Optimising medicines for COPD and Asthma – an integrated approach.

Vanessa Burgess

Chief Pharmacist, Assistant Director of Commissioning

Dr Azhar Saleem Respiratory Lead GP.

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- Population 366,574- Densely populated and

ethnically diverse borough- 48 General Practices- 3 Locality Care Networks

North Lambeth

(95,816)

SE Lambeth

(113,701)

SW Lambeth

(157,054)

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Four principles of medicines optimisation

“Models of care” for pharmacy

http://www.rpharms.com/promoting-pharmacy-pdfs/moc-report-executive-summary.pdf

http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf

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National strategies

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What’s going on

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£2.3 M

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Local Data.• 35% of patients on COPD registers did

not have spirometry consistent with this diagnosis,

• 38% of patients were receiving inhaled corticosteroid (ICS) therapy outside national guidance

• lack of focus on high value interventions like quit smoking support and pulmonary rehabilitation

Principle 1 : Understanding the patient experience

Patrick White et al, 2013. 41 London general practices (population 310,775)

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Principle 3: Safety of medicines

• When figures describing the significant risks associated with high dose ICS use (including pneumonia, adrenal suppression and reduction on bone mineral density) were applied, it suggested that this overuse of ICS could account for up to :

• 12 additional cases of pneumonia • waste of >£500,000 per year.

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The evidence and standards are here

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Principle 2 : Evidence Based Choice of Medicines & Outcome Based Approach

London Respiratory Network

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Common Message

• COPD. Review of Inhaled Corticosteroid in mild & moderate.

• Asthma. Step down clinics for pts on high dose ICS (at step 4)

• Metric. Reduction in high dose ICS as a % of all ICS items

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Collaboration

What is a virtual clinic?

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• Delivered in GP practice by an integrated respiratory consultant and/or respiratory pharmacist or GP respiratory lead.

• 2-hour structured sessions for practice clinicians to discuss optimal patient management on a case by case basis.

• Pre-work – searches and templates• Follow up – sustainability (GP/nurse actions) and patient

engagement in the plan;

ideally within 2 weeks.

Virtual Clinics – a model for change ..“help it happen”

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Why Virtual Clinics ?

• Information alone doesn’t change behaviour

• Asthma and COPD registers are currently quite inaccurate for many different reasons

• Diagnostic spirometry is not performed well in primary care

• COPD is often incorrectly staged and there are ‘false’ Asthma diagnoses

• Respiratory prescribing is often poorly understood

Principle 4: Making medicines optimisation part of routine practice

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 smoking3. 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

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Principle 4: Making medicines optimisation part of routine practice

• IT point of care support

• Contractual incentives

• Data monitoring• Resources

“Make it happen”

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VCs - Typical changes

• Many patients on Seretide/Symbicort but not on Tiotropium

• Many patients had not had PR or smoking cessation prior to being on high dose ICS

• Many patients on high dose ICS with FEV1 % predicted above 50%

• Some patients on high dose ICS didn’t even meet diagnostic criteria for Asthma or COPD

• Poor understanding between different devices and doses of equivalent steroid eg Accuhaler vs Evohaler

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Protected Learning Time Event• 112 participants across 38 practices

– ‘it has changed my practice for ever’ – ‘wish it could have been a whole day’– ‘will use the Single Point of Referral’– ‘know more about risk of pneumonia with ICS’– ‘much better understanding of PR and LTOT’– ‘I now know how to refer for PR’– ‘understand importance of smoking cessation and flu jab

in COPD’– ‘clear & straightforward recommendations re inhaler

use/prescribing’

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Q1 2012-13

Q2 2012-13

Q3 2012-13

Q4 2012-13

Q1 2013-14

Q2 2013-14

Q3 2013-14

Q4 2013-14

Q1 2014-15

Q2 2014-15

Q3 2014-15

24%

25%

26%

27%

28%

29%

30%

31%

32%

33%

34%

Percentage high-dose ICS prescribing (of all ICS)2012-13 2013-14 2014-15

Launch of Respiratory Virtual Clinics

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The change in high dose ICS prescribing, London CCGs (as a percentage of all ICS items).

July 2014 - September 2014, (blue bar)

July 2013- September 2013 (red line)

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The trend in total ICS expenditure, London CCGs

Quarter 2 in 2014/15 (blue bar) and quarter 2 in 2013/14 (purple line).

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AprMay

Jun Jul AugSep

OctNov

DecJan Feb

Mar

£150,000.00

£160,000.00

£170,000.00

£180,000.00

£190,000.00

£200,000.00

£210,000.00

Respiratory Corticosteroids Spend by Month

2012/13 2013/14 2014/14

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Inhaled Corticosteroid Items – High dose and total, Lambeth CCG

1st Quarter 2013/2014

2nd Quarter 2013/2014

3rd Quarter 2013/2014

4th Quarter 2013/2014

1st Quarter 2014/2015

2nd Quarter 2014/2015

3rd Quarter 2014/2015

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

High Dose ICS ItemsCorticosteroids (Respiratory) Items

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Tiotropium items, Lambeth CCG

1st Quarter 2013/2014

2nd Quarter 2013/2014

3rd Quarter 2013/2014

4th Quarter 2013/2014

1st Quarter 2014/2015

2nd Quarter 2014/2015

3rd Quarter 2014/2015

2,400

2,500

2,600

2,700

2,800

2,900

3,000

3,100

3,200

3,300

3,400

Tiotropium Items

Tiotropium Items

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Tiotropium spend, Lambeth CCG

1st Quarter 2013/2014

2nd Quarter 2013/2014

3rd Quarter 2013/2014

4th Quarter 2013/2014

1st Quarter 2014/2015

2nd Quarter 2014/2015

3rd Quarter 2014/2015

£0.00

£20,000.00

£40,000.00

£60,000.00

£80,000.00

£100,000.00

£120,000.00

£140,000.00

£160,000.00

£180,000.00

Tiotropium Cost

Tiotropium Cost

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Total referrals for 2012

1st & 2nd Q’s 2013 3rd & 4th Q’s 2013 Total Referrals for 2013

0

100

200

300

400

500

600

700

800

900

1000

Pulmonary Rehabilitation - referral data

GP Referrals, Lambeth CCGAll referrals incl hospital referrals

PR referral increased by 40%

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Admissions data

• Between 2011/12 and 2013/14 COPD admissions in Southwark decreased by 6%, saving £37,016 and £43,926 per year. Lambeth has shown a smaller impact to date.

• From 2011/12 to 2013/14 neither boroughs had an increase in COPD admissions attributable to the ICS “step down.

Asthma 7.9% 6.5% 1.6% 6.3% 0.4% 5.1% 7.7% 1.4% 14.3% 2.6% 1.9% 5.8% 2.4% 1.5% 64.1%

Cancer 6.2% 8.4% 2.9% 4.0% 0.8% 3.9% 8.8% 1.1% 20.1% 3.0% 2.8% 5.0% 1.6% 2.2% 60.5%

CHD 8.3% 13.8% 8.8% 10.3% 2.4% 5.1% 20.2% 1.7% 40.1% 4.6% 10.7% 8.1% 4.4% 6.5% 34.5%

CKD 8.3% 19.5% 35.8% 13.7% 5.6% 5.6% 36.1% 2.0% 64.1% 6.9% 16.7% 10.5% 4.8% 11.3% 14.1%

COPD 18.8% 15.4% 24.1% 7.8% 2.4% 7.2% 17.5% 2.5% 38.4% 5.4% 10.3% 11.1% 3.5% 6.9% 26.1%

Dementia 5.3% 14.6% 27.7% 15.5% 11.8% 9.0% 24.6% 4.9% 55.5% 7.7% 13.7% 14.2% 1.2% 26.4% 13.4%

Depression 10.0% 9.9% 7.8% 2.1% 4.7% 1.2% 8.5% 1.8% 14.9% 3.6% 2.5% 18.6% 2.5% 3.1% 54.0%

Diabetes 6.9% 10.1% 14.1% 6.2% 5.2% 1.5% 3.9% 0.9% 41.7% 3.7% 4.6% 8.5% 3.7% 4.1% 39.7%

Epilepsy 9.4% 9.8% 9.0% 2.6% 5.9% 2.4% 6.2% 7.1% 17.5% 3.3% 3.8% 13.7% 1.5% 8.4% 50.1%

Hypertension 7.1% 12.7% 15.4% 6.1% 6.3% 1.9% 3.7% 23.0% 1.2% 4.0% 5.8% 6.4% 3.4% 5.4% 44.3%

Hypothyroidism 7.8% 11.5% 10.8% 4.0% 5.4% 1.6% 5.5% 12.5% 1.5% 24.5% 4.4% 5.7% 2.9% 3.2% 48.7%

Heartfailure 8.4% 16.4% 37.4% 14.4% 15.5% 4.2% 5.8% 23.0% 2.4% 52.6% 6.6% 9.5% 4.5% 11.1% 19.8%

Mental Health 7.9% 8.7% 8.6% 2.7% 5.0% 1.3% 12.9% 13.0% 2.7% 17.7% 2.6% 2.9% 2.0% 3.1% 53.0%

Obesity 12.4% 10.6% 17.8% 4.8% 6.0% 0.4% 6.7% 21.8% 1.1% 35.9% 5.0% 5.3% 7.9% 2.0% 36.7%

Stroke 8.0% 15.0% 26.8% 11.4% 12.2% 9.6% 8.3% 24.2% 6.5% 58.1% 5.6% 13.1% 12.0% 2.0% 16.3%

Not forgetting multimobidity…

People with this condition….

…who also have this condition

Source: LTCs from acute inpatient data (11/12) & PHMCCNote: Data is based on patients registered at practices which submit data to PHMCC

Share of people with co-occurring LTCs in %

Local Perspective

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Sustainability• More virtual clinics – focus on asthma too• Spirometry service to be commissioned• New medicines for COPD, and consider co-morbidities

in pathway ie. nutrition. • Integrate Community Pharmacy more fully• Fully resourced specialist Pharmacist established into

the IRT.• Continue ICS targetted work.• Patient support – waste campaign• CQUIN on discharge communication and care

planning which focussed on respiratory patients.

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Thanks and acknowledgements

• Integrated Respiratory Team, Kings Health Partners and Acute / primary care leads

• Specialist Pharmacists, GSTfT and KCH.• London Respiratory Network.• GPs, nurses and Community Pharmacists,

Lambeth CCG• Medicines Team, Lambeth CCG

• South London CSU Communications Team.

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More Information• London Respiratory team – responsible prescribing messages.

http://www.london.nhs.uk/what-we-do/our-current-projects/london-respiratory-team/workstreams

• Also : http://www.londonrespiratoryteamconference.com

• BTS/SIGN Guidelines for asthma http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx

• NICE COPD Guideline http://www.nice.org.uk/CG101

• GOLD guideline for COPD. http://www.goldcopd.org/uploads/users/files/GOLD_AtAGlance_2013_Feb20.pdf

• Primary Care Respiratory Journal – Risk to benefit ratio of inhaled corticosteroids in patients with COPD, David Price et al. http://www.thepcrj.org/journ/aop/pcrj-2012-02-0014-R2.pdf

• Milbank Q. 2004;82(4):581-629. Diffusion of innovations in service organizations: systematic review and recommendations. Greenhalgh T et al.

• White P, Thornton H, Pinnock H, Georgopoulou S, Booth HP (2013) Overtreatment of COPD with Inhaled Corticosteroids - Implications for Safety and Costs: Cross-Sectional Observational Study. PLoS ONE 8(10): e75221. doi:10.1371/journal.pone.0075221

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Thank you