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

2. Responsible Prescribing should be based on: Evidence-Based Efficacy (Grade A) Safe (primum non nocere) Value “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

3. What is Value?

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

5. QUALITY vs VALUE 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

6. To understand VALUE – you have to know COST

7. What are the top 5 costliest drugs in the NHS (Dec 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

9. Why is Seretide 250 the commonest prescribed combination inhaler in the NHS?

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

11. COPD NICE Guidance

12. Evidence of Overuse of Inhaled Corticosteroids in COPD De la Rosa et al. ERJ 2011: P4627

13. Evidence from UK ERS 2011, Sept. 26 — Many patients with chronic obstructive pulmonary disease (COPD) managed in primary care practices in the south of London are being overtreated with inhaled corticosteroids (ICS), according to researchers based at King's College in London, United Kingdom. Co-investigator Dr. Hilary Pinnock from the Allergy and Respiratory Research Group at the University of Edinburgh, who presented the study on behalf of the research team, said the study findings show both the increased risk for patients and the excessive cost to the system that result from the inappropriate use of ICS. In the study, data including spirometry, inhaled medications and recent COPD exacerbations were obtained for 3,537 patients with COPD at 65 general practices in Lambeth and Southwark. Of patients included in the study, complete spirometry data were available for 61% and, in 71% of these cases, spirometry results confirmed the diagnosis of COPD. Only 60% of patients were being treated appropriately with 9% undertreated and 37% overtreated. Of those cases in which there was deemed to be overtreatment, inhaled steroids were involved in 96% of cases. Pinnock said the main categories of overtreatment were overprescribing ICS in patients with less severe disease and in using ICS when there were no exacerbations of disease. Half of the patients for whom the diagnosis was not confirmed on spirometry were receiving ICS at high doses. While the researchers conclude these findings "must give considerable cause for concern," Pinnock did note that the 2010 NICE guidelines "blur" the advice for when to use ICS and widen their indications.

14. Triple Therapy (£7000- £187000/QAL Y 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 London Respiratory Team Value Pyramid - Cost/QALY

15. LAMA + LABA +ICS – TRIPLE THERAPY LABA LAMA PR Stop Smoking Flu Vaccine The low value pyramid? Representation based on national GP contract data and locally retrieved data Do less low value – Do more high value

16. Added value from doing things right (quality improvement) Added value from doing the right things (making the right decisions) High Value High Value High Value Low Value Do less low value – Do more high value

17. Are we getting the most out of our inhaler spend?

18. Doing the Right Things Right – Inhaler Technique In some studies, up to 90% of patients may not be able to use an MDI effectively 91% of healthcare professionals who teach use of an MDI cannot demonstrate it correctly* Even with effective technique, lung deposition from an MDI is at best 12% (excluding newer fine particle inhalers)** Large volume spacer may be easier to use and may increase deposition to over 20%** If used incorrectly – a lot of the drug from MDI is wasted *Thorax 2010;65:A117 ** Newman S. Chest 1985; 88: 152S-160S

19. SAFETY

20. * NNT to observe 1 extra pneumonia event on fluticasone propionate/salmeterol (FPS) † The TORCH and INSPIRE studies were not powered to investigate pneumonia 1. Crim C et al. Eur Respir J 2009; 34: 641-7. 2. Calverley PM et al. Chest 2011; 139: 505-12. 3. Janson C et al. ERS 2012. Swedish RWE: Pneumonia data in context Increased incidence of pneumonia with fluticasone propionate/salmeterol in studies with >2 yrs of follow up Pneumonia rate per 100 patient-years Placebo FPS 500 bd Tiotropium BF

21. Inhaled corticosteroid doses Licensed doses for COPD (used in studies) BF - Symbicort 400 Turbohaler 1p BD Beclometasone equivalence 800mcg/day FS - Seretide 500 Accuhaler 1p BD Beclometasone equivalence 2000mcg/day

22. Risks of high dose ICS D Price et al. Prim Care Respir J 2012; http://dx.doi.org/10.4104/pcrj.2012.00092 HPA suppression ✔

23. What can we do? ENCOURAGE RESPONSIBLE RESPIRATORY PRESCRIBING

24. RIGHT CARE - Responsible Respiratory Prescribing If your patients knew the risks – what would they chose? Often – use of high dose inhaled corticosteroid not appropriate for stage of disease for asthma and COPD In COPD – possible to use evidence based lower potency with same clinical efficacy Poor inhaler technique often cause for treatment failure and not “fixed” by increasing the dose Treatment rarely stepped down when stable or not effective Lack of awareness of potential harm of high potency inhaled corticosteroids – would patients use if fully informed?

25. London Respiratory Team – Responsible 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

26. Tools for change – Inhaled steroid card

27. ? Tools for change – Prescribing data

28. What can and will you do to encourage Responsible Respiratory Prescribing? Optimise – not Maximise Do more of what is right!