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Benefits of Implementing

Medicines Optimisation

in a COPD and Asthma Clinic

Clare Watson

Medicines Management Pharmacist (NHS Hampshire)

Independent Prescriber (Victoria Practice, Aldershot)

The Victoria practice participated in a

National Improvement programme to improve

management of patients with COPD and

Asthma, by providing a patient centred

service focusing on

Use of Motivational Interviewing techniques

Adherence

Inhaler technique

Implementing Evidence based cost effective

prescribing in line with current national guidance eg.

Nice, BTS/SIGN

Regular patient review and follow up

Reducing waste

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What is Medicines Optimisation?

Medicines optimisation is a more patient-focused

approach to getting the best from medicines.

Focused on the patient and their experience, it can

help more patients take their medicines correctly,

reduce waste of medicines, avoid patients taking

unnecessary medicines and improve medicines

safety. Ultimately it can help encourage patients to

take more ownership of their treatment.

Royal Pharmaceutical Society – Good Practice Guidance for

Healthcare Professionals Sept 2012

Why Medicines Optimisation?

Suboptimal prescribing and/or patient adherence

affects patients’ ability to self manage, use of primary

care, admissions, A&E attendance and medicines cost

Current cost of all asthma and COPD medication:

£1.17billion pa

Choice and cost of medicines

How do patients really use medicines?

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BMJ October 2012….

“45 million prescriptions for respiratory inhalers were

dispensed in 2011 in England alone—at a cost of

£900 million to the NHS—everyone needs to be more

clued up on correct inhaler technique to make sure

these drugs work well for patients and offer the best

value for money for the NHS”

BMJ October 2012….

“45 million prescriptions for respiratory inhalers were

dispensed in 2011 in England alone—at a cost of

£900 million to the NHS—everyone needs to be more

clued up on correct inhaler technique to make sure

these drugs work well for patients and offer the best

value for money for the NHS”

Designing and commissioning services

for adults with asthma: A good practice

guide. PCC 2012

http://www.pcc.nhs.uk/asthma-guide

Many patients do not lead lives free of symptoms and

this is despite the availability of well-constructed

guidelines and good medicines

When patients do take their medication, many do it

incorrectly, which will have an impact on the cost of

treatment and lead to suboptimal outcomes

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How did we know if we had made an

improvement?

Indicated by cost of respiratory prescribing, medicines

mix, admissions and patient CAT score / ACT score

before and after the intervention

CAT: COPD assessment test: www.catestonline.co.uk

ACT: Asthma control test: www.asthmacontroltest.com

Context

Practice list size: 8476

5 partners (4.5 whole time equivalents)

135 COPD patients

378 Asthma patients

Annual reviews offered scope to address medicines

use and optimisation

Pharmacist led Asthma & COPD clinic (Independent

prescriber and Medicines Management Pharmacist,

COPD Diploma, Clinical Diploma, Community

pharmacy background

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Approach

1 x 5 hour session per week

30 minute appointments

Understanding the patient’s attitude to and actual use

of medication

Encouraging realistic goal setting and behaviour

change

Using technical knowledge to optimise prescribing

(clinical benefit/cost effectiveness)

Patient reviews

Review compliance, exacerbations, control and

medicines ordering over last 12 months

Patient consultation incorporating:

Understanding current attitudes & motivation

Good things/Not so good things – decisional balance

Eliciting self sufficiency & patient responsibility

Optimisation of treatment

Follow up

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Understanding current attitudes and

motivation using open questions Tell me some more about that

What are your thoughts about…?

In what ways does that concern you?

Describe what it’s like when?

How do you feel about….?

Tell me what you like about X

Tell me some of the things you don’t like about X

Goal Setting

Where does this leave you?

What’s your plan?

Given all we’ve talked about today, where would you

like to go from here?

What do you want to do next?

What are the difficulties/benefits of taking your

medicine?

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Commitment

On a scale of 0 to 10 (where 0 = not at all and 10 = very much):

How much do you want to start/continue this treatment?

How important is it to you to start/continue this treatment?

How ready do you feel you are to start/continue this treatment?

How much better do you think your life would be if you start/continue this treatment?

Wrapping Up

How confident do you feel that you will be able to do this?

One a scale of one to 10, how confident do you feel?

If patient is negative, ask how can you get it up to an 8?

Confidence building: Why 7 and not 5?

In a month’s time, what is going to be different now that you are

taking your medicines?

If patient is negative say, “Some people find that…..”

If there is no response say, “So nothing is going to change at all?”

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Availability

Is the patient on the “right” treatment (medication and

device) for their needs?

Is it a clinically effective choice?

Is it a cost effective choice? Cost comparison tables

available on the website below

http://www.nyrdtc.nhs.uk/Services/presc_supp/presc_sup

p.html

Evidence based? Cost effective?

Right choice of medication for condition and severity of

disease?

Able to use it?

Cost effective choice?

Examples:

Adding on an aerochamber®

to MDI device

Adding LAMA / LABA

Substituting Seretide Acculaher® for Evohaler ®

Smoking cessation / pulmonary rehabilitation

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Knowledge

Inhaler technique – maintaining own skills as well as

checking others

In-Check Dial to achieve optimal inspiratory flow

(http://www.clement-clarke.com/products/in-check-dial)

2Tone device for MDI users (Now replaced by In-

Check Flo-Tone http://www.flo-tone.com)

Follow up calls or appointments to check progress &

understanding

New medicines not added to repeats until impact

assessed

Victoria Practice Prescribing cost

0

2000

4000

6000

8000

10000

12000

14000

16000

Apr-07

May

-07

Jun-07

Jul-0

7

Aug

-07

Sep

-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb

-08

Mar-08

Apr-08

May

-08

Jun-08

Jul-0

8

Aug

-08

Sep

-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb

-09

Mar-09

Apr-09

May

-09

Jun-09

Jul-0

9

Aug

-09

Sep

-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb

-10

Mar-10

Apr-10

May

-10

Jun-10

Jul-1

0

Aug

-10

Sep

-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb

-11

Mar-11

Apr-11

May

-11

Jun-11

Jul-1

1

prescribing cost

£

£ The Mean (Average) Upper Control Limit Lower Control Limit

10

Change in consecutive CAT score by patient

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9 10

Patient

CA

T s

co

re

Original CAT score

Second CAT score

Key Learning

30 minute appointments allow time to establish rapport with the patient and understand issues affecting adherence

Follow up reinforces patient understanding and behaviour

Telephone calls in advance can reduce DNAs.

Synchronise repeats where possible to reduce waste, patient inconvenience and surgery work load

Relationships are key

Pharmacist skills can provide a cost effective approach to improving medicines optimisation in the management of any long term condition and enhance the skill mix in the practice team

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