Understanding respiratory spend and increasing value: Inhalers and nicotine replacement therapy

1. Responsible Respiratory Prescribing Understanding respiratory spend and increasing value: Inhalers and nicotine replacement therapy Dr Louise Restrick on behalf of the London Respiratory Team

2. Right Care Respiratory Prescribing NICE 2010 • ‘Ensure all patients with COPD are on the appropriate therapy for the severity of, and symptoms from, their disease.’ • ‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’

3. Total cost of Respiratory Medication by BNF Chapters 2008 and 2009 for England £ millions ~£1 billion on respiratory medication not including antibiotics… Source: NHS Information Centre

4. Volume of Respiratory Medication by BNF Chapters 2008 and 2009 for England Number of prescriptions (millions) but a relatively low volume of respiratory prescriptions ... Source: NHS Information Centre

5. Item cost of Respiratory Medication by BNF Chapters 2008 and 2009 in EnglandAverage net ingredient cost per prescription item £ Respiratory items are the most expensive category of item prescribed ..... …… inhalers Source: NHS Information Centre

6. NHS budget & respiratory meds • Seretide (all) is the most expensive drug • Seretide 250 Evohaler is the most expensive individual item (second is atorvastatin) • Symbicort 200 is 5th most expensive item Of the top 5 costliest drugs to the NHS currently 3 are inhalers Source: NHS Information Centre

7. Long-term effectiveness & cost-effectiveness of smoking cessation interventions in patients with COPD Tiotropium £7,112/QUALY Eur J Health Econ. 2007; 8(2): 123135 Pulmonary Rehabilitation £2,000-8,000/QALY Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65:711-718

8. Smoking prevalence in COPD At best one in four Londoners with COPD are still smokers….

9. Smoking prevalence in COPD

10. Smoking prevalence in COPD

11. Best value from inhaled therapy Right care prescribing • Smokers offered support to stop smoking and prescribed NRT therapy each time inhalers prescribed….. • Use NICE criteria • No new inhaler without patient-centred education, training and review • Mechanisms for reducing duplicate prescribing • Steroid cards for high dose ICS/combinations

12. Best value from inhaled therapy Working with patients … • Support and pharmacotherapy to stop smoking • Each patient has and uses • inhaler devices that work for them • MDI with spacer or DPI • right technique for drug delivery into the lung • inhaler regime as prescribed for evidence-based benefit

13. Responsible Respiratory Prescribing Are we providing Right Care? Are commissioners, prescribers and patients getting best value from our inhaler spend? Do we have and use integrated quit smoking systems so that our respiratory patients have the best chances of quitting smoking? Clinical Lead Responsible Respiratory Prescribing, Dr Vince Mak, Respiratory Physician Clinical Lead Quit Smoking as treatment for COPD, Dr Noel Baxter GP