Responsible Respiratory Prescribing

1. Responsible Respiratory Prescribing Dr Vince Mak London Respiratory Team Clinical Lead Medicines Management Workstream May 2012

2. NHS London Respiratory Team Who are we? Aim is to improve the experience of Londoners with COPD and reduce the impact of the disease

3. What is the London Respiratory Team? Clinically-led multi-disciplinary team (Team Leader – Dr Louise Restrick, Consultant Physician Whittington) Community and hospital health professionals Patient/carer voice Project manager Funded by Department of Health NHS London Team

4. London Respiratory team approach: Strategy RIGHT CARE APPROACH • Doing the Right Thing • Doing the Right Things Right Identify priorities in delivering COPD Right Care in London Quality, innovation, performance, productivity and safety framework - QIPP

5. Value Framework Health Outcomes Patient defined bundle of care Value = Health Outcomes Cost of delivering Outcomes Cost Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

6. RIGHT CARE for COPD • Doing the Right Thing – what is cost effective? • Encourage Responsible Prescribing

7. Cost of Respiratory Medication by BNF Chapters ~£1 billion on respiratory medication not including antibiotics… Source: NHS Information Centre

8. Volume of Respiratory Medication but a relatively low volume of respiratory prescriptions ... Source: NHS Information Centre

9. Item cost of Respiratory Medication Respiratory items are the most expensive category of item prescribed ..... …inhalers Source: NHS Information Centre

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

15. Seretide (all) in London

16. Symbicort (all) in London

17. Seretide vs Symbicort

18. LRT - 7 Key Prescribing Messages 1.      Respiratory medications are expensive

19. RIGHT CARE for COPD • Doing the Right Thing – what is evidenced based and cost effective? • Stop smoking as a priority when seeing patients with respiratory symptoms

20. Smoking prevalence in COPD TORCH, Uplift Studies and …POET-COPD

21. What works long term and is cost effective? A cost effective intervention in COPD - Stopping Smoking Tiotropium QALY £7112 Eur J Health Econ. 2007 June; 8(2): 123135 Systematic Review of 9 studies Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH. Thorax 2010: 65:711-718

22. RIGHT CARE for COPD • Doing the Right Thing – what is evidenced based and cost effective? • Ensuring patients with COPD have access to Pulmonary Rehabilitation programmes.

23. High Value Care in COPD Pulmonary Rehabilitation

24. Value of Pulmonary Rehabilitation • Reduces admissions, improves exercise capacity, improves health related quality of life • Post exacerbation PR v effective in avoiding admissions • Numbers needed to Treat = 4 • The only intervention to date that has been shown to reduce the very high 3 month readmission rate seen in COPD (33% to 7%) • Only costs £2,000-£8,000/QALY • Puhan et al 2011 Cochrane Database of Systematic Reviews 2011 • Seymour et al Thorax 2010;65:423-428 doi:10.1136/thx.2009.124164

25. What is Pulmonary Rehabilitation? • 26 hours of contact with a respiratory specialist team • Appropriate for patients disabled by breathlessness – usually MRC 3-5, and some MRC 2 • Comprehensive, holistic assessment – 1.5 hours / patient • 6 weeks minimum, twice / week, 2 hours each session • Exercise and education • Effective post hospitalisation episode for COPD

26. Pulmonary Rehabilitation ‘Before pulmonary rehabilitation I wasn’t afraid to die I was afraid to live, … but after pulmonary rehabilitation I wasn’t afraid to live any more.’

27. COPD ‘Value’ PyramidWhat we know so far…. Cost/QALY 2010Value work now continued by IMPRESS www.impressresp.com • References: • J Epidemiol Community Health. 1998 Feb;52(2):120-5 £50 saving for over 65 • Thorax. 65(8):711-8,2010 Aug. • Thorax 2001;56:779-784 £0-1000 per QALY • Tiotropium in the treatment of COPD: Health technology Assessment KCE reports 108C Neyt M et al £7,456 per QALY • OBA Y Cost effectiveness of long acting bronchodilators for COPD. Mayo Clinic Proc 2007;82:575-582 £5,396 per QALY • CADTH. LABA plus Corticosteroids vs LABA alone for COPD. Issue 83 March 2007. Mayers I et al £130,000 per QALY and NICE COPD management of COPD in adults in primary and secondary care 2010 £131,000 per QALY

28. LRT - 7 Key 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.

29. 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 an increases deposition to 30% If used incorrectly – most of the drug from MDI is wasted – Seretide 250 is £60/month *Thorax 2010;65:A117

30. Doing the Right Things Right! Optimise use of inhaled medicines – Minimise Waste – Maximise safety • Each patient with COPD is using an inhaler device that works for them (MDI with spacer or DPI) • Each patient with COPD has learnt the right technique for drug delivery into the lung • Each patient with COPD uses their inhaled therapy regime as prescribed for evidence-based benefit • Each patient with COPD has safe inhaled therapy • ie minimum evidenced based dose of inhaled steroid for their stage of disease

31. Right Care respiratory prescribing Minimise waste – maximise value • Ensure patient centred education about the disease and medication from a competent trainer • Ensure compliance • Ensure correct technique …working with health professionals

32. LRT - 7 Key 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

33. Right Care respiratory prescribing Minimise risk – ensure safety When prescribing high dose inhaled corticosteroids (>1000ug BDP equivalent?), ensure that the patient is issued an inhaled steroid safety card (warning about pneumonia, increased risk of diabetes, reduced bone density and potential for adrenal suppression) …working with health professionals

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

35. Minimise Risk : Patient Safety • Warn about high dose ICS side effects: • Pneumonia • Diabetes • Bone Loss/ Fractures • Adrenal Suppression • In COPD – very high dose ICS (2000µg BDP equivalent) same clinical efficacy of moderate dose ICS (800µg 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 just 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.

36. Minimise Risk : Patient Safety 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

37. SIMPLE SWITCH Saves £40 million/year + Less waste caused by poor inhaler technique Fewer Exacerbations England – 2 million items/yr

38. SIMPLE SWITCH Saves £40 million/year + Less waste caused by poor inhaler technique Fewer Exacerbations England – 2 million items/yr

39. LRT - 7 Key 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

40. Responsible Respiratory PrescribingBest value from Prednisolone • No evidence that EC prednisolone tablets (red) result in fewer GI problems or protect against peptic ulceration • EC prednisolone costs 6-15 times more than plain prednisolone (white) • Switch from EC prednisolone to prednisolone could save £2 million per year in London X

41. LRT - 7 Key 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

42. DH – Outcomes Strategy – Companion Document

43. Responsible Respiratory Prescribing • Understand costs • Ensure optimal drug therapy for COPD/Asthma patients • Optimise use of prescribed therapy • Right care • Minimise waste • Maximise value • Minimise unwarranted variation Clinical Lead Dr Vince Mak, Respiratory Physician