1. Use of Inhalers Medicines Optimisation workshop 14 th September 2015, Holiday Inn Gatwick

2. To optimize the use of inhalers across Kent Surrey Sussex, to reduce the cost burden to the NHS and maximise patient benefit of such medications through effective and appropriate high quality care Aim

3. 1.To move forwards with optimising the use of inhalers across KSS 2.To agree specific ways forward and scope pieces of work 3.To share examples of good practice 4.To identify volunteers and partners for project work that is agreed Objectives of this workshop

4. NHSE set a medicines optimisation priority to all AHSN regions KSS AHSN hosted a MO event 19 th May 2015 covering: –National view from NHSE –Polypharmacy –AF and HF medications –Inhalers Agreed to work up strategies and projects The story so far…..

5. spirometry 1.Need for spirometry competencies to be increased across all kinds of professionals, for accurate earlier diagnosis and ongoing effective monitoring inhaler technique 2.Need for improved effective use of inhalers by patients and their carers, through improved inhaler technique capabilities and training inhaler prescribing 3.Need for appropriate, effective and responsible inhaler prescribing in terms of both medication and devices Agreed Priorities

6. Quality Assured Spirometry Vikki Knowles Respiratory Nurse Consultant G & W CCG

7. Setting the scene ●Spirometry is the recommended objective test performed to identify abnormalities in lung volumes and air flow 1. ●It is used in conjunction with physical assessment, history taking, blood tests and x- rays, to exclude or confirm particular types of lung disease, enabling timely diagnosis and treatment.

8. Why do Spirometry? ●Gold standard for diagnosing and monitoring. ●Classifies defect ●Airflow Limitation ●Early Diagnosis ●Response to Tx ●Suitability for anaesthetic Recommended for use in both Asthma and COPD guidelines (BTS/Sign/Nice 2003/2004). Quality Points (GMS Contract) for using spirometry in respiratory diseases £££ To do this you need: Access Spirometry Equipment Trained Staff Maximal Effort

9. The Global view ●Standardisation of spirometry (2005) Eur Resp Journal 26: 319-338 ●BTS NICE QS 10 (2011) COPD

10. STANDARDS DOCUMENT Diagnostic Spirometry in Primary Care Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society Recommendations A General Practice Airways Group (GPIAG)1 document, in association with the Association for Respiratory Technology & Physiology (ARTP)2 and Education for Health3 1 www.gpiag.org 2 www.artp.org 3 www.educationforhealth.org.ukwww.educationforhealth.org.uk Mark L Levy, Philip H Quanjer, Rachel Booker, Brendan G Cooper, Stephen Holmes, Iain R Small

11. Quality Assurance ●Diagnostic spirometry should only be conducted by an operator trained and assessed to Association for Respiratory Technology and Physiotherapy (ARTP) or equivalent standards in the performance of spirometry by recognised training bodies. ●Interpretation of results may be performed separately. The interpreter must be trained and assessed to ARTP or equivalent standards in the interpretation of spirometry by recognised training bodies 2.

12. Pitfalls in Spirometry: An Educational Piece Jo Congleton, Consultant Physician, Clinical Co-lead South of England (east) SHA Breathing Matters Nov 2010 Other useful educational information Restrictive Spirometry: An Educational Piece Jo Congleton, Consultant Physician, Clinical Co-lead South of England (east) SHA Breathing Matters Sept 2011 QA Diagnostic spirometry for COPD. Ten minute tutorial (2013) www.copdexchange.co.uk

14. Issues re training ARTP certification Gold standard but: ●Significant cost and time implications ●Practices may disengage with spirometry training ●Increased referrals to separate spirometry service QA Spirometry training ●Silver standard training ●Alternative way of achieving a safe and cost effective service ●Practical to achieve across a CCG ●Starting point for those practices wishing to achieve the ARTP certification

15. Risk of poor quality spirometry ●Incorrect diagnosis ●Poor patient outcomes ●Inappropriate use of inhaled treatment with increased risk of side effects for no benefit.

16. COPD in KSS 68,000 people diagnosed; 55,000 undiagnosed 1,891 deaths in 2010 equating to a DSR of 21.92 (against England rate of 25.19) 1,891 deaths in 2010 equating to a DSR of 21.92 (against England rate of 25.19) 1,557 years of life lost Standardised LoS 6.3 days below national average 6.4, however, reducing to best area’s (London) could save 3,196 bed days Standardised LoS 6.3 days below national average 6.4, however, reducing to best area’s (London) could save 3,196 bed days 49,504 bed days KSS spend £46.6m on inhaled corticosteroids in 2010 Ageing population will mean these figures will worsen

17. Spirometry in Primary Care ●Unlike many medical tests during which the patients remain passive, spirometry testing requires co- operation and an almost athletic breathing manoeuvre. ●With submaximal effort, the results are erroneous (false positive and false negative for disease or change in severity). ●The misclassification rate is about 5% in most research and sub-speciality settings, but has been shown to be higher in primary care settings. ●The most common cause of error is inadequate spirometry training and experience of the person performing the test

18. Common Errors ●Sub maximal inhalation ●Excessive extrapolated volume ●Slow start ●Cough ●Early termination ●Variable effort ●Cessation of airflow – glottis closure ●Leak ●Extra breaths

19. Local spirometry provision ●How does your service stack up? ●Have you used a QA checklist to assess the quality of the service being provided. ●Who carries out spirometry? ●What training have the HCP’s providing spirometry undertaken?

20. What happens in other areas ●Leicester ask practices to submit 10 traces to RCT lead for approval. ●Stockport had a spirometry LES initially but this created problems when the HCP leading it left. ●Moved towards accrediting a limited number of local practitioners (ARTP) and maintaining register but reaccreditation proving a problem.

21. Supportive documents ●Commissioning Toolkit ●Service Specifications ●Read costing tool for spirometry

22. Spirometry and Assessment Service Model Number of patients referred Cost of service Increase in cost of on- going treatment in primary care Reduction in cost of treatments for exacerbations Case finding diagnoses patients earlier than they would otherwise have been diagnosed Net cost QALY Gains

23. Commissioning pack cost benefit model

24. Achieving QA Spirometry Silver standard ●2 full days attendance ●Submission of portfolio ●Local assessment ●Annual half day attendance to maintain QA

25. Morning session – Day 1 ●Introduction in to the rationale for performing spirometry followed by: ●Practical session on performing spirometry to include: ●Preparation of equipment ●Review of different spirometers (Attendees asked to bring along spirometer they use where possible. ●Calibration techniques ●Patient preparation ●Information on Contraindications ●Practical Assessment

26. Afternoon session – Day 1 ●Introduction into interpretation ●Review all the spirometry strips from the morning assessment (QA) ●Within 6 weeks submit portfolio, 5 cases, calibration log and pre test check list.

27. Day 2 Interpretation day ● GP and PN to attend with portfolio containing 3 spirometry tracings. ●GP part of protected learning QA: One GP per practice to attend ●Morning session ●Introduction to interpretation of spirometry results with link to diagnosis. ●Review of spirometry tracings brought to day; Assess quality of tracing and interpretation of results ●Afternoon session ●Assessment of 5 cases to complete the day ●Certificate of attendance if passed

28. Maintaining QA Spirometry ●Annual half day attendance for all staff who have completed initial QA spirometry sessions. ●Submission and review of 5 cases ●Information / signposting - ARTP Gold standard accredited spirometry courses.

29. The Next Step ●How would you define a QA spirometry service? ●Do you think the silver standard level offers a robust first step to achieving QA spirometry? ●What is your preferred model of delivery? ●Should we be insisting on ARTP qualification across the CCG within all GP practices?

30. Respiratory Leaders Programme TAKE THE LEAD ….. Visit http://www.pcrs-uk.org/respiratory-leaders-home to join the programme and find out about our next event Inspiring you to make a difference

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32. Inhaler Technique How do we get it right and improve technique, knowledge and understanding of both HCP’s and patients? Jo Wookey KSS AHSN Respiratory programme co lead.

33. Why is so important? 4 of the top 5 costliest drugs to the NHS are Respiratory inhalers

34. Top 5 costliest drugs in the NHS ? (Mar 2014) Source: www.drugtariff.co.uk = last accessed Sep 2014www.drugtariff.co.uk 5.Sitagliptin 100mg -£5.8 million/mo 4.Seretide 500 accuhaler -£8 million/mo 3.Symbicort 200 - £8.5 million/mo 2.Tiotropium -£12 million/mo 1.Seretide 250 evohaler -£12.5 million/mo Thus, of the top 5 costliest drugs to the NHS currently, 4 ARE RESPIRATORY INHALERS Total for high potency Seretide approx £260 million/yr

35. Why is it so important? 90% of patients have the wrong technique. Poor technique means patients aren’t getting the dose they require Think its ineffective Doesn’t help symptom management Keep changing inhalers or stepped up onto inappropriate regimes Studies have shown between 70-94% of HCP’s unable to demonstrate ability to use inhale correctly If we can’t do it right how can the patient?? Therefore, it is a costly mistake to both the patient and the NHS getting it wrong!

36. What do we need to do? Improve the knowledge of all HPC’s Understanding the different devices, how they work, pro’s & con’s Patient appropriate device selection Use of spacers- the correct type for the correct device Understanding of the prescribing guidelines Improve skills in teaching inhaler technique Check and re-check inhaler technique at every opportunity Improve patient knowledge and technique Provide patients with information about their device Ensure carer/partner knows how to use the device Involve them in the selection of the device

37. How do we do this? Examples…. Train the trainer Isle of Wight project- HCPs were instructed on how to use the inhalers themselves, and then trained to measure a patient's ability to use their prescribed inhaler. Emergency admissions due to asthma reduced by 50%, and deaths by 75%. PCT Bronchodilator spend down by 20% Hospital inpatient costs for asthma-related admissions have fallen by 66% South West inhaler training project- training ambassadors( primary and secondary nurses and pharmacists) supported by on-line competency and then running further training sessions locally to other HCP’s Consistent messages ITT East Sussex Trained the trainers Learnt that targeting specific groups/ organisation was more effective than a “mass marketing” approach with better uptake. Have delivered workshops to practice nurses, ACNPs, school staff, domiciliary care workers and housing support workers and more recently nursing and therapy teams in HWLH. Getting engagement is key

39. Examples… Online training Greater Manchester inhaler improvement innovation project- WIRES Podcasts hosted by Wessex AHSN Medicines.org.uk- video’s showing use of inhaler + info on each device and medication Pharma websites

42. Examples On-line information/resources BLF Asthma uk Local CCG websites hosting information Local pharmacy websites

46. How shall we do this across KSS? ? Build on Train the trainer ? Agreed standardised training for the region- slide set ? Consistent messages ? Accredited training/competency sets ? combining training with MUR’s- utilise pharmacists ? Develop regional on-line resource- utilising existing resources ? Patient/carer information Over to you …………..

47. Responsible Respiratory Prescribing Messages Draft update for discussion Helen Marlow, Lead Primary Care Pharmacist and NICE Medicines and Prescribing Centre Associate August 2015

48. Responsible Prescribing in COPD (old messages) South East Coast Principles Do the right things: Smoking cessation is the most effective intervention for COPD Pulmonary rehabilitation reduces admissions and health care resource use, improves exercise capacity and health related quality of life Prescribe according to guidelines Do the right things right: Ensure correct inhaler technique most patients don’t know how to use their inhaler and many health care professionals who teach the use of MDI cannot demonstrate it correctly Use a spacer when using an MDI correctly a max of 15% of the drug enters the lung. With a spacer this can be increased up to 30% Use an ICS patient safety card

49. What are we trying to achieve? Maximise value Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

50. The challenge for the NHS is to get more for less in an era of “no more money”. To do this, the NHS needs to shift from lower value interventions to higher value interventions

51. Right Care “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  Do the right thing  Do the right thing right  Doing the right thing right first time should deliver quality and value

52. Telehealth £92000/ QALY Triple Therapy £7000- £187000/QALY Long term Oxygen Therapy £11-16000/QALY LABA £5-8000/QALY Tiotropium/LAMA £7000/QALY Pulmonary Rehabilitation £2000-8000/QALY Stop Smoking Support with pharmacotherapy £2000/QALY Flu vaccination? £1000/QALY in “at risk” population COPD Value Pyramid (from London RespiratoryTeam) Cost per QALY* *Quality Adjusted Life Year

53. Responsible Prescribing in COPD (old messages) South East Coast Principles Do the right things: Smoking cessation is the most effective intervention for COPD Pulmonary rehabilitation reduces admissions and health care resource use, improves exercise capacity and health related quality of life Prescribe according to guidelines Do the right things right: Ensure correct inhaler technique most patients don’t know how to use their inhaler and many health care professionals who teach the use of MDI cannot demonstrate it correctly Use a spacer when using an MDI correctly a max of 15% of the drug enters the lung. With a spacer this can be increased up to 30% Use an ICS patient safety card

55. Asthma – potential RRP messages Do the right things: Smoking cessation is the most effective intervention for COPD Personalised asthma action plans improve outcomes and may reduce readmission rates Do the right things right: Titrate dose of inhaled preventative therapy to optimise asthma control and minimise risk of side effects Know the equivalent dose of ICS when changing to a combination inhaler Check adherence to and use of preventer and reliever therapy, to identify patients at risk of severe exacerbations Use an ICS patient safety card

56. COPD – potential RRP messages Do the right things: Smoking cessation is the most effective intervention for COPD Flu vaccination reduces the risk of COPD exacerbations Pulmonary rehabilitation reduces admissions and health care resource use, improves exercise capacity and health related quality of life Prescribe according to guidelines Provide individualised self management plan and exacerbation rescue pack, to patients with COPD exacerbations Do the right things right: Encourage a trial of therapy, if it does not work don’t be afraid to stop it Use an ICS patient safety card for patients on high dose ICS Reserve ICS for more severe COPD and frequent exacerbations to minimise risk of harm and optimise benefit

57. Inhalers - – potential RRP messages Do the right things: With the patient, decide the best device for them assess their ability to inhale, let them see, touch and feel the inhaler, then describe, show and provide written information Do the right things right: Ensure correct inhaler technique most patients don’t know how to use their inhaler and many health care professionals who teach the use of MDI cannot demonstrate it correctly Use a spacer when using an MDI correctly a max of 15% of the drug enters the lung. With a spacer this can be increased up to 30% Prescribe inhalers by brand, so patient receives correct inhaler device Rationalise inhaler devices for an individual patient, avoid mixing too many DPI devices (check evidence) Re-check inhaler technique often, inhaler technique deteriorates over time, and lots of patients think they are using their inhalers correctly when they are not

58. Updating messages Do we have any new evidence / important issues in practice to include? Do we need separate messages for asthma and COPD? Messages need to be relevant and valid How should they be presented? What do you think?