Download Andy Cooke - Respiratory Futures

Strategies to optimise the
use of Respiratory Medicines
Andy Cooke MRPharmS
Assistant Director,
Head of Medicines Management
Medicines optimisation
‘Helping patients to
make the most of
medicines’
+𝑅𝒙 =
£500m
Principles of Medicines Optimisation
Putting the concept into reality
• Opportunities for medicines optimisation
within a patient pathway in a chronic long
term condition. Helping patients with their
medicines to improve their out comes
What we did
1.
2.
3.
4.
Audit and guidelines
Support for patients in care homes
Practice nurse-led stepping down (and off)
Community pharmacy support
Top 5 drug costs in Bedfordshire:
June 2012 - May 2013
1.
2.
3.
4.
5.
£2,911,942 Fluticasone Propionate (Inh)
£1,004,172 Tiotropium
£929,149 Pregabalin
£925,885 Budesonide
£730,392 Beclometasone Dipropionate
What opportunities are there to
support medicines optimisation for
patients with COPD?
COPD Pathway
Person with possible
COPD
Diagnosis
First Prescription
Manage stable COPD
Manage exacerbations
End of life care
Smoking cessation service
MUR – other possible causes
of symptoms?
Signposting
Advice at dispensing
NMS
Therapeutic guidelines
Patient information
Patient decision aids
Therapeutic guidelines
Repeat dispensing questions
MURs
Inhaler technique and ability
Patient support for adherence
Public health interventions
Access to medicines
Pharmaceutical advice – goal of
treatments, rationalising and deprescribing
Where are we?
Audit of COPD treatment in
Bedfordshire 2013
Linking the findings to a programme budget
and implementation of NICE CG 101
COPD audit:
Number of co-morbidities
33%
34%
no co-morbidities
1 co-morbidity
2 or more co-morbidities
33%
COPD Guidelines
• NICE Clinical Guidelines support a medicines
optimisation approach
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
But this is only one page
Inhalers prescribedICS alone
12%
14%
2%
LABA alone
LAMA alone
9%
ICS + LABA
ICS + LAMA
30%
LABA + LAMA
26%
2%
5%
ICS + LABA + LAMA
Not using
ICS/LABA/LAMA
Inhalers prescribed ICS alone
73% of COPD patients
prescribed Inhaled
Corticosteroids
14%
12%
2%
LABA alone
LAMA alone
9%
ICS + LABA
ICS + LAMA
30%
LABA + LAMA
26%
2%
5%
ICS + LABA + LAMA
Not using
ICS/LABA/LAMA
COPD ‘VALUE PYRAMID’
Triple
therapy
TIOTROPIUM
£35,000 £187,000 / QALY
£7.5K/QALY
LABA £5K/QALY
Pulmonary Rehabilitation
£2K-£8K/QALY
Stop smoking support with pharmacotherapy
£2K/QALY
Flu vaccination in “at risk” population £1K/QALY
30% of our patients with COPD on triple therapy
(range: 10% - 100%)
Source: London Respiratory Team
COPD “value” pyramid compared to drug spend
London Respiratory Team –
COPD “value” pyramid
2012/13 drug spend in BCCG
Triple
therapy
Triple therapy £3,574,435
£7k-£187k/
QALY
77,372 items
TIOTROPIUM
£8K/QALY
Tiotropium £982,026
28,019 items
LABA £5K/QALY
Pulmonary Rehabilitation
£2k-£8k/QALY
Pharmacotherapy and
stop smoking service
costs £905,761
17,737 nicotine
dependence items
Flu vaccination
£495,971
Stop smoking support with
pharmacotherapy £2k/QALY
Flu vaccination in “at risk” population
£1k/QALY
85,380 items
LABA
£197,222
6,222 items
How Many QALYS?
(boaec!)
Intervention and Spend
• Triple Therapy £3,574,435
• Tiotropium £982,026
• LABA £197,222
• stop smoking costs
£905,761
• Flu vaccination £495,971
Total =£6,155,415
Quality Adjusted Life YearS
19 -102
140
25
452
496
1,132 -1,215
NHS London Respiratory Team
Proportion of patients audited who have
received other interventions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Stop smoking
advice
Flu vaccination
Pneumococcal Weight in healthy
vaccination
range
Pulmonary
rehabilitation
+𝑅𝒙 =
Bedfordshire COPD Audit:
Assessment of inhaler technique
technique
not
assessed,
24%
technique
assessed
76%
Can health professionals demonstrate inhaler technique?
Baverstock M, et al. Thorax 2010;65:A117–A118
All 7 steps and correct
7% inspiratory flow
All 7 steps correct 23%
70% Incorrect technique
• 113 (75%) of the participants said they were involved in the teaching
of inhaler technique. Of these 113, only 11(9%) could demonstrate all
the recognised steps
Better use of inhalers
Improving the use of inhalers in care homes
• Hospital admissions prevented
• Antibiotic courses prevented
Bedfordshire Care Homes initiative
What else can we do?
Acute Management of Exacerbation
3%
2%
antibiotics only
steriods only
32%
antibiotics and steriods
63%
no standby supply of
steroids or antibiotics
issued
100%
90%
50%
40%
30%
20%
10%
0%
M ROAD SURGERY
ASHBURNHAM ROAD SURGERY
STREET SURGERY
CATER STREET SURGERY
M ROAD SURGERY
CLAPHAM ROAD SURGERY
ANFIELD SURGERY
CRANFIELD SURGERY
MEDICAL CENTRE
DE PARYS MEDICAL CENTRE
AVENUE SURGERY
GOLDINGTON AVENUE SURGERY
ON ROAD DR DAS
GOLDINGTON ROAD DR DAS
ROAD DR TOOVEY
GOLDINGTON ROAD DR TOOVEY
ARFORD SURGERY
GREAT BARFORD SURGERY
EDICAL PRACTICE
HARROLD MEDICAL PRACTICE
STREET SURGERY
KING STREET SURGERY
COURT SURGERY
KINGSBURY COURT SURGERY
E ROAD SURGERY
LANSDOWNE ROAD SURGERY
N ROAD SURGERY
LINDEN ROAD SURGERY
D HEALTH CENTRE
LONDON ROAD HEALTH CENTRE
BERLEY SURGERY
PEMBERLEY SURGERY
MEDICAL CENTRE
PRIORY MEDICAL CENTRE
TRE PARTNERSHIP
PUTNOE MEDICAL CENTRE PARTNERSHIP
K HEALTH CENTRE
QUEENS PARK HEALTH CENTRE
OTHSAY SURGERY
ROTHSAY SURGERY
E ROAD SURGERY
SHAKESPEARE ROAD SURGERY
BROOK SURGERY
SHARNBROOK SURGERY
MEDICAL CENTRE
SHORTSTOWN MEDICAL CENTRE
STREET SURGERY
ST. JOHN'S STREET SURGERY
Y LIVING CENTRE
WOOTTON VALE HEALTHY LIVING CENTRE
Bedford locality
Bedford locality
INGTON SURGERY
CADDINGTON SURGERY
N HILLS PRACTICE
CHILTERN HILLS PRACTICE
STGATE SURGERY
EASTGATE SURGERY
MEDICAL CENTRE
HOUGHTON REGIS MEDICAL CENTRE
Y ROAD SURGERY
KIRBY ROAD SURGERY
MEDICAL CENTRE
TODDINGTON MEDICAL CENTRE
STREET SURGERY
WEST STREET SURGERY
ATFIELD SURGERY
WHEATFIELD SURGERY
iltern Vale Locality
Chiltern Vale Locality
MEDICAL CENTRE
ARLESEY MEDICAL CENTRE
AND CARRAGHER
DR COLLINS AND CARRAGHER
LL AND PARTNERS
DR GLEDHILL AND PARTNERS
M AND PARTNERS
DR KIRKHAM AND PARTNERS
SANDS (POTTON)
GREENSANDS (POTTON)
MEDICAL CENTRE
IVEL MEDICAL CENTRE
CAL PARTNERSHIP LARKSFIELD SURGERY MEDICAL PARTNERSHIP
Y HEALTH CENTRE
SANDY HEALTH CENTRE
D HEALTH CENTRE
SHEFFORD HEALTH CENTRE
Ivel Valley Locality
Ivel Valley Locality
SON & PARTNERS
DR JL HENDERSON & PARTNERS
Y ROAD SURGERY
GROVEBURY ROAD SURGERY
N ROAD SURGERY
LEIGHTON ROAD SURGERY
HOUSE SURGERY
SALISBURY HOUSE SURGERY
n Buzzard Locality
Leigthon Buzzard Locality
MEDICAL CENTRE
ASPLANDS MEDICAL CENTRE
LAZE & PARTNERS
DR GLAZE & PARTNERS
LITWICK SURGERY
FLITWICK SURGERY
GERY (AMPTHILL)
GREENSAND SURGERY (AMPTHILL)
N CLOSE SURGERY
HOUGHTON CLOSE SURGERY
STREET SURGERY
OLIVER STREET SURGERY
WMB Locality
WMB Locality
Management of acute exacerbation by practice
Management of acute exacerbation by practice
80%
100%
70%
90%
60%
50%
80%
40%
30%
70%
20%
60%
10%
0%
antibiotics only
steriods only
antibiotics and steriods
no standby supply issued
BCCG Objectives
• Improve compliance with inhalers and
technique.
• Rescue medication issued to appropriate
patients
• Reduce use of high dose ICS inhalers for safety
and cost-effectiveness.
• Improve patient outcomes
BCCG high dose ICS inhalers as a % of all
ICS inhalers (including combination)
Who are you going to call?
First prescription: New Medicines
Service (NMS)
Four conditions/therapy areas were selected to
be included in the initial rollout of the NMS.
These are:
• asthma and COPD
• type 2 diabetes
• antiplatelet/anticoagulant therapy
• hypertension
New Medicines Service (NMS)
PSNC Website – accessed July 2013
• improve patient adherence which will generally
lead to better health outcomes
• increase patient engagement with their condition and
medicines, supporting patients in making
decisions about their treatment and selfmanagement
• reduce medicines wastage
• reduce hospital admissions due to adverse
events from medicines
Stable COPD: Medicines Use
Review (MUR)
PSNC website accessed July 2013
Establish the patient’s actual use, understanding and experience
of taking all their medicines; identifying, discussing and
assisting in the resolution of poor or ineffective use of
drugs by the patient; identifying side-effects and drug
interactions that may affect the patient’s compliance with
instructions given to him/her; and improving the clinical
and cost-effectiveness of drugs prescribed to patients
thereby reducing the wastage of such drugs.
Medicines Use Review (MUR)
PSNC Website – accessed February 2015
National target groups for MURs
The national target groups are:
1.patients taking high risk medicines;
2.patients recently discharged from hospital who had changes made to their
medicines while they were in hospital. Ideally patients discharged from hospital with
receive an MUR within four weeks of discharge but in certain circumstances the MUR
can take place within eight weeks of discharge;
3.patients with respiratory disease; and
4.patients at risk of or diagnosed with cardiovascular disease and regularly being
prescribed at least four medicines.
At least 70% of all MURs undertaken by each pharmacy
from 1st April 2015 should be on patients within the
national target groups.
.
Palliative care
NICE CG101
Palliative care depends on good understanding of patients’:
- Perception of their quality of life
- Satisfaction with current functioning
- Expectations
Opioids, benzodiazepines, tricyclic antidepressants, major
tranquilisers and oxygen can be used for the palliation of
breathlessness in patients with end stage COPD unresponsive to
other medical therapy
Opportunities for medicines optimisation
Summary – Medicines Optimisation
• Identify medicines optimisation opportunities (every
possible contact)
• Focus on ‘Can you? Do you?’ at least as much as the
choice of inhaled medicine
• Employ shared decision making
• Stepping down (and off) ICS is possible
• Maximise existing interventional opportunities
• Help patients make the most of their medicines as part
of routine practice every day
Next Steps?
What will you do to make a change?