Responsible Respiratory Prescribing Dr Louise Restrick* and Dr Chris Cooper London Respiratory Team NHS Islington and Whittington Health*

NHS London Respiratory Team Aim is to improve the experience of Londoners with COPD and reduce the impact of the disease Funded by DH 2010-13 Clinically-led multi-disciplinary team (0.5 -1 day/week) Community and hospital health professionals Patient/carer voice

Cost of delivering Outcomes Value Framework Health Outcomes Patient defined bundle of care Value = Health Outcomes Cost of delivering Outcomes Cost Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

Right Care Respiratory Priorities Quit smoking support and therapy as treatment for COPD (and asthma) Responsible Respiratory Prescribing … … of Medicines and Oxygen Pulmonary Rehabilitation

COPD ‘Value’ Pyramid What we know…. Cost/QALY Triple Therapy £35,000-£187,000/QALY LABA £8,000/QALY Tiotropium £7,000/QALY Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £?1,000/QALY in “at risk” population

NICE Respiratory Prescribing ‘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.’ Seem to be three key issues we need to address: 1. Cultural change so that clinicians believe that supporting patients to stop smoking is a treatment they should be delivering NOT a lifestyle choice. 2. Equipping clinicians with motivational interviewing skills to support behaviour change rather than the ‘you must stop smoking’ approach. 3. Providing clinicians with prescribing knowledge on nicotine replacement, varenicline and bupropion. These are relatively new products and have been seen to be the business of stop smoking services rather than all clinicians who look after patients with COPD.

Cost of Respiratory Medication by 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 ... Source: NHS Information Centre

Item cost of Respiratory Medication Respiratory items are the most expensive category of item prescribed ..... …inhalers Source: NHS Information Centre

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 Source: NHS Information Centre

Price per puff of inhaled therapy

COPD ‘Value’ Pyramid What we know…. Cost/QALY Triple Therapy £35,000-£187,000 LABA £8,000/QALY Tiotropium £7,000/QALY Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £?1,000/QALY in “at risk” population

London Combination Inhaler Prescribing

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 increases deposition to 30% *Thorax 2010;65:A117

Responsible Respiratory Prescribing Best value from inhaled therapy 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

X Responsible Respiratory Prescribing Best 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 X

Right Care for COPD Doing the Right Thing – what is evidenced based and cost effective? Encourage Responsible Prescribing Supporting patients to stop smoking as a priority when seeing patients with respiratory symptoms Ensure that all eligible patients are referred for pulmonary rehabilitation Source: NHS Information Centre

Mechanisms to support Responsible Respiratory Prescribing QOF Medicines management M6,10,11-12 QOF Quality & productivity:QP1-5 Medicines Audits COPD Guidelines COPD Local Enhanced Service (LES) Systems solutions Prescribing Incentives/Commissioning for Quality Schemes

Doing the Right things Right Minimise Waste – Maximise safety Each patient with COPD or asthma is using an inhaler device that works for them (MDI with spacer or DPI) Each patient with COPD or asthma has learnt the right technique for drug delivery into the lung Each patient with COPD or asthma uses their inhaled therapy regime as prescribed for evidence-based benefit Each patient with COPD or asthma has safe inhaled therapy ie minimum evidenced based dose of inhaled steroid for their stage of disease

Increasing value from prescribing systems

Right Care, Value and QIPP in COPD Doing the right things Helping people to stop smoking Helping people complete pulmonary rehabilitation Helping people get the right medicines And doing the right things right Intensive stop smoking counselling + drugs The right PR programme in the right place The right inhaler and the correct technique

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: 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, ensure that the patient is issued with an inhaled steroid safety card 7.      No Prednisolone EC prescribing without good clinical reason