London Respiratory Team Understanding respiratory spend and increasing value: Inhalers and nicotine replacement therapy Responsible Respiratory Prescribing Dr Louise Restrick on behalf of the London Respiratory Team

London Respiratory Team Right Care Respiratory Prescribing NICE 2010 ‘Ensure all patients with COPD are on the appropriate therapy for the severity of, and symptoms from, their disease.’ ‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Total cost of Respiratory Medication by BNF Chapters 2008 and 2009 for England £ millions Source: NHS Information Centre ~£1 billion on respiratory medication not including antibiotics…

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Volume of Respiratory Medication by BNF Chapters 2008 and 2009 for England Number of prescriptions (millions) Source: NHS Information Centre but a relatively low volume of respiratory prescriptions...

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Item cost of Respiratory Medication by BNF Chapters 2008 and 2009 in England Average net ingredient cost per prescription item £ Source: NHS Information Centre Respiratory items are the most expensive category of item prescribed..... …… inhalers

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team NHS budget & respiratory meds Source: NHS Information Centre Seretide (all) is the most expensive drug Seretide 250 Evohaler is the most expensive individual item (second is atorvastatin) Symbicort 200 is 5th most expensive item Of the top 5 costliest drugs to the NHS currently 3 are inhalers

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Long-term effectiveness & cost-effectiveness of smoking cessation interventions in patients with COPD 1 year abstinence % QALY £ Usual care1.4 Minimal counselling2.614,735 Intensive counselling67,149 Intensive counselling + pharmacotherapy 12.32,092 Tiotropium £7,112/QUALY Eur J Health Econ. 2007; 8(2): Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65: Pulmonary Rehabilitation £2,000-8,000/QALY

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Smoking prevalence in COPD At best one in four Londoners with COPD are still smokers….

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Smoking prevalence in COPD

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Smoking prevalence in COPD

London Respiratory Team Best value from inhaled therapy Right care prescribing Smokers offered support to stop smoking and prescribed NRT therapy each time inhalers prescribed….. Use NICE criteria No new inhaler without patient-centred education, training and review Mechanisms for reducing duplicate prescribing ? Steroid cards for high dose ICS/combinations

London Respiratory Team Best value from inhaled therapy Working with patients … Support and pharmacotherapy to stop smoking Each patient has and uses inhaler devices that work for them MDI with spacer or DPI right technique for drug delivery into the lung inhaler regime as prescribed for evidence-based benefit

London Respiratory Team Responsible Respiratory Prescribing Are we providing Right Care? Clinical Lead Responsible Respiratory Prescribing, Dr Vince Mak, Respiratory Physician Clinical Lead Quit Smoking as treatment for COPD, Dr Noel Baxter GP Are commissioners, prescribers and patients getting best value from our inhaler spend? Do we have and use integrated quit smoking systems so that our respiratory patients have the best chances of quitting smoking?

Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Right Care Respiratory Prescribing Prednisolone No evidence that EC prednisolone tablets (red) result in fewer GI problems or protect against peptic ulceration EC prednisolone costs six times more than plain prednisolone (white) Switch from EC prednisolone to prednisolone could save £2 million per year in London