Asthma: Room for improvement in management Hasanin Khachi Lead Respiratory Medicine Pharmacist Barts Health NHS Trust July 2014
Challenges that the NHS faces are well documented
What are the challenges? NHS - financial burden Savings of 20 billion by 2014! Where are these savings going to come from? Greatest expense: 1 st : Staff 2 nd : Medicines Patient numbers are rising Mergers: fewer acute providers, more to 1º care BTS/SIGN Asthma Guidelines: QOF attainment: >90% Outcomes: Twice as likely to die from asthma in UK 90% of deaths are avoidable; 75% of admissions avoidable
Funding Gap for Hospitals in England Committed to QIPP savings of 4%/ yr up to 2015 If funding is held flat / yr and QIPP savings achieved Shortfall of 28-34billion by 2022 Austerity here to stay for another decade? Nuffield Trust 2012
Asthma Prevalence
Asthma: Facts & Figures UK: highest rates self reported asthma in the world >5.2million people affected 4.1million GP consultations per year >1000 die from asthma each yr Every 2pxs admitted to hospital, 5 treated in A&E 80% NHS expenditure is for 20% with severe asthma Cost of asthma to the NHS: Direct costs: > 1b/yr; Indirect cost: > 2.3b/yr DoH: largest case load in 1º care resp disease
BTS/SIGN May 2008
Asthma Prevalence UK: 5.93% Tower Hamlets: 4.46% City & Hackney: 4.31% London SHA: 4.72% Newham: 4.37% Waltham Forest: 4.54% http://www.gpcontract.co.uk/child/q36/asthma%201/12
But, can we work differently?
Background UKCPA Asthma Award 2012 GP practice - 1 day a week Patients: Asthma & COPD - identified by EMIS Web Based on severity of disease, defined as: Phase 1: Frequency of exacerbations: OCS/Abx, Hosp, A&E Baseline medicines: high dose ICS/LABA Phase 2: Undiagnosed, smokers/ex-smokers, frequency of exac s Legacy - developing others: Practice Nurses & Pharmaceutical Advisers
Overview Asthma COPD Total Patients 120 82 202 Consultations 181 127 308 Male (%) 33.3 57.3 Mean Age (years) 54.4 67.7 % Follow Up 50.8% 54.9% 52.5%
Asthma
Inhaler Technique
Getting the Basics Right Inhaler Technique >90% of patients cannot use an MDI effectively 91% of healthcare professionals who teach use of respiratory inhalers cannot demonstrate them correctly* *Thorax 2010;65:A117
How Frequently do Patients make Errors Using Inhaler Devices? Accuhaler (n = 894) % pmdi (n = 552) % Turbohaler (n = 868) % At least one error 49 76 54 At least one critical error 11 28 32 GPs opinion that the patient inhaled the correct dose Overestimation of good inhalation by GPs 75 50 70 9 6 24 Molimard M et al. Journal of Aerosol Medicine 2003;16:249-54
Inhaler Use & Symptoms Inhaler Technique: 60.5% poor technique 14.3% moderate 25.2% good technique Daily Salbutamol Use: Range: 0-15 times per day Average: 2.1 times per day Night Time Waking: 39.2% Range: 1-7 days / week Average: 3.3 days / week
Adherence
Assess the factors that influence adherence 30-50% medicines prescribed for long term illnesses are not taken as directed (1) Non-adherence is an important contributory factor to poor asthma control (2) Improving adherence is one of ten priorities for reducing the burden of asthma on individuals and society, identified in a recent EU directive (3) (1) World Health Organization Report 2003. 2Horne R et al. Concordance, adherence and compliance in medicine taking. NIHR SDO 2006 (2) Gamble J, Stevenson M, McClean et al. The prevalence of non-adherence in difficult asthma. Am. J. Respir. Crit. Care Med. 180(9). 817-822 (2009) (3) Holgate S, Bosgaard H, Bjermer L et al. The Brussels Declaration: the need for change in asthma management. Eur. Respir. J. 32, 1433-1422 (2008)
Responsible Respiratory Prescribing Understand costs Ensure optimal drug therapy for respiratory patients Optimise use of prescribed therapy Right care Minimise waste Maximise value Minimise unwarranted variation http://discovery.ucl.ac.uk/1350234/1/evaluation_of_nhs_medicines_waste web_publication_version.pdf
Adherence - Asthma 1.8m not compliant Compliance associated with 75 saving/px/yr (incremental QALY 0.11) Changing partially compliant pxs to become 80% compliant: savings of 130m Not including additional improvements in health outcomes http://discovery.ucl.ac.uk/1350234/1/evaluation_of_nhs_medicines_waste web_publication_version.pdf
Adherence & Smoking Hx Adherence - inhaler pick up in previous 12m: Maintenance: Range: 1-26 inhalers! Average: 7.5 inhalers per year; Median: 6 Reliever: Range: 1-48 inhalers! Average: 9.1 inhalers per year; Median: 7 (Tablets: 8.0 / year) Smoking History: 27.5% current smokers (ex smoker, 19.2%) Cigarettes: 1-30 per day, average: 8.5 cig/day Average Smoking Pack Years: 29.2 55% agreed to stop
Are patients on the correct inhaler therapy? Based on symptoms, pxs on correct therapy? 24.2% on correct therapy 75.8% not on correct therapy 75.8% were stepped down on their ICS/LABA dose 22% stopped medicines 9.9% query or change diagnosis
BTS/SIGN May 2008
QIPP - High Dose ICS in Asthma 2013/2014 High Dose: Adults: 800-2000mcg/day BDP or equivalent Children: 400-800mcg/day BDP where licensed i.e. BTS Step 4-5 Review ICS medicines routinely Step down dose where clinically appropriate RV every 3/12 by 25-50% each time
NICE: High Dose ICS in Asthma High Dose: Adults: 800-2000mcg/day BDP or equivalent Children: 400-800mcg/day BDP where licensed i.e. BTS Step 4-5 Standard dose ICS: Adults: 200 800 mcg/day BDP or equivalent Children 12 years: 200 400mcg/day BDP where licensed 1 st choice preventer drug for both adults & children Mild-Mod asthma: starting at very high doses of ICS & stepping down is not beneficial http://www.nice.org.uk/media/7a6/64/academic_detailing_aid_high_dose_inhaled_corticosteroids_(ics)_in_asthma_2nd_edition.pdf
Is stepping down possible in practice? 259 stable asthma patients in Scotland: on high dose ICS (mean 1430 micrograms BDP or equivalent) randomised to no alteration OR 50% reduction in dose. Followed-up for 1 year: no difference in exacerbations no difference in visits to GP or hospital no difference in health status (SGRQ) Hawkins G, et al. BMJ 2003;326:1115 20
BDP Usage Range: 200-4000 mcg / day Average: 1693.6 mcg / day After Pharmacy Review: 981 mcg / day All patients: Given advice in event of greater symptoms Follow-up, PEF, ACT Less symptomatic & wheezy, better exercise tolerance Despite step down - all patients improved! PEF ACT scores Symptoms
Khachi H, Karikari P. Thorax 2013;68:A110-A111 doi:10.1136/thoraxjnl-2013-204457.228
Cost Effectiveness Asthma COPD Total Patients 120 82 202 Consultations 181 127 308 % Follow Up 50.8% 54.9% 52.5% Annual Savings 30,199.08 15,046.80 45,245.88 Doesn t include savings due to reductions in: Outpx appointments due to uncontrolled asthma or COPD 139 per appointment Admissions Asthma admission: 919 per spell COPD admission: 2263 per spell A&E attendances
Summary Mean reliever use per day PEF rate (L/min) % Suffering from any night time wakening Mean days per week of night time wakening Exacerb ations Asthma Baseline 2.0 351.6 39.2 3.3 2.0* Follow Up 1.2 373.9 18.3 3.4 0.3** COPD Baseline 2.8 NA 20.7 4.9 3.0* Follow Up * Baseline prior to pharmacy reviews ** 6 Months post pharmacy review 1.9 NA 18.2 4.7 0.1**
Summary High proportion of patients: Are smokers or ex smokers Poor inhaler technique & adherence Poorly controlled disease Correlations with NRAD Respiratory pharmacy reviews: Doing the basics well - in line with QS, QIPP, Gx Cost effective service Improves patients quality of life & overall care
Questions