Download LRT Stop smoking as treatment

Stop Smoking as Treatment
Noel Baxter and Louise Restrick
Stop smoking as treatment workstream
2010-2013
COPD in London: What do we know?
COPD Mortality
COPD in London: What do we know?
Londoners dying from smoking
‘1 in 5 deaths due to
smoking’
Is current smoking an issue in COPD?
TORCH, Uplift and POET-COPD Studies
Is current smoking an issue in COPD?
2010 ERS Audit
NEJM 3: 2012
% COPD registered patients who smoke (if their smoking
status is recorded)
0
Kingston PCT
Richmond And…
Barnet PCT
Havering PCT
Harrow PCT
Redbridge PCT
Haringey Teaching PCT
Hillingdon PCT
Bexley Care Trust
Bromley PCT
Waltham Forest PCT
Sutton And Merton…
Croydon PCT
Ealing PCT
Westminster PCT
Enfield PCT
Brent Teaching PCT
Kensington And…
Hounslow PCT
Wandsworth PCT
Camden PCT
Greenwich Teaching…
Hammersmith And…
Lambeth PCT
Newham PCT
Tower Hamlets PCT
Islington PCT
Lewisham PCT
City And Hackney…
Southwark PCT
LONDON
ENGLAND
What is the prevalence of smoking in London
in people with COPD?
London PCTs 2005-06 QOF
100
90
80
70
60
50
40
30
20
10
So do we know what the extent of the problem is?
…Yes in Tower Hamlets
Confirmed COPD registered patients that are current smokers
50.00%
45.00%
40%
40.00%
%age of patients
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Network 1
Network 2
Network 3
Network 4
Network 5
Network 6
Network 7
Network 8
Borough Total
April
39.08%
41.02%
32.35%
34.00%
38.87%
42.86%
38.63%
43.06%
38.76%
May
41.13%
40.68%
32.84%
34.41%
39.09%
43.09%
38.72%
43.36%
39.11%
June
41.11%
40.96%
31.73%
33.41%
37.94%
42.91%
39.11%
43.49%
38.84%
July
41.18%
41.71%
33.65%
33.41%
38.96%
40.82%
38.87%
43.20%
38.98%
August
40.20%
41.92%
33.96%
33.33%
38.31%
41.87%
39.12%
43.33%
39.00%
September
38.87%
42.03%
33.18%
34.73%
41.71%
43.15%
38.88%
43.85%
39.64%
And in Southwark in 2013
Prevalence of current
smoking where status
recorded in last 15 months
1550/3335 = 46.5%
COPD smokers in last year receiving evidence based stop smoking
support – 17.5%
What treatment reduces lung decline in
COPD?
Fletcher and Peto British Medical Journal 1977
Effect of Smoking Cessation Intervention on
Mortality in COPD
Randomised
Clinical Trial
5887 people
with airway obstruction
over 14.5 years
Anthonisen NR, Skeans MA , Wise RA; Manfreda J, Kanner RE & Connett JE for the Lung Health Study Research Group*
Ann Intern Med. 2005;142:233-239.
What treatment for COPD is highly cost
effective the more you do?
1 year abstinence
%
QALY
£
Usual care
1.4
Minimal counselling
2.6
14,735
Intensive counselling
6
7,149
Intensive counselling +
pharmacotherapy
12.3
2,092
Systematic Review of 9 studies Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH.
Thorax 2010: 65:711-718
We know what stop smoking interventions are good
value – when they are done in the right way
Triple Therapy
£35,000£187,000/QALY
LABA
£8,000/QALY
Tiotropium
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £1,000/QALY in “at risk” population
This is how it really looks
Its not just COPD but COPD is a good
marker for sick smokers?
We need to change how we think
about smoking
Do we have a blind spot for sick smoker
treatment opportunities?
Changing how we think about smoking
Supporting smokers who have COPD (or asthma
or….) is their number one TREATMENT
Sick smokers are admitted to hospital
Smoking is tobacco addiction
Evidence based quit smoking treatment is the most important
treatment for sick smokers:
Behaviour change support and quit smoking medication
‘Smoking kills, stopping works’
Sir Richard Peto 2012
Is Very Brief Advice happening for
every smoker?
Online training module
WWW.NCSCT.CO.UK/VBA
‘This training is relevant to anyone who comes into
contact with smokers… GPs, practice nurses, hospital
doctors, pharmacists & other healthcare professionals.
… certificate on successful completion to provide
evidence of continuing professional development
(CPD).’
Do you have and use or commission
behaviour change skills to support
smokers to stop?
Are your staff able, & confident to,
prescribe Quit Smoking medication?
Does your hospital provide nicotine
replacement therapy routinely on
admission for smokers?
Mean age 57 years
Mean FEV1 2.3 L (70% predicted)
40 pack-years
High nicotine dependence
80% previous serious quit attempt
Varenincline and support
Tashkin et al, Chest 2011: 139:591-599
Even those with severe disease
~500 smokers with severe COPD
Mean age 58 years
60 pack-years of smoking
High nicotine dependence
10 intensive behavioral interventions with medication:
233 Nicotine Replacement Therapy & 190 Varenicline
48.5% abstinence at 6 months
61% with Varenicline and 44% with NRT
Safe
Jiminez Ruiz et al Nicotine and Tobacco Research 2011
Even before that paper we knew
enough to proceed at a clinical level
‘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.’
NICE 2010
Varenicline
a4b2 neuronal nicotinic acetylcholine receptor partial agonist
Reduces craving
Reduces withdrawal
Reduces pleasure of smoking (prevents binding)
Costs £2 /day; £60/month12 week course ~ £160
… may need 24 weeks in COPD
Cheaper than ‘triple
therapy’ (inhalers!)
and …
higher value
7 days treatment July 2012
Where are the people?
Sick smokers in hospital beds
Smokers in mental health services
In prisons
Quietly stoical at home
Multiple prescriptions
Interventions based on local knowledge
http://www.londonhp.nhs.uk/wpcontent/uploads/2011/06/COPDprofile-Bromley.pdf
Are people with mental health problems
getting the treatment they need?
200 out-patients with SMI
• 60% current smokers (mean age 44)
• 23% COPD prevalence (self-reported)
• Only 36% reported having COPD treatment
Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psychiatry 2004;161:2317-2319 0
147 Medicaid patients with SMI
• 31% COPD prevalence; 50% as co-morbidity
• Annual costs for SMI and COPD were 4 x higher
• 45% (5/11) deaths due to respiratory disease
Jones DR, Macias C, Barreira PJ et al Psychiatric Services 2004;55:1250-1257
Smoking prevalence & tobacco dependence
in people with mental illnesses
Very high smoking prevalence
%
(>20 cigarettes/day)
50%
of smokers
heavy
smokers
30% of smokers
heavy
smokers
Adults
21% smokers
9% heavy
smokers
Inpatients
with serious
mental
illness
People
living
with mental
illnesses
O’Brien et al 2002, Farrell et al 2001
High prevalence of severe tobacco
dependence
Just like our smokers
with COPD …
COPD, smoking and outcomes for
people with mental illness
‘People with mental health problems … die on
average 16-25 years sooner than the general
population.
… have higher rates of respiratory,
cardiovascular & infectious disease...’
‘Increased smoking is responsible for most of
the excess mortality of people with severe
mental health problems.
Adults with mental health problems …. smoke
42%* of all tobacco in England.
Very high prevalence of cannabis smoking too
* not including mental health settings, prisons, homeless or temp housing
Do people with mental illnesses get the
right COPD treatment?
Population
5 year COPD mortality
Schizophrenia
Bipolar disease
Age adjusted population
28%
19%
12%
Five year mortality for respiratory disease much higher in
people with mental illness
At least 1 in 4 deaths in people with mental illnesses due to
respiratory disease
Hippisley-Cox J et al . Health outcomes for patients with serious mental health problems: 2nd report to the DRC 2006
Joukamaa et al British Journal of Psychiatry 2006:188;122-127, Jones D et al Psychiatric Services 2004;55:1250-1257
www.rcpsych.ac.uk/pdf/No%20Health%20-%20%20the%20evidence_%20revised%20May%2010.pdf
Smoking prevalence
> 40%
prevalence
…in people with
mental illnesses
2004
> 70%
prevalence
…in people living in mental
health institutions
Do people with mental illnesses want
to stop smoking?
70% of smokers
want to stop
>50% of smokers
with mental illness
also want to stop
Clearing the Air. King’s Fund 2006
Do quit smoking interventions work for
people with mental illnesses?
Addiction 2010;105:1176-118
2011
Cost-effectiveness studies?
Do we support people with mental illnesses to
stop smoking (in London)?
Data courtesy of Dr Lisa McNally, NHS Surrey and Lead Smoke Free Minds
Changing how we think about smoking
in mental health settings?
Treating tobacco dependence is effective in SMI
Same treatments work as for anyone else
Treatment does NOT worsen mental state
‘Attitudes and therapeutic actions of mental health
professionals must also be taken into consideration…’
Banham L, Gilbody S. Addiction 2010;105:1176-118
Do mental health care professionals
believe this?
‘Unfortunately, no ready-made interventions exist to
address this problem, because tobacco addiction has
an illness-related aetiology and smoking cessation
may elevate psychiatric symptoms.’
Jones et al. Psychiatric Services 2004
‘Some practitioners expressed doubt
about the value of smoking
cessation advice for people with
mental health conditions’.
The case for change …
Getting COPD Care and stop smoking
interventions right for people with
mental illnesses
Respiratory
& GP
Services
Mental
Health
Services
Druug
Dependency
Services
Stop
Smoking
Services
Getting COPD Care and stop smoking
interventions right for people with
mental illnesses
Respiratory
Nurse
Specialist
Mental
Health Key
Worker
Respiratory Physician
Quit
Smoking
Advisor
So if we dealt with smoking in physical
and mental illness patients would it
tackle….
• Premature mortality
• Optimising bed days
• Waste – human spirit, staff resources,
time, prescriptions
What does smoking cost?
£2.7 billion a year spent on treating smoking related illness
‘ … less than £150 million spent on smoking cessation …’
5% of the NHS 'smoking' budget is currently
spent on quit smoking support …
Why does COPD matter?
•
•
•
•
Costs to patients
Costs to health service
It can be treated
Treatment alters outcomes
We know how to allocate resource at
population level
http://www.impressresp.com/index.php?option=c
om_content&view=article&id=167:impressions-28relative-value-of-copdinterventions&catid=11:impressions&Itemid=3
Effect of smoking on hospital
admissions for COPD
For every 1% increase in prevalence of smoking
in your COPD population there is a 1%
increase in COPD admission rates.
Do you as a commissioner believe that Quit
Smoking treatment is high value for patients
and staff?
Do you as a hospital decision maker believe
that Quit Smoking treatment is high value for
patients and staff?
Do you as a health professional believe that
Quit Smoking treatment is high value for your
patient?
Fall in children's
asthma
admissions
equivalent to
6802 fewer
hospital
admissions in 3
years after
smoking ban
.http://pediatrics
.aappublications.
org/content/earl
y/2013/01/15/pe
ds.20122592.abstract …
Supporting
sick smokers:
CQUIN,
NRT, stop smoking
champions
Its not just about
prevention….
Where does the
clinical
commissioner
come in?
Primary care management
of tobacco dependence and
long term conditions,
ongoing, sustained, LES,
QOF
http://jpubhealth.oxfordjou
rnals.org/content/34/1/37.l
ong 200 public health
interventions analysed for
cost-effectiveness 15% were
cost -saving 85% were
under 20k per QALY
Does your hospital have incentives
for Quit Smoking as treatment?
The case for a COPD discharge bundle CQUIN in London: recommendation of London
Respiratory Team, implementing the national strategy for COPD
Why COPD in London?
London spends over £100m on COPD per year
with an average of £5000 per year per
inpatient. There is an admission rate of 140
per 1000 patients on the QOF registers across
London. In Q1 2009/10 COPD was the second
highest cause of emergency admission. In
2008-09 the total number of bed for emergency
hospital admissions for COPD as a primary
diagnosis was 91,140. Average length of stay
in London is 6.8 days ranging from 8.0 in
Havering to 4.7 in Kensington and Chelsea.
Nationally 15% of patients admitted to hospital
with COPD die within 3 months and a quarter
die within a year of admission. It is this
significant unwarranted variation and use of
urgent care which the consultative national
strategy (“the Strategy”) aims to address and
which the NHS London Respiratory programme
intends to reduce in London.
Why discharge?
Admitted patients are the most needy and
vulnerable group of COPD patients and need
the application of evidence-based care to
improve their quality of life and reduce
readmission. Patients discharged from hospital
following an exacerbation of COPD have high
levels of depression (64%) and anxiety (40%)
and uncertainty that drives help seeking
behaviour. Therefore there is a need for
significantly improved hospital discharge
procedures that can then be picked up by the
community services through the provision of
the services the patient is assessed for in
hospital such as stop smoking; pulmonary
rehabilitation and encouragement of self1i
management strategies . This is reinforced in
the Strategy.
Why a bundle approach?
The Strategy includes a number of evidencebased recommendations. The bundle
incorporates the important ones to improve
patient safety and quality of care by acute
trusts. These bundles are already in use in four
London acute trusts: Imperial, Chelsea and
Westminster, North West London and St
Georges following a systematic literature
review by CLAHRC. The bundle should be
used and applied to every patient admitted with
a primary diagnosis of an acute COPD
exacerbation whether on a respiratory ward or
acute medical assessment unit or other
medical wards. It should be personalised to the
individual – not all components are needed for
1
Gruffydd-Jones K et al. What are the needs of
patients following discharge from hospital after an
acute exacerbation of chronic obstructive pulmonary
disease (COPD)? Prim Care Resp J
2007;16(6):363-368.
everyone. In this way it has the power to
change clinical behaviour and achieve
sustainable change. It is simple to use.
Why a CQUIN?
2
The bundle is a major step-up in care, but
will only have a meaningful impact if it is
implemented across a trust, requiring clinical
leadership and management intervention. The
CQUIN provides the right incentive to prioritise
this. It is also a light-touch approach as it
incentivises improvements in at least five
evidence-based interventions. And whilst the
ultimate aim is to keep people out of hospital
as much as possible, hospitals will continue t
care for many people with COPD because it is
a progressive, terminal disease that can cause
frightening breathlessness and also because
there remain many undiagnosed people living
in the community. Therefore a hospital CQUIN
is valid.
What is the bundle proposed?
(i) Referral to smoking cessation service if a
current smoker; (ii) Assessment of suitability
and/or enrolment into a pulmonary
rehabilitation programme; (iii) Have appropriate
education, written information, self
management plans and rescue packs for future
exacerbations; (iv) Ensure that patient
understands their medications and have
demonstrated good inhaler technique whilst on
the wards; (v) Ensure that they have
appropriate follow up once discharged from
hospital. These five elements are included in
a checklist – see appendix. The checklist can
be printed onto sticky labels that can be stuck
into the person’s notes, completed by the
clinician – eg the respiratory nurse specialist,
before discharge and easily located by the
coder.
Numerator: Number of patients admitted with
HRG code DZ21A-K as primary diagnosis and
are discharged with a completed care bundle
Denominator: Number of patients admitted
with HRG code DZ21A-K as primary diagnosis
Payment threshold: 75% in year one 2011/12
and 95% in year two 2012/13.
The bundle can be altered for local usage and
can be updated into a collection tool with ease.
Appendices include example of patient
checklist, and also clinician checklist
2
this is an NINR CLAHRC for NW London
development
Different tariffs for different problems 2013-14 (* nonmandatory)
1st
single
Respiratory
189
medicine OP
COPD or bronchitis
with NIV without
intubation with CC
emergency
admission
Stop smoking West General
pop’n
Midlands (2012no Rx
13*)
1st
multi
245
FU
single
104
FU multi Non face
to face*
145
Target
ed
pop’n
no Rx
General Targeted
pop’n
pop’n
with Rx with Rx
(4 week quitter
94
136
166
214)
12 week quitter –
verified in primary
care
129
271
228
427
Spell
Trimpoint
(days)
2771
24
23
What commissioning for sick
smokers could provide
• A full complement of NICE-recommended
pharmacotherapy’s
• A fulltime stop smoking specialist (Band 7 or above) with
further trained dedicated stop smoking staff
• A robust data collection and referral system with linkage to
other providers
• Stop smoking clinics led by clinical specialists
• A mandatory training program for all health professionals
• Mandatory recording of smoking status, stop smoking
interventions on discharge summaries and inclusion of
smoking on death certificates for patients where smoking
contributed to long term illness and/or directly to death
• Clinician led hospital or other provider stop smoking steering
group
Do you have a Quit Smoking service for
patients and staff in your service?
•
•
•
Services Offered:
Outpatient Quit Smoking Clinics: for patients and staff
Inpatient Assessment for Quit Smoking Support
Special Clinics – Pre-operative Assessment & Maternity
Support for smokers to quit
Do your staff know your Quit Smoking
advisors and refer to your Service?
Does your hospital have a BTS Quit Smoking
Champion lead (/consultant Quit Smoking
clinical lead)?
Are we supporting sick smokers
with COPD to stop during hospital admission?
ERS Audit
2010
Offered NRT
NRT
prescribed
SCS offered
SCS referral
made
Smokers
n=16
Smokers on
Respiratory Ward
n=9
Smokers on
other Wards
n=7
Are we supporting sick smokers
with COPD to stop during hospital admission?
ERS Audit
2010
Smokers
Offered NRT
12
(75%)
8
(50%)
11
(69%)
7
(44%)
NRT
prescribed
SCS offered
SCS referral
made
n=16
Smokers on
Respiratory Ward
n=9
Smokers on
other Wards
n=7
Are we supporting sick smokers
with COPD to stop during hospital admission?
ERS Audit
2010
Smokers
Offered NRT
12
(75%)
8
(50%)
11
(69%)
7
(44%)
NRT
prescribed
SCS offered
SCS referral
made
n=16
Smokers on
Respiratory Ward
n=9
Smokers on
other Wards
n=7
9/9
3/7
6/9
2/7
7/9
4/7
4/9
3/7
What should we do for sick smokers
during hospital admission?
NEJM 3: 2012
Using Motivational Interviewing with
tobacco dependent smokers with COPD
How important is it to you to stop smoking?
On a scale of 0-10 where 0 is not at all
important and 10 is very important.’
‘How confident are you that you can stop
smoking?
On a scale of 0-10 where 0 is not confident at
all and 10 is completely confident.’
‘20/4/2012
9/10 importance and 6/10 confidence’
Building a Quit Smoking as
Treatment Service
Respiratory clinical leadership > 10 years
BTS Quit smoking champion > 5 years
Quit smoking advisor in hospital > 5 years
Smoking addressed on post-take ward rounds >
5 years
NRT ‘offered’ to all smokers admitted ~ 5 years
NRT available on all medical wards ~ 3 years