1. VALUE IN RESPIRATORY PRESCRIBING Dr Vince Mak, Consultant Physician, NWLH Trust

2. Value Framework Health Outcomes CostValue = Health Outcomes Cost of delivering Outcomes Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

3. QUALITY vs VALUE paradigm Source: NHS Information Centre Quality and Value are not mutually exclusive RIGHT CARE Do the right thing Do the right thing right Doing the right thing right first time should deliver quality and value

4. What are the top 5 costliest drugs to NHS (June 2012)? Source: www.drugtariff.co.uk 5.Seretide 125 evohaler -£81 million/yr 4.Seretide 500 accuhaler -£85 million/yr 3.Symbicort 200 - £90 million/yr 2.Tiotropium -£120 million/yr 1.Seretide 250 evohaler -£180 million/yr Thus, of the top 5 costliest drugs to the NHS currently, ALL ARE RESPIRATORY INHALERS

7. WHY IS SERETIDE 250 THE NO.1 COMBINATION INHALER

8. Position in BTS/SIGN Asthma Guidelines Does this mean majority of asthmatics are at Step 4+ of BTS guidelines?

9. London Respiratory Team Triple Therapy (£7000- £187000/QALY LABA £5-8000/QALY Tiotropium £7000/QALY Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination? £1000/QALY in “at risk” population COPD Value Pyramid What we know…. Cost/QALY

10. ARE WE GETTING THE MOST OUT OF OUR INHALER SPEND?

11. 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 may be easier to use and can increase deposition to 30% If used incorrectly – most of the drug from MDI is wasted – Seretide 250 is £60/month *Thorax 2010;65:A117

12. PRIMARY CARE PRACTITIONERS SAY THAT PRESCRIBING IS LED BY SECONDARY CARE Can that be true?

13. In NWLH Trust over 2011/12 - What were the top 10 costliest drugs in Emergency Medicine Directorate? Top 30 Drugs for Emergency Medicine Directorate - NWLH April, May, June, July, August, September, October, November, December, January 2011/12 Drug Name2011/12 DALTEPARIN£29,297.29 SERETIDE£28,763.14 OPTIUM H£20,761.34 OCTAPLEX (KEPT IN BLOOD TRANSFUSION EXT 2746)£19,040.00 MEROPENEM£15,683.04 TIOTROPIUM (SPIRIVA)£13,711.00 TETANUS, Low Dose Diphtheria & POLIO (REVAXIS)£12,855.98 DALTEPARIN (GRADUATED SYRINGE)£12,605.43 CLARITHROMYCIN£12,006.87 SYMBICORT£11,594.38

15. WHAT CAN WE DO? ENCOURAGE RESPONSIBLE RESPIRATORY PRESCRIBING “clinicians will need to accept that they are responsible for the stewardship of resources and not just their use” Sir Muir Gray BMJ Oct 6 2012

16. RIGHT CARE - Responsible Respiratory Prescribing Optimise – not Maximise Often – use of high potency inhaled corticosteroid not appropriate for stage of disease for asthma and COPD Poor inhaler technique often cause for treatment failure and not “fixed” by increasing the dose In COPD – possible to use evidence based lower potency alternative with less risk Treatment rarely stepped down when stable or not effective

17. 7 Key COPD 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

18. Minimise Risk : Patient Safety Warn about potential for adrenal suppression on high doses of ICS Warn about not stopping high dose ICS suddenly

19. Minimise Risk : Minimise waste : Maximise Value Warn about high dose ICS side effects: – Pneumonia – Diabetes – Bone Loss In COPD – moderate dose ICS (800µg BDP equivalent) same clinical efficacy as very high dose ICS (2000µg BDP equivalent). In asthma – little evidence for efficacy of ICS above 800µg/day (BTS/SIGN Grade D evidence) Checking inhaler technique, using ICS through a spacer or changing inhaler device may be more effective than increasing the dose or stepping up treatment If dose of ICS has been stepped up in the treatment of asthma and patient is well controlled – consider stepping down after 3 months.

20. Minimise Risk : Increase awareness Traffic light reference card BDP dose equivalence Which inhalers and at what dose may deliver >1000µg BDP equivalent/day Also gives some idea of cost for BDP equivalent doses of different brands of inhaler

21. WHAT CAN AND WILL YOU DO TO ENCOURAGE RESPONSIBLE RESPIRATORY PRESCRIBING IN YOUR TRUSTS? Optimise – not Maximise