1. Responsible Respiratory Prescribing
Dr Louise Restrick* and Dr Chris Cooper London Respiratory Team
NHS Islington and Whittington Health*

2. NHS London Respiratory Team
Aim is to improve the experience of Londoners with COPD and reduce the impact of the disease
Funded by DH
Clinically-led multi-disciplinary team ( day/week)
Community and hospital health professionals
Patient/carer voice

3. Cost of delivering Outcomes
Value Framework
Health Outcomes
Patient defined
bundle of care
Value =
Health Outcomes
Cost of delivering Outcomes
Cost
Porter ME; Lee TH NEJM 2010;363: ;

4. Right Care Respiratory Priorities
Quit smoking support and therapy as treatment for COPD (and asthma)
Responsible Respiratory Prescribing …
… of Medicines and Oxygen
Pulmonary Rehabilitation

5. COPD ‘Value’ Pyramid What we know…. Cost/QALY
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

6. NICE Respiratory Prescribing
‘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.’
Seem to be three key issues we need to address: 1. Cultural change so that clinicians believe that supporting patients to stop smoking is a treatment they should be delivering NOT a lifestyle choice.
2. Equipping clinicians with motivational interviewing skills to support behaviour change rather than the ‘you must stop smoking’ approach.
3. Providing clinicians with prescribing knowledge on nicotine replacement, varenicline and bupropion. These are relatively new products and have been seen to be the business of stop smoking services rather than all clinicians who look after patients with COPD.

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

11. Price per puff of inhaled therapy

12. COPD ‘Value’ Pyramid What we know…. Cost/QALY
Triple Therapy
£35,000-£187,000
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

13. London Combination Inhaler Prescribing

14. 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 increases deposition to 30%
*Thorax 2010;65:A117

15. Responsible Respiratory Prescribing Best value from inhaled therapy
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

16. X Responsible Respiratory Prescribing Best 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

17. Right Care for COPD
Doing the Right Thing – what is evidenced based and cost effective?
Encourage Responsible Prescribing
Supporting patients to stop smoking as a priority when seeing patients with respiratory symptoms
Ensure that all eligible patients are referred for pulmonary rehabilitation
Source: NHS Information Centre

18. Mechanisms to support Responsible Respiratory Prescribing
QOF Medicines management M6,10,11-12
QOF Quality & productivity:QP1-5
Medicines Audits
COPD Guidelines
COPD Local Enhanced Service (LES)
Systems solutions
Prescribing Incentives/Commissioning for Quality Schemes

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

21. Increasing value from prescribing systems

22. Right Care, Value and QIPP in COPD
Doing the right things
Helping people to stop smoking
Helping people complete pulmonary rehabilitation
Helping people get the right medicines
And doing the right things right
Intensive stop smoking counselling + drugs
The right PR programme in the right place
The right inhaler and the correct technique

23. 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, ensure that the patient is issued with an inhaled steroid safety card
7.      No Prednisolone EC prescribing without good clinical reason