Responsible Respiratory Prescribing

Responsible Respiratory Prescribing

Dr Vince Mak

London Respiratory Team Clinical Lead

Medicines Management Workstream

May 2012

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

NHS London Respiratory TeamWho are we?

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

What is the London Respiratory Team?


• 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

London Respiratory team approach:Strategy

Value Framework

Health OutcomesPatient definedbundle of care

CostValue=

Health Outcomes Cost of delivering

Outcomes

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

RIGHT CARE for COPD

• Doing the Right Thing – what is cost effective?– Encourage Responsible Prescribing

Cost of Respiratory Medicationby BNF Chapters

~£1 billion on respiratory medication not including

antibiotics…

Source: NHS Information Centre

Volume of Respiratory Medication


but a relatively low volume of respiratory

prescriptions ...

Item cost of Respiratory Medication


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

…inhalers

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

Seretide (all) in London

Symbicort (all) in London

Seretide vs Symbicort

LRT - 7 Key Prescribing Messages

1. Respiratory medications are expensive

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

Smoking prevalence in COPDTORCH, Uplift Studies and …POET-

COPD

1 year abstinence %

QALY£

Usual care 1.4

Minimal counselling 2.6 14,735

Intensive counselling 6 7,149

Intensive counselling + pharmacotherapy

12.3 2,092

Systematic Review of 9 studies Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH.Thorax 2010: 65:711-718

A cost effective intervention in COPD - Stopping Smoking

What works long term and is cost effective?

Tiotropium QALY £7112Eur J Health Econ. 2007 June; 8(2): 123135

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.

High Value Care in COPD

Pulmonary Rehabilitation

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?

• 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

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.’

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

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

References:1.J Epidemiol Community Health. 1998 Feb;52(2):120-5 £50 saving for over 65 2.Thorax. 65(8):711-8, 2010 Aug. 3.Thorax 2001;56:779-784 £0-1000 per QALY4.Tiotropium in the treatment of COPD: Health technology Assessment KCE reports 108C Neyt M et al £7,456 per QALY5.OBA Y Cost effectiveness of long acting bronchodilators for COPD. Mayo Clinic Proc 2007;82:575-582 £5,396 per QALY6.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 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

• >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

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 lungEach patient with COPD uses their inhaled therapy regime as prescribed for evidence-based benefitEach patient with COPD has safe inhaled therapy ie minimum evidenced based dose of inhaled steroid for their stage of disease

Right Care respiratory prescribing Minimise waste – maximise value

…working with health professionals

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

• Ensure compliance

• Ensure correct technique

LRT - 7 Key Prescribing Messages1. Respiratory medications are expensive




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


Right Care respiratory prescribing Minimise risk – ensure safety

…working with health professionals

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)

Minimise Risk : Patient Safety

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

• Warn about not stopping high dose ICS suddenly

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.

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

England – 2 million items/yr

Saves £40 million/year +Less waste caused by poor inhaler techniqueFewer Exacerbations

SIMPLE SWITCH

England – 2 million items/yr

Saves £40 million/year +Less waste caused by poor inhaler techniqueFewer Exacerbations








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

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








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

DH – Outcomes Strategy – Companion Document

London Respiratory TeamUnderstand costsEnsure optimal drug therapy for COPD/Asthma patientsOptimise use of prescribed therapyRight care Minimise waste Maximise value Minimise unwarranted variation

Responsible Respiratory Prescribing

Clinical Lead Dr Vince Mak, Respiratory Physician

Documents

Responsible Respiratory Prescribing