1. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Medicines Management Workstream Dr Vince Mak October 2010

2. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Objectives Ensure Optimal drug therapy for COPD patients Optimise use of prescribed therapy Minimise waste – Maximise value Minimise variation

3. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Cost of Respiratory Medication in England Source: NHS Information Centre

4. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Volume of prescriptions is low Source: NHS Information Centre

5. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Cost per item is high Source: NHS Information Centre

6. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Respiratory Medications are costly Seretide (all) is the most expensive drug in UK (£344 million/yr) Seretide 250 Evohaler is the most expensive individual item for NHS (£165million/yr) – second is atorvastatin Symbicort 200 is 5th most expensive item for NHS (£80 million/yr) Source: www.drugtariff.co.uk Sourced Aug 2010

7. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Seretide by device

8. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team COPD vs Asthma

9. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Tiotropium prescriptions in London Source: EPACT Jun2010

10. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Seretide prescription in London Source: Source: EPACT Jun2010

11. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Tiotropium as COPD surrogate marker Total spend on Tiotropium in London for 1 year (2009/10) was approx £10.5 million At on average £35/item = 300,000 units dispensed in London Total spend on Seretide 250 evohaler for same period was roughly £16 million At average of £60/item = 266,666 units dispensed ?How much Seretide 250 may be accounted for by prescribing for COPD.

12. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Optimise therapy Ensure all patients with COPD are on the appropriate therapy for the stage of their disease –New NICE guidance 2010

13. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Optimise use of medicines Ensure all patients with COPD are using an appropriate inhaler device (spacer or DPI) Ensure compliance Ensure correct technique Ensuring safety (steroid cards for high dose ICS/combinations)

14. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Minimise waste – Maximise value Awareness of high cost of medications (healthcare professionals and patients) If medications appropriate - use of cost effective evidence based option (e.g. Plain prednisolone vs EC – potential £2 million saving per year in London) Ensure compliance Avoid duplicate prescribing

15. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Minimise variation Data suggests that across London after allowing for prevalence of COPD – there is large variation in: –Use of high dose inhaled steroids alone –Use of tiotropium –Use of combination therapy –Choice of combination therapy

16. Improving the experience of all Londoners with COPD and minimising the impact of the disease London Respiratory Team Next Steps Understand the data Understand the causes of variation Find and promote examples of good practice (work with LIP and QIPP programs) Disseminate information to healthcare professionals, patient groups, carers and patients