Optimising medicines for COPD and Asthma – an integrated approach. Vanessa Burgess Chief Pharmacist, Assistant Director of Commissioning Dr Azhar Saleem Respiratory Lead GP.

North Lambeth (95,816) SE Lambeth (113,701) SW Lambeth (157,054) 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)

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

National strategies The NHS Five Year Forward View, October 2014 ..break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The NHS will provide more support for frail older people living in care homes NICE Medicines Optimisation Guideline. Skill mix...cross-organisational working provides seamless care during the patient care pathway when using health and social care services. Consider a multidisciplinary team approach to improve outcomes for people who have long-term conditions and take multiple medicines (polypharmacy). Shared decision making and self management Medicines reconciliation – within 24 hours in acute and within 7 days in primary care. Medicines safety

What’s going on

45% dying without seeking medical assistance 10% admitted to hospital in last month prior to death 39% received more than 12 reliever inhalers in last yr prior to death

Acute medical admission on the rise, 13% increase in COPD admissions, LOS reducing, Good early supported discharge. No specialists on weekends

£2.3 M £2.3million spend on ICS (including combinations) London Respiratory Network Responsible Prescribing Messages. Known harms from high dose ICS - Pneumonia, adrenal suppression, growth retardation, decrease in bone mineral density, cataracts and glaucoma ; psychological and behavioural effects. Waste – patient returns from a local Pharmacy.

Principle 1 : Understanding the patient experience 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 Waiting for different tests or blood tests results before being able to access treatment and having different tests arranged on different days so the patient was coming back and forth to hospital. Access to the correct specialist team on acute 1st presentation and for ongoing management post-operatively or following “flare”. Access to and advice on non-pharmacological support for IBD. Education and peer support in the community Patrick White et al, 2013. 41 London general practices (population 310,775)

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. Waiting for different tests or blood tests results before being able to access treatment and having different tests arranged on different days so the patient was coming back and forth to hospital. Access to the correct specialist team on acute 1st presentation and for ongoing management post-operatively or following “flare”. Access to and advice on non-pharmacological support for IBD. Education and peer support in the community

The evidence and standards are here

London Respiratory Network Principle 2 : Evidence Based Choice of Medicines & Outcome Based Approach Waiting for different tests or blood tests results before being able to access treatment and having different tests arranged on different days so the patient was coming back and forth to hospital. Access to the correct specialist team on acute 1st presentation and for ongoing management post-operatively or following “flare”. Access to and advice on non-pharmacological support for IBD. Education and peer support in the community London Respiratory Network

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

Collaboration

What is a virtual clinic?

Virtual Clinics – a model for change ..“help it happen” 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. Waiting for different tests or blood tests results before being able to access treatment and having different tests arranged on different days so the patient was coming back and forth to hospital. Access to the correct specialist team on acute 1st presentation and for ongoing management post-operatively or following “flare”. Access to and advice on non-pharmacological support for IBD. Education and peer support in the community

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 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 In summary

Principle 4: Making medicines optimisation part of routine practice “Make it happen” IT point of care support Contractual incentives Data monitoring Resources Principle 4: Making medicines optimisation part of routine practice Waiting for different tests or blood tests results before being able to access treatment and having different tests arranged on different days so the patient was coming back and forth to hospital. Access to the correct specialist team on acute 1st presentation and for ongoing management post-operatively or following “flare”. Access to and advice on non-pharmacological support for IBD. Education and peer support in the community

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

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’ 5 group sessions led by IRT and respiratory GPs: Spirometry Interpretation Pulmonary Rehab and smoking cessation How to undertake a high-value COPD review Responsible respiratory prescribing in COPD Oxygen therapy

2012-13 2013-14 2014-15 Launch of Respiratory Virtual Clinics

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)

The trend in total ICS expenditure, London CCGs Quarter 2 in 2014/15 (blue bar) and quarter 2 in 2013/14 (purple line).

Inhaled Corticosteroid Items – High dose and total, Lambeth CCG

Tiotropium items, Lambeth CCG

Tiotropium spend, Lambeth CCG

PR referral increased by 40% N.B. 1. None of the above figures include referrals to St Thomas’ 2. Referrals received via the Single point access system which indicate PR at St Thomas’ have been forwarded on to them. In some instances these return to us when the patient choice is for a community based programme. 3. We are still receiving referrals by letter and on out-dated referral forms.   I have added the total number of referrals from all sources (primary and secondary care) for patients in Lambeth and the total is 402.  So Lambeth produces some 45% of all referrals to our service (excluding STH).  Southwark provides a further 48% with the balance coming from other boroughs. Please find attached a note concerning the referrals received from GP/Practice Nurses in Lambeth.  I have extracted referral numbers for the calendar years 2012 and 2013.  As you will see, there has been a 60% increase in referrals for these years.  I have also shown comparative numbers for all referrals received for both periods, from which you  will note that overall the increase is almost 41%.  Regrettably, we have not recorded which referrals were received via SPR against a specific source but a quick count of the number of emails received to the SPR gives a total of 292, forty six of which were referred on to St Thomas’ since SPR started. Please let me know if you need any further  information.

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.

Not forgetting multimobidity… Local Perspective Not forgetting multimobidity… People with this condition…. Share of people with co-occurring LTCs in % …who also have this condition Source: LTCs from acute inpatient data (11/12) & PHMCC Note: Data is based on patients registered at practices which submit data to PHMCC

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.

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.

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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