REACTTO TO THE ASTHMA OUTCOMES STRAETGY & QIPP - AN ACTION PLAN. Tuesday, 10 th July 2012 The Holiday Inn Ipswich

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1 REACTTO TO THE ASTHMA OUTCOMES STRAETGY & QIPP - AN ACTION PLAN Tuesday, 10 th July 2012 The Holiday Inn Ipswich CHF0S d June 2012

2 Welcome & Introduction Professor Anthony Davison NHS Lung Improvement

3 Controlling Asthma Symptoms the View of a Person with Asthma Surayya Khan Asthma UK Volunteer

4 Are my symptoms controlled? My asthma history Triggers Allergy related Environment Infection Ups and downs Preventer / Reliever

5 Are my symptoms controlled? In conclusion 90% under control Trigger management Being self-aware Experience and advice Responding appropriately to that 10% (worsening symptoms)

6 What is the impact on my quality of life? Employment Activities Worry / anxiety Making adjustments / precautions Perceptions Symptoms not taken seriously Appropriate level of medication

7 How I need to improve my quality of life Self management what is needed to achieve this? Better access to healthcare services postcode lottery? what is available? More joined up approach recent repeat prescription experience

8 How I need to improve my quality of life Asthma UK peer support / helping others knowledge / empowerment Asthma reviews variability in practice Personal Asthma action Plan Asthma clinics / nurses

9 How I need to improve my quality of life

10 Controlling Asthma Symptoms the View of a Person with Asthma Thank you for listening. Adviceline:

11 Questions

12 An Outcome Strategy for Asthma A Round Table Discussion Professor Anthony Davison NHS Lung Improvement Dr Tim Howes Consultant Respiratory Physician, Colchester Rosie Newbigging Executive Director, Nations, Regions & Services Asthma UK Clive Johnstone Managing Director, MMS (Chair)

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15 Respiratory health and good lung health Early accurate diagnosis Active partnership between healthcare professionals and people with asthma Chronic disease management and Tailored evidence based treatment

16 Asthma car crash:collision of allergy and bronchial hyper-reactivity

17 Asthma phenotypes Early onset/ atopic High sputum eosinophils Increased hyper-reactivity More frequent exacerbations and need to use prednisolone Obese, mostly female Reduced sputum eosinophils Intermediate hyper-reactivity High level of symptoms Benign No airway inflammation Minimal hyper-reactivity Fewer exacerbations

18 Phenotype vs guidelines Asthma is a condition of complex phenotypes without a single well defined pathogenic process Classifications based on severity alone, reflect this poorly This is most important in those with severe or refractory disease where empirical treatment is less likely to work Addressing the pathological components of severe asthma may allow more directed and effective management.

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20 56 male mild asthma virus infection admitted as an emergency 2011 and ventilated on ICU had been poorly concordant with inhaled steroids Seen several times since Peak flow chart very good for 3-4 months Once again ran out of inhalers and had a moderate self limiting exacerbation Very apologetically turned up in outpatients Wife says I have to take inhalers IgE 15 negative skin/rast tests

21 30 year old female ECG technician in hospital Continuous severe symptoms Multiple allergies Very severe symptoms in pregnancy believed to have psychological overlay Multiple GP hospitals visits (weekly) very low peak flows IgE 32 Omalizumab completely resolved symptoms Peak flows

22 60 female 15 pack year smoker Rheumatoid arthritis Peak flow very symptomatic IgE 3 Minimal bronchiectasis on CT scan Neutrophils in sputum responds to IV aminophylline every 3 months or so oral steroid dependent (originally given for RA)

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24 Questions

25 Impact of BTS / Sign & NICE Guidelines on Asthma Dr Duncan Keeley PCRS-UK Executive

26 Conflicts of interest.. 0

27 I hope this short talk will.. Change clinicians practice Influence commissioners priorities Influence the work of the NICE Asthma Quality Standard Topic Expert Group Allow time for questions and discussion No pressure

28 Contents Why early accurate diagnosis is important Why stepping up and down treatment and regular reviews are vital When is an ICS/LABA combination appropriate and what are their benefits What clear markers are likely to be in the NICE Quality Standard for asthma

29 Early and accurate diagnosis is vital Diagnostic delay results in avoidable ill health and health care costs Diagnostic error can result in serious harm. Over-diagnosis results in potentially harmful unnecessary treatment Physiological confirmation of diagnosis by spirometry or PEFR monitoring should be documented ( age 7 +)

30 Getting the diagnosis right.. History Examination Physiological testing spirometry or PEFR Exclusion of alternative diagnoses CXR and other tests if necessary Trial of therapy Repeated clinical reassessment early on

31 What s this?

32 A bean

33 ADULT with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) Intermediate Probability High Probability Obstructive Normal FEV/FVC <70% FEV/FVC >70% Trial of Treatment Response? Yes No Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Asthma diagnosis confirmed Continue Rx Low Probability Investigate and treat alternative diagnosis Reconsider probable diagnosis Further investigation Response? No Yes Manage according to 33 alternative diagnosis

34 Asthma diagnosis using form FP1010 Available free from PCO s

35 A combined PEF chart and self management plan..

36 Regular review is vital.. Assess control and explore perceptions (ICE) If control poor review diagnosis, check and correct inhaler technique, assess compliance, assess and treat rhinitis, check smoking status ( remember cannabis), adjust treatment if necessary If control good consider stepping down Give or review a written self management plan

37 Reference Pinnock H, Fletcher M, Holmes S, Keeley D, Leyshon J, Price D, Russell R, Versnel J, Wagstaff B. Setting the standard for routine asthma consultations: a discussion of the aims, process and outcomes of reviewing people with asthma in primary care. Prim Care Respir J 2010;19(1): DOI:

38 Assessing control How s your asthma? Fine? Have some more inhalers and see you in a year. This common from of asthma review is not enough. People with asthma often tolerate symptoms and prefer them to steroids and education Use a simple standard symptom questionnaire How long does one blue inhaler last?

39 The RCP 3 Questions..now in QOF

40 Asthma Control Test (ACT) 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? During the past 4 weeks, how often have you had shortness of breath? During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning? 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)? 5. How would you rate your asthma control during the past 4 weeks? Copyright 2002, QualityMetric Incorporated. Asthma Control Test Is a Trademark of QualityMetric Incorporated. Incorporated. Patient Total Score Score

41 Adults

42 When is an ICS/LABA combination appropriate? Poor control at stage 2 ( 400mcg daily of BDP equivalent (adult) mcg daily of BDP equivalent (child under 12) But not before checking adherence, inhaler technique etc. and not before trying the most underused effectiveness booster for inhaled asthma treatment.

43 Spacers. Double the lung deposition of ICS Reduce oral deposition of ICS by 80% Improve outcomes, promote steroid dose minimisation and reduce treatment costs As effective as nebulisers for exacerbations

44 Reference Large volume plastic spacers in asthma: should be used more. BMJ 1992; 305: Keeley D.

45 People won t use a spacer.. (?) Lives on the bathroom shelf no need to carry Gets better treatment results Allows us to get your steroid dose down to a minimum Very powerful for treating attacks of wheeze Saves on your prescription costs you ll need fewer inhalers If I was using an inhaled steroid, I d use one..

46 Wider use of spacers would.. Improve treatment outcomes Cut treatment costs Minimise adverse effects of ICS Prevent avoidable admissions

47 Combinations BTS/SIGN COMBINATION INHALERS In efficacy studies, where there is generally good compliance, there is no difference in efficacy in giving inhaled steroid and a long-acting β2 agonist in combination or in separate inhalers.318 In clinical practice, however it is generally considered that combination inhalers aid compliance and also have the advantage of guaranteeing that the long-acting β2 agonist is not taken without the inhaled steroids. Combination inhalers are recommended to:. guarantee that the long-acting β2 agonist is not taken without inhaled steroid. improve inhaler adherence.

48 LABA / ICS Together Convenient Helps compliance.. Ensures no LABA without ICS Cuts prescription costs for patients Guideline encouraged May delay step down in ICS dosage Separate Allows separate changing of ICS and LABA dosage for stepping up/down Preserves the signal (minimal rescue treatment) for step down Needs more careful monitoring of adherence and prescription pattern

49 Smart (ie intelligent) use of treatment in moderate exacerbations Key to effective self-management is a graded increase in inhaled treatment doses Dose of short acting bronchodilator may need to increase by a factor of 10 Dose of ICS may need to increase by a factor of 5 Spacers maintain effectiveness of inhaled treatment in exacerbations Everyone with asthma should have one

50 NICE Asthma Quality Standard Coming soon to a health economy near you NICE quality standards are a set of specific, concise statements and associated measures. They set out aspirational, but achievable, markers of high-quality, costeffective patient care, covering the treatment and prevention of different diseases and conditions. Derived from the best available evidence such as NICE guidance and other evidence sources accredited by NHS Evidence, they are developed independently by NICE, in collaboration with NHS and social care professionals, their partners and service users, and address three dimensions of quality: clinical effectiveness patient safety and patient experience.

51 NICE quality standards enable: Health and social care professionals to make decisions about care based on the latest evidence and best practice. Patients and carers to understand what service they should expect from their health and social care provider. Service providers to quickly and easily examine the clinical performance of their organisation and assess the standards of care they provide Commissioners to be confident that the services they are purchasing are high quality and cost effective

52 What might the standards be.. Asthma mortality rates ITU admission and Ventilation rate Asthma admission rates/1000 population Readmission rates (7.45% readmissions in BTS audit) Asthma ED attendance rates/1000 population Spacer versus nebuliser usage rates in EDs Structured discharge package at hospital discharge including review/provision of written SMP Immediate detailed discharge information to primary care on discharge from ED or hospital to include admission and discharge PEFR

53 What might the standards be.. Evidence in records of guideline-consistent diagnosis Record of occupation in all adults with asthma Annual structured asthma review in primary care including symptom control measure and review/provision of written SMP Primary care follow up within 2 weeks of admission or ED attendance Evidence based smoking cessation offers and quit rates for persons with asthma who smoke Provision of and instruction in spacer use (standard 100%) Record of asthma-specific training in nursing staff undertaking asthma reviews in primary care

54 Thank you

55 Questions & Discussion

56 How a Good Asthma Service is Delivered - Case Example Dr Julian Brown King s Lynn, Norfolk

57 The Key Ingredients Formulary Integrated Care Regular Reviews Self Management Plans for Patients Technique Compliance Analysis of Performance Risk Profiling Education Program

58 Formulary Simple Cost-effective Shared Regularly updated Easily Accessible Compliance League Tables

59 Integrated Care Medicines Management GPwSIs Respiratory Consultants Nurse Specialists GPs Practice Nurses Pharmacists Commissioning Patient! Scotland.gov.uk

60 Regular Meaningful Reviews QOF Admissions Use Rescue Inhalers OMR sheets Compliance Smoking High Dose Inhalers eguidelines.co.uk

61 Admissions Data Have a system of collecting your surgery admissions data. Have an automated system of reviewing all patients that are admitted.

62 Use of Rescue Inhalers Which of your patients are needing these? How often are they collecting them? Are they getting side effects? Those not needing rescue inhalers can be stepped down.

63 OMR questionnaires Waiting Room Post them out Find out what is really happening. Change in inhalers.

64 Compliance Who isn t collecting their inhalers regularly. Excellent opportunity to downgrade high dose inhalers. Opportunity for education.

65 Smoking Regularly offer smoking cessation programs to smokers. Identify Passive smokers Read codes.

66 Self-Management Plans Allow education Goals Planning for emergencies. Include: Medication Regime Inhaler technique Follow up Emergency Planning Step Down planning Contacts

67 Inhaler Technique Do the Trainers know? Not good enough just to ask Must Watch Every Time!

68 Analysis Performance against Yourself Important to keep practices informed of their own statistics. Must include admissions, referrals, medication costs and prevalence of asthma. Must be automatically updated.

69 Analysis Performance vs Others Allows Practices to address their weaknesses Allows strong practices to feed positivity back to their practice staff. Allows CCGs to explore methods adopted in stronger practices.

70 Analysis Performance 3 Detailed analysis of prescribing Formulary Comliance Spend per patient Relative use of drug classes.

71 Risk Profiling Know who your most at risk patients are. Monitor them closely through automated systems. Have self-management plans for each of these patients.

72 Education Program Local Guidelines Formulary Data RespiratoryManager Embrace Support Implementation

73 I you would like Copy of Asthma Formulary Contact me Access to your eclipse data. Analysis of the savings you can make by some simple formulary alterations. Questions????????? Local Respiratory Manager system

74 Questions & Discussion

75 Syndicate Workshop

76 What are the Implications for CCGs & Primary Care Dr Duncan Keeley PCRS-UK Executive

77 REACT Outcome Strategy for COPD & Asthma Objective 6: To ensure that people with asthma, across all social groups, are free of symptoms because of prompt and accurate diagnosis, shared decision making regarding treatment, and ongoing support as they self manage their own condition and to reduce need for unscheduled health care and risk of death.

78 NICE Commissioning Outcomes Framework (COF) The COF is an accountability framework for CCGs Allows the NHS Commissioning Board to identify CCGs contribution to achieving priorities for health improvement in the NHS Outcomes Framework COF becomes operational from April 2013 The NHS Outcomes Framework 2011/12 and COF have 5 high level outcome domains and indicators developed from NICE evidence based quality standards

79 NHS Outcome Framework 2011/12 & COF 5 Domains Domain 1: Preventing people from dying prematurely Domain 2: Enhancing quality of life for people with long-term conditions Domain 3: Helping people to recover from episodes of ill health or following injury Domain 4: Ensuring people have a positive experience of care and Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

80 Domain 1 & 2 Domain 1: Preventing People from Dying Prematurely o 90% of asthma deaths are believed to have preventable features Domain 2: Enhancing Quality of Life for People with LTCs o Emergency attendance at A&E: asthma

81 Quality Innovation Productivity Prevention Improve the quality of healthcare while making savings of 20bn by 2015 E.g. Improve the Quality of asthma diagnosis with Innovative treatment and management which will improve the Productivity of the patient and Prevent asthma attacks resulting in hospital admissions

82 Potential Indicators for Future Development Domain 1: 1. Asthma deaths systematically investigated Domain 2: 1. Patient Reported Outcome Measurements (PROMs): asthma 2. Risk categorisation of asthma 3. Assessment based on RCP scores of patients with asthma 4. Self-management plans for patients with asthma 5. Reviews of patients with asthma 6. Use of medicines by patients with asthma 7. Days lost from work by patients with asthma

83 Questions & Panel Discussion

84 How to Empower Patients in Self Management Linda Pearce Respiratory Nurse Consultant West Suffolk Hospital

85 How to Empower Patients in Self Management Dr Linda Pearce Respiratory Nurse Consultant & Clinical Lead Suffolk COPD Services West Suffolk Hospital

86 Asthma compromises lifestyles in the UK 27% feel that asthma totally controls their life or has a major effect on it1 44% say that at least one activity is totally or very limited by asthma2 Only 40% usually feel well3 Two-thirds of patients who say their asthma is well controlled use reliever twice a day4 1. National Asthma Campaign & Allen and Hanburys. The Impact of Asthma Survey, National Asthma Campaign. Asthma J Gruffydd Jones et al. Int J Clin Pract Price et al. Asthma J 1999.

87 Most people with asthma should not need to feel like asthmatics People with asthma should expect to: Achieve and maintain control of symptoms Prevent asthma exacerbations Maintain normal activity levels, including exercise Maintain lung function as close to normal levels as possible 1. British Thoracic Society et al, Thorax National heart, lung and blood institute, World Health Organisation BTS/SIGN guidelines. Thorax 2011

88 Patient Perceptions After being shown international guidelines, significantly fewer patients thought their asthma was under control Before That can t be right. My treatment doesn t do that After 0% 10% 20% 30% 40% 50% 60% % respondents who thought that their asthma was under control Haughney J et al. Prim Care Resp J 2004; 13: 28-35

89 Health Belief Model These beliefs make it more likely that patients will follow preventive or therapeutic recommendations I am susceptible to this health problem The threat to my health is serious The benefits of the recommended action outweigh the costs I am confident that I can carry out the recommended actions successfully

90 A Lot Going On Beneath The Surface Symptoms Airflow obstruction Bronchial hyperresponsiveness Airway inflammation

91 Beliefs About Susceptibility Some patients resist accepting the diagnosis because I never have asthma attacks Resisting the diagnosis reduces the likelihood that a treatment plan will be followed If the patient thinks their condition is not serious, they are less likely to follow the treatment plan

92 Beliefs About Benefits and Costs The benefits of therapy, obvious to the clinician, are often unclear to patients or irrelevant to them Hard to carry out Don t know what each medicine does Fear that medicines will cause harm Don t understand how therapy will help them do Financial burden of prescriptions is an issue for some

93 Can we gain control of asthma? Vast majority seen in primary care should achieve guideline level control (total control) Appropriate dose of inhaled steroid +/- LABA AT STEP 2 OR 3 Optimal inhaler technique Compliance Understanding to be able to self manage

94 Ask & Tell ZERO TOLERANCE FOR SYMPTOMS Simple questions are needed to gain an insight how patients really are: Have you had any asthma symptoms recently? Have you needed your blue inhaler recently? Do you ever wake up in the night due to your asthma? Have you had an attack or needed an emergency visit recently? Do you ever avoid doing things because of your asthma? Tell them that the aim of asthma management is zero symptoms

95 SELF-BELIEF AND CONFIDENCE Research in psychology shows that when you are confident you can do something successfully You do it more often You are more persistent in the face of difficulty Many patients and their families lack confidence that they can manage their asthma

96 SELF-BELIEF AND CONFIDENCE Confidence in self management involves them understanding their individual susceptibility the seriousness of their condition the balance of risks & benefits of different strategies Then developing an ability to cope

97 What does an action plan include? Clear explanation of diagnosis, different asthma treatments, when to use them Symptoms / PEF scores to watch for that require increase in treatment When and where to seek emergency help When and how to step down medication Lifestyle advice

98 The aftermath of an exacerbation is a particularly good time to address these issues ALL PATIENTS SHOULD HAVE A SELF MANAGEMENT PLAN BEFORE BEING DISCHARGED

99 Self management planning as a communication tool Discuss events leading up to a (recent) exac Prior use of therapy/concerns about medication Early symptoms/warning signs -OrReview a recent PEF chart, identify PEF levels related to stable/symptomatic phases

100 Self management planning as a communication tool Cont - events leading up to a (recent) exac Choose a credible symptom/pef which triggers the plan Describe plan for increasing medication/use of oral steroid Write it down (Asthma UK Cards) Review - did the plan work? Adjust if necessary

101 Cochrane review Asthma self management (36 studies, 6090 patients) hospitalisations ( RR 0.64, 95% confidence interval 0.50 to 0.82) emergency room visits (RR 0.82, 95% CI 0.73 to 0.94) unscheduled visits to the doctor (RR 0.68, 95% CI 0.56 to 0.81) days off work or school (RR 0.79, 95% CI 0.67 to 0.93) nocturnal asthma (RR 0.67, 95% CI to 0.79) quality of life (standard mean difference 0.29,CI 0.11 to 0.47) Measures of lung function were little changed

102 real-life benefits Patients benefit Feel in control of their asthma/sense of independence Reduced fear/uncertainty Improved symptom control = improved QoL Doctors/nurses benefit Reduced demands on time improved patient QoL /outcome = improved professional satisfaction QoF? NHS benefits NHS saves money, reduced hospital admissions / GP visits

103 Patient education and self-management Be aware of those with complex needs, e.g. ethnic minorities, socially disadvantaged groups, adolescents and the elderly Provide self-management advice focusing on individual needs Give specific advice on recognising loss of asthma control Summarise actions required if asthma control deteriorates and include information on how to seek help, the role of oral steroids and how to safely increase medication Self-management will only achieve better health outcomes if the prescribed asthma treatment is appropriate and within recommended guidance BTS/SIGN British Guideline on the Management of Asthma, 2011:

104 Summary-Asthma self-management Importance of developing self efficacy for people with chronic disease Grade-A evidence for secondary care mod/severe asthma SMPs Less evidence for primary care and the very young give less formal plan Think of it as a tool for discussion

105 Self-Management Self Monitoring Med adherence Problem Solving

106 Evidence for doubling the dose of inhaled CS? Small pharmacological studies no benefit; a fourfold increase may be needed Cochrane review self management works

107 Standard Action Plan Inhaled steroid component Double dose of inhaled CS in response to specific symptoms or PEF Stay on this double dose until symptom settles, or PEF rises to previous best Count how many days this took and Maintain double dose for the same number of days again (= insurance policy) Go back to regular long term dose SMART Rx if 2 consecutive days of 8 doses/day (or specified in PEF) seek urgent medical attention or start OCS as above

108 Standard action plan Oral steroid component Discuss recognition worsening symptoms indicating an exacerbation Identify PEFR at time of exacerbation / admission Agree cut-off PEFR which represents significant exacerbation eg 60-70% for 2 days Steroid dose to be taken on basis of symptoms / PEFR eg prednisolone 30mgs for 4-7days / until control restored Report exacerbation

109 Standard Action Plan Severe exacerbation Recognition Symptoms very tight chest / too wheezy to walk No or very brief response to reliever PEFR less than..eg 50% Action Relief treatment repeat / dosage Oral steroid Seek help GP / Hospital

110 Questions & Discussion

111 Syndicate Workshop

112 Plenary Feedback

113 Chair s Remarks Professor Anthony Davison NHS Lung Improvement

114 Close