1. Medicines optimisation can help reduce COPD related hospital admissions and exacerbations - LCH MMT Approach
Alison McMinn Respiratory Lead Pharmacist MMT, Liverpool Community Health (LCH)

2. Objectives of the session
Brief overview of COPD
Medicines Optimisation
Liverpool priority
Process
Outcomes
Lessons Learnt along the way

3. Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease
Implementing NICE guidance
This slide set was amended in April 2012 and now includes information about the National Prescribing Centre resources. The NICE guideline has not changed.
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on ‘Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care’ (partial update). This guideline has been written for all healthcare professionals, people with COPD and their carers, patient support groups, commissioning organisations and service providers.
The development of this guideline has updated sections of NICE clinical guideline 12 (published February 2004). Other recommendations from 2004 remain appropriate and form part of the new comprehensive guideline. New or updated recommendations have been made for spirometry, assessment of prognostic factors, and to the section on inhaled therapy (which now incorporates the previously separate sections on inhaled bronchodilators, inhaled corticosteroids and inhaled combination therapy).
In this presentation and in the NICE guideline, recommendations are marked as following:
[2004] indicates the evidence has not been updated and reviewed since the original guideline.
[2007] applies to two specific recommendations that were developed as part of a technology appraisal in 2007.
[2010] indicates that the evidence has been reviewed but no change has been made to the recommendation.
[new 2010] indicates that the evidence has been reviewed and the recommendation has been updated or added.
The guideline is available in a number of formats, including a quick reference guide, which can be viewed at
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
NICE clinical guideline 101

4. Epidemiology1
About 3 million people have chronic obstructive pulmonary disease (COPD) in the UK
Nearly 900,000 people in England and Wales are diagnosed as having COPD and an estimated 2 million people have COPD which remains undiagnosed
Most patients are not diagnosed until they are in their fifties

5. Background1
COPD is predominantly caused by smoking and is characterised by airflow obstruction that: - is not fully reversible - does not change markedly over several months - is usually progressive in the long term
Exacerbations are commonly see, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations requiring a change in treatment

6. Definition of COPD1
Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7)
If FEV1 is ≥ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough
COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction.

7. Diagnose COPD1 Consider a diagnosis of COPD for people who are:
over 35, and
smokers or ex-smokers, and
have any of these symptoms:
- exertional breathlessness
- chronic cough
- regular sputum production,
frequent winter ‘bronchitis’
Wheeze

8. Diagnose COPD: assessment of severity1
Assess severity of airflow obstruction using reduction in FEV1
NICE clinical guideline 12 (2004)
ATS/ERS 2004
GOLD 2008
NICE clinical guideline 101 (2010)
Post-bronchodilator FEV1/FVC
FEV1 % predicted
Post-bronchodilator
< 0.7
80%
Mild
Stage 1 (mild)
Stage 1 (mild)*
50–79%
Moderate
Stage 2 (moderate)
30–49%
Severe
Stage 3 (severe)
< 30%
Very severe
Stage 4 (very severe)**
NOTES FOR PRESENTERS:
Key points to raise:
Disability in COPD can be poorly reflected in the FEV1. A more comprehensive assessment also includes:
- degree of airflow obstruction and disability
- frequency of exacerbations
- prognostic factors such as breathlessness (assessed using the Medical Research Council [MRC] scale), carbon monoxide lung transfer factor [TLCO], health status, exercise capacity, BMI, partial pressure of oxygen in arterial blood [PaO2] and cor pulmonale. [adapted from ]
Investigate symptoms that seem disproportionate to the spirometric impairment using a CT scan or TLCO testing.
Calculate the BODE index (BMI, airflow obstruction, dyspnoea and exercise capacity) to assess prognosis (where the component information is currently available).
Assess severity of airflow using the table on the slide.
Recommendation in full:
The severity of airflow obstruction should be assessed according to the reduction in FEV1 as shown in table on the slide [ ]
Abbreviations:
ATS, American Thoracic Society; ERS, European Respiratory Society; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease
References :
Quanjer PH, Tammeling GJ, Cotes et al. (1993) Lung Volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. European Respiratory Journal (Suppl) 16:5-40.
Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position Paper. European Respiratory Journal 23(6):
Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
* Symptoms should be present to diagnose COPD in people with mild airflow obstruction
** Or FEV1 < 50% with respiratory failure

9. Managing stable COPD: inhaled therapies1
NOTES FOR PRESENTERS:
This slide shows the treatment algorithm included within the full guideline (Algorithm 2a) and is reproduced on page 9 of the QRG.
On pages 12 and 13 of the QRG there is also find a useful table which summarises the recommendations for managing symptoms and conditions in stable COPD.

12. COPD Management1 Smoking Cessation Vaccination Accurate diagnosis
Accredited post bronchodilator spirometry
Pulmonary Rehabilitation
Breathlessness management
Other symptoms
Anxiety Management
Low BMI
Low oxygen saturations (<92%)
Palliative Care

13. Two main clinical priorities…
Reduce Exacerbations
Reduce Breathlessness

14. Managing exacerbations1
Minimise impact of exacerbations by:-
giving self-management advice on responding promptly to symptoms of exacerbation
starting appropriate treatment with oral steroids and/or antibiotics – (Rescue Pack – 8bmw)
use of non-invasive ventilation when indicated
use of hospital-at-home or assisted-discharge schemes
The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations

15. MRC Scale – Breathless score1
GRADE Degree of breathlessness related to activities
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when
walking at own pace.
4 Stops for breath after walking about 100m or after a few minutes on the level
5 Too breathless to leave the house, or breathless when dressing or undressing

16. CAT Score Read coded on clinical systems – 38Dg
Improvement of > 2 shows improvement in quality of life

17. Medicines Optimisation
Reduce Exacerbations and Admissions
Identify: All patients with ≥ 2 exacerbation or ≥ 1 admission in the last 12 months
Check inhaler technique, concordance prior to further optimisation
Consider rescue pack (8bmw)
Self Management Plan
Improve breathlessness
Identify: All patients with an MRC ≥ 3 and ensure their long acting bronchodilators are optimised
Check inhaler technique, concordance prior to further optimisation
Refer to pulmonary rehabilitation
Check pulse oximetry
Self Management Plan

18. Pharmacist Medicines Optimisation
COPD Medicines Optimisation
Inhaler Technique
Holistic Medication Review
Smoking Cessation
Pulse Oximetry (<92%)
Weight/BMI check
Depression Screening
MRC Score
Referral for Pulmonary Rehabilitation
Vaccination
Self Management Plan
Rescue Pack (8bmw)
Education
Follow up

19. Why was the management of COPD so important in Liverpool?

20. British Lung Foundation Liverpool PCO was ranked 3rd worst COPD ‘hotspot’ in the UK ‘People in Liverpool are 43% more likely to be admitted to hospital with COPD than the UK average”.

21. “Six Steps”* Accurate diagnosis Optimal stable management
Referral to Pulmonary Rehabilitation
Acute management
Oxygen assessment
End of life
*Devised by Steve Callaghan (formerly of Liverpool PCT)

22. North Mersey COPD QIPP
Overall Aim: Reduce non elective COPD admissions by 10%
3 Key priorities
Patient access to clinician at time of exacerbation (4hours)
Nursing team (redesign)
Optimisation of medication
In Liverpool the Medicines Management work was rolled out across the city

23. MMT Objectives Reduction in Admissions Reduction in Exacerbations
Pharmacist Medicines Optimisation
Patient Education and Self Management
Supporting Healthcare Professionals

24. How Practices where Selected?
Admission data was obtained & reviewed for all practices
The priority practices (based on actual admissions and practice need) were identified and MMT worked with each practice as per the 6 steps as a framework
MMT had a project lead & a clinical lead for the COPD optimisation work

25. How the MMT worked through the 6 steps
Band 4 - COPD register validation
Accredited post bronchodilator spirometry
Severity of COPD
Determine if under specialist respiratory team
Smoking Status
Housebound status

26. 26

27. How the MMT worked through the 6 steps
Band 6 registered pharmacy technician
Triaged all those patients with confirmed diagnosis
Identified patients that required ‘optimisation of medications’ if they had over a 12 month period 2 or more exacerbations or 1 or more hospital admissions
From April 2015, we are now also looking at MRC ≥ 3 and not on optimal bronchodilators
Identify & address any over ordering of respiratory medication (cost saving)

28. 28

29. Review Criteria Doctor
Consider Secondary Care/Case Management Referral
Palliative Care issues – end of life register
Differential diagnosis e.g. heart failure, anaemia
Nurse (from April Pharmacy Technician)
Nurse already has a rapport with the patient, so may find it easier to address concordance and inhaler technique issues
Developmental role for the technician and also a way of ensuring concordance checks have been reviewed
Pharmacist
Optimisation of COPD medications + full medication review

30. Triage for Review Triage for review GP Nurse /Technician Pharmacist
Prescribed Optimal Therapy
Medicines to be Optimised
Inhaler technique/ compliance to be checked
Unclear diagnosis/ referral GP
Nurse /Technician
Pharmacist

31. Pharmacist Medicines Optimisation Review

32. 32

33. 6 week and 12 month outcomes33

34. Lessons Learnt on our journey
Continuous need for education and training
Realistic goal Setting for patients
Telephone/Face to Face follow up after interventions
Outcomes – showcases the benefits of a pharmacy team
Multidisciplinary working
Improved engagement with neighbourhood working
Register Validation
‘Missing Millions’ – how MMT can help
Emis Web – advanced searches/reports

35. Outcomes

36. Total Results of Triage for 7884 patients across 52 practices

37. 12 month outcomes Exacerbation Data
Compare 12 month prior to the pharmacist review to 12 month post pharmacist review
Admission Data

38. Long Term Impact of Medicines Optimisation over 3 years
Admissions reduced from*
194 to % reduction
Exacerbations reduced from*
2620 to % reduction
* For the cohort of patients seen by a pharmacist

39. Long Term Impact in Liverpool
19% reduction in admissions since North Mersey QIPP 2010/11

40. Our Achievements Objective Outcomes Reduction in Admissions
36% Reduction (12 months post pharmacist review)
Reduction in Exacerbations
26% Reduction (12 months post pharmacist review)
Pharmacist Medicines Optimisation
1,004 patients
3125 Respiratory interventions
1622 Non-respiratory interventions
Patient Education and Self Management
Consultation and information
Self management/rescue pack
Supporting Healthcare Professionals
Development of local guidelines
Education/training/advice

41. “WIN WIN” Liverpool working together Consistent results
Holistic Approach
Quality of care for Patients
Innovative approach to service delivery
Prevention of COPD admissions and
exacerbations
Productivity - optimisation

43. References http://guidance.nice.org.uk/CG101
British Lung Foundation: Invisible Lives COPD – finding the missing millions (accessible via
COPD Guidelines