1. Introduction Method Acknowledgements The impact of respiratory virtual clinics in primary care on responsible respiratory prescribing and inhaled corticosteroid withdrawal in patients with COPD: a feasibility study Ms Grainne d'Ancona*; Dr Irem Patel*; Dr Azhar SaleemΨ; Mr Finlay RoyleΨ; Ms Anna HodgkinsonΨ; Ms Vanessa BurgessΨ; Dr Cathrine McKenzie*; Prof John Moxham* and Prof Tariq Sethi*; *Kings Healthcare Partners, ΨLambeth CCG. London, UK An inhaled corticosteroid (ICS) is indicated for patients with severe COPD (FEV 1 2 exacerbations/year. Published data from Lambeth suggested 38% of patients were receiving an ICS inappropriately, potentially resulting in 12 additional cases of pneumonia at a cost of ~£500K annually 1. Respiratory virtual clinics (VC) were developed to re-focus the management of COPD on high value care and where appropriate to withdraw ICS therapy. The London Respiratory Network COPD Value Pyramid 2 (figure 1.) outlines high value interventions (eg support for tobacco dependence and pulmonary rehabilitation) versus lower value drug therapies. Results Data from 372 patients on COPD registers were reviewed in 25 VCs  321 (86%) patients had their diagnosis of COPD confirmed  279/321 (87%) patients had a recommendation made  Recommendations included:  64 (23%) referrals to PR  45 (16%) referrals for smoking cessation support  41 (15%) patients to initiate a LAMA  16 (6%) patients to initiate a LABA  198 (71%) patients to step down/withdraw the ICS The outcomes associated with the ICS intervention are in table 1. Figure 3. illustrates that the proportion of high dose ICS prescribing in Lambeth decreased from 1.7% above the London average, to 2.5% below it during the intervention A responsible respiratory prescribing (RRP) group agreed COPD prescribing guidance across primary/ secondary care. As there were concerns about COPD misdiagnosis and that only limited data has been published on the feasibility of withdrawing an ICS in COPD 3, implementation of the step down protocol created by the RRP (figure 2.) was supported by a virtual clinic (with an integrated respiratory consultant or GP respiratory lead) and educational events. Conclusions Integrated working through respiratory VCs offers huge scope to provide high value care for COPD patients. Overuse of ICS in COPD is common and GP-led withdrawal of high dose ICS where appropriate is feasible, acceptable and well tolerated by patients. This novel method of partnership working can bring specialist expertise to the care of large numbers of respiratory patients and improve value to the NHS Thank you to the Lambeth practices who hosted virtual clinics, made the interventions and submitted their data. Correspondence to: irempatel@nhs.net and grainne.dancona@gstt.nhs.uk References Figure 2. ICS Withdrawal Protocol 1.White et al. (2013) Overtreatment of COPD with Inhaled Corticosteroids - Implications for Safety and Costs: Cross-Sectional Observational Study. PLoS ONE 8(10): e75221 www.plosone.org/article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.pone.0075221&representation=PDF 2.November 2014, Volume 69, Issue 11 http://thorax.bmj.com/content/69/11.cover-expansion 3.Rossi et al. Respiratory Research 2014, 15:77 http://respiratory-research.com/content/15/1/77 OutcomeNo. of patients (n=198) ICS successfully stopped61 ICS stepped down58 Patient due for step down at time of data submission33 Patient was not stepped down, but reason not given19 Patient asked not to have ICS stopped9 Patient did not tolerate lower dose9 Patient excluded as no-longer fulfilled inclusion criteria7 Patient could not be contacted2 Table 1. Outcomes associated with the ICS withdrawal Figure 3. Changes in High Dose ICS Prescribing Figure 1. The LRN COPD Value Pyramid