive category of item prescribed .....

…inhalers

Source: NHS Information Centre


Responsible respiratory prescribing

NHS budget & respiratory medication

  • Seretide (all) is the most expensive drug in NHS

  • Seretide 250 Evohaler is the most expensive individual item (second is atorvastatin)

  • Tiotropium is 6th most expensive

  • Symbicort 200 is 5th most expensive item

Of the top 5 costliest drugs to the NHS currently 3 are inhalers

Source: NHS Information Centre


Seretide all in london

Seretide (all) in London


Symbicort all in london

Symbicort (all) in London


Seretide vs symbicort

Seretide vs Symbicort


Lrt 7 key prescribing messages

LRT - 7 Key Prescribing Messages

1.      Respiratory medications are expensive


Right care for copd1

RIGHT CARE for COPD

  • Doing the Right Thing – what is evidenced based and cost effective?

    • Stop smoking as a priority when seeing patients with respiratory symptoms


Responsible respiratory prescribing

Smoking prevalence in COPD

TORCH, Uplift Studies and …POET-COPD


Responsible respiratory prescribing

What works long term and is cost effective?

A cost effective intervention in COPD - Stopping Smoking

Tiotropium QALY £7112

Eur J Health Econ. 2007 June; 8(2): 123135

Systematic Review of 9 studies Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH.

Thorax 2010: 65:711-718


Right care for copd2

RIGHT CARE for COPD

  • Doing the Right Thing – what is evidenced based and cost effective?

    • Ensuring patients with COPD have access to Pulmonary Rehabilitation programmes.


Responsible respiratory prescribing

High Value Care in COPD

Pulmonary Rehabilitation


Responsible respiratory prescribing

Value of Pulmonary Rehabilitation

  • Reduces admissions, improves exercise capacity, improves health related quality of life

  • Post exacerbation PR v effective in avoiding admissions

  • Numbers needed to Treat = 4

  • The only intervention to date that has been shown to reduce the very high 3 month readmission rate seen in COPD (33% to 7%)

  • Only costs £2,000-£8,000/QALY

  • Puhan et al 2011 Cochrane Database of Systematic Reviews 2011

  • Seymour et al Thorax 2010;65:423-428 doi:10.1136/thx.2009.124164


What is pulmonary rehabilitation

What is Pulmonary Rehabilitation?

  • 26 hours of contact with a respiratory specialist team

  • Appropriate for patients disabled by breathlessness – usually MRC 3-5, and some MRC 2

  • Comprehensive, holistic assessment – 1.5 hours / patient

  • 6 weeks minimum, twice / week, 2 hours each session

  • Exercise and education

  • Effective post hospitalisation episode for COPD


Responsible respiratory prescribing

Pulmonary Rehabilitation

‘Before pulmonary rehabilitation I wasn’t afraid to die I was afraid to live,

… but after pulmonary rehabilitation I wasn’t afraid to live any more.’


Responsible respiratory prescribing

COPD ‘Value’ PyramidWhat we know so far…. Cost/QALY

2010Value work now continued by IMPRESS www.impressresp.com

  • References:

  • J Epidemiol Community Health. 1998 Feb;52(2):120-5 £50 saving for over 65

  • Thorax. 65(8):711-8,2010 Aug.

  • Thorax 2001;56:779-784 £0-1000 per QALY

  • Tiotropium in the treatment of COPD: Health technology Assessment KCE reports 108C Neyt M et al £7,456 per QALY

  • OBA Y Cost effectiveness of long acting bronchodilators for COPD. Mayo Clinic Proc 2007;82:575-582 £5,396 per QALY

  • CADTH. LABA plus Corticosteroids vs LABA alone for COPD. Issue 83 March 2007. Mayers I et al £130,000 per QALY and NICE COPD management of COPD in adults in primary and secondary care 2010 £131,000 per QALY


Lrt 7 key prescribing messages1

LRT - 7 Key Prescribing Messages

1.   Respiratory medications are expensive

Doing the Right Things:

2.   When prescribing any new respiratory inhaler, ensure that the patient has undergone NICE-recommended support to stop smoking

3.   Pulmonary rehabilitation is a cost effective alternative to stepping up to triple therapy and should be the preferred option if available and the patient is suitable.


Doing the right things right inhaler technique

Doing the Right Things Right – Inhaler Technique

>90% of patients cannot use an MDI effectively

91% of healthcare professionals who teach use of an MDI cannot demonstrate it correctly*

Even with effective technique, maximum lung deposition from MDI is 15%

Large volume spacer may be easier to use an increases deposition to 30%

If used incorrectly – most of the drug from MDI is wasted – Seretide 250 is £60/month

*Thorax 2010;65:A117


Responsible respiratory prescribing

Doing the Right Things Right!

Optimise use of inhaled medicines – Minimise Waste – Maximise safety

  • Each patient with COPD is using an inhaler device that works for them (MDI with spacer or DPI)

  • Each patient with COPD has learnt the right technique for drug delivery into the lung

  • Each patient with COPD uses their inhaled therapy regime as prescribed for evidence-based benefit

  • Each patient with COPD has safe inhaled therapy

  • ie minimum evidenced based dose of inhaled steroid for their stage of disease


Responsible respiratory prescribing

Right Care respiratory prescribing Minimise waste – maximise value

  • Ensure patient centred education about the disease and medication from a competent trainer

  • Ensure compliance

  • Ensure correct technique

…working with health professionals


Lrt 7 key prescribing messages2

LRT - 7 Key Prescribing Messages

1.    Respiratory medications are expensive

Doing the Right Things:

2.    When prescribing any new respiratory inhaler, ensure that the patient has undergone NICE-recommended support to stop smoking

3.    Pulmonary rehabilitation is a cost effective alternative to stepping up to triple therapy and should be the preferred option if available and the patient is suitable.

Doing the Right Things Right:

4.    When prescribing any inhaled medication, ensure that the patient has undergone patient centred education about the disease and inhaler technique training by a competent trainer

5.    When prescribing an MDI (except salbutamol), ensure that a spacer is also prescribed and will be used


Responsible respiratory prescribing

Right Care respiratory prescribing Minimise risk – ensure safety

When prescribing high dose inhaled corticosteroids (>1000ug BDP equivalent?), ensure that the patient is issued an inhaled steroid safety card (warning about pneumonia, increased risk of diabetes, reduced bone density and potential for adrenal suppression)

…working with health professionals


Responsible respiratory prescribing

Minimise Risk : Patient Safety

  • Warn about potential for adrenal suppression on high doses of ICS

  • Warn about not stopping high dose ICS suddenly


Responsible respiratory prescribing

Minimise Risk : Patient Safety

  • Warn about high dose ICS side effects:

    • Pneumonia

    • Diabetes

    • Bone Loss/ Fractures

    • Adrenal Suppression

  • In COPD – very high dose ICS (2000µg BDP equivalent) same clinical efficacy of moderate dose ICS (800µg BDP equivalent).

  • In asthma – little evidence for efficacy of ICS above 800µg/day (BTS/SIGN Grade D evidence)

  • Checking inhaler technique, using ICS through a spacer or changing inhaler device may be more effective than just increasing the dose or stepping up treatment

  • If dose of ICS has been stepped up in the treatment of asthma and patient is well controlled – consider stepping down after 3 months.


Responsible respiratory prescribing

Minimise Risk : Patient Safety

Traffic light reference card

BDP dose equivalence

Which inhalers and at what dose may deliver >1000µg BDP equivalent/day

Also gives some idea of cost for BDP equivalent doses of different brands of inhaler


Simple switch

SIMPLE SWITCH

Saves £40 million/year +

Less waste caused by poor inhaler technique

Fewer Exacerbations

England – 2 million items/yr


Simple switch1

SIMPLE SWITCH

Saves £40 million/year +

Less waste caused by poor inhaler technique

Fewer Exacerbations

England – 2 million items/yr


Lrt 7 key prescribing messages3

LRT - 7 Key Prescribing Messages

1.    Respiratory medications are expensive

Doing the Right Things:

2.    When prescribing any new respiratory inhaler, ensure that the patient has undergone NICE-recommended support to stop smoking

3.    Pulmonary rehabilitation is a cost effective alternative to stepping up to triple therapy and should be the preferred option if available and the patient is suitable.

Doing the Right Things Right:

4.    When prescribing any inhaled medication, ensure that the patient has undergone patient centred education about the disease and inhaler technique training by a competent trainer

5.    When prescribing an MDI (except salbutamol), ensure that a spacer is also prescribed and will be used

6.    When prescribing high dose inhaled corticosteroids (>1000ug BDP equivalent?), ensure that the patient is issued with an inhaled steroid safety card


Responsible respiratory prescribing

Responsible Respiratory PrescribingBest value from Prednisolone

  • No evidence that EC prednisolone tablets (red) result in fewer GI problems or protect against peptic ulceration

  • EC prednisolone costs 6-15 times more than plain prednisolone (white)

    • Switch from EC prednisolone to prednisolone could save £2 million per year in London

X


Lrt 7 key prescribing messages4

LRT - 7 Key Prescribing Messages

1.    Respiratory medications are expensive

Doing the Right Things:

2.    When prescribing any new respiratory inhaler, ensure that the patient has undergone NICE-recommended support to stop smoking

3.    Pulmonary rehabilitation is a cost effective alternative to stepping up to triple therapy and should be the preferred option if available and the patient is suitable.

Doing the Right Things Right:

4.    When prescribing any inhaled medication, ensure that the patient has undergone patient centred education about the disease and inhaler technique training by a competent trainer

5.    When prescribing an MDI (except salbutamol), ensure that a spacer is also prescribed and will be used

6.    When prescribing high dose inhaled corticosteroids (>1000ug BDP equivalent?), ensure that the patient is issued with an inhaled steroid safety card

7.    No Prednisolone EC prescribing without good clinical reason


Responsible respiratory prescribing

DH – Outcomes Strategy – Companion Document


Responsible respiratory prescribing

Responsible Respiratory Prescribing

  • Understand costs

  • Ensure optimal drug therapy for COPD/Asthma patients

  • Optimise use of prescribed therapy

  • Right care

    • Minimise waste

    • Maximise value

    • Minimise unwarranted variation

Clinical Lead Dr Vince Mak, Respiratory Physician


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