In a joint initiative between City & Hackney CCG and Barts Health NHS Trust, asthma and COPD reviews were undertaken by a respiratory pharmacist in general practice with a view to improve adherence to medication.
This was in line with recommendations from NICE guidelines:
• CG76 & NG5 on patient centred assessment and support of adherence
• NG115 to promote effective inhaled therapy, review inhaler systems and promote smoking cessation
• QS25 & QS10 to provide those with asthma and COPD with training & assessment of their inhaler technique
Structured reviews in line with national guidelines by the pharmacist resulted in significant interventions that improved Quality of Life (QoL), adherence to therapy, reductions in exacerbations, reduced over prescribing and resulted in a large cohort of patients successfully stop smoking.
Furthermore, it showed appropriate prescribing and disease management in line with national standards of care also resulted in significant drug costs and utility, amounting to approximately £220K annually.
- Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence (CG76)
- Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (NG5)
- Asthma (QS25)
- Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115)
Aims and objectives
Our aim was to assess the impact of a pharmacist led asthma/COPD medicines optimisation clinics in accordance with national standards of care.
We specifically wanted to explore the ways in which this service could improve adherence, rationalise the use of high dose inhaled corticosteroids, reduce medicines wastage and ultimately improve patients’ clinical outcomes.
Reasons for implementing your project
In City & Hackney CCG, workstreams are highly influenced by views of member general practices as well as patients/residents. The CCG and member practices were keen that QiPP work on medicines did not focus on the cost of prescribed products and that all aspects of the ‘medicines chain’ were reviewed.
The NICE guidance for medicines optimisation (NG5) highlighted the benefits of structured medication reviews to include reduction in medicines waste. The DoH had also in Dec 2012 published, “Use of Medicines for Better Outcomes and Reduced Waste. An Action Plan” outlining that unused medicines cost the NHS £300M pa. In 2013, the CCG supported a community pharmacy audit to quantify the level of medicines waste in the CCG. The audit identified that inhalers represented the most costly proportion of unused medicines returned to pharmacies.
Extrapolating the value of medicines returned, suggested that annually, at least £1m of medicines issued in City and Hackney were not being taken as intended. Within the CCG, the reported prevalence of asthma & COPD was significantly lower than the London and England averages. However, there were disproportionately high hospital admission rates.
The Interactive Health Atlas of Lung Conditions in England (INHALE) benchmarking tool for asthma & COPD, showed A&E attendances and hospital admissions for both conditions in C&H CCG to be significantly worse than the national average (Appendix 1 in the supporting material). We consulted with local residents as to what they felt were the reasons why significant amounts of medicines were not taken as intended. Reasons identified by users included:
• Patients need to have medication reviews in dedicated time – GP appointments do not allow sufficient time for patients to obtain information they need to enable them to take their medicines optimally
• Many patients don’t feel empowered to ask GPs / community pharmacists to spend time explaining their medicines
• Patients feeling better on newly initiated drugs don’t always understand the importance to continue their medication
• Certain medication is over prescribed and GPs don’t ask how much medicines patients already have
Taking this feedback from patients, as well as results from the waste audit, we embarked on a pilot project to assess the impact of a specialist respiratory pharmacist on addressing the medicines optimisation needs of asthma and COPD patients. We chose this clinical area in line with findings of our waste audit, CCG’s clinical priorities and higher than expected admission rates for asthma and COPD.
How did you implement the project
The project was carried out by the specialist respiratory pharmacist over a 2-year period, across 13 GP practices.
A checklist was devised to ensure that the standards incorporated within national and international guidelines e.g. NICE Guidelines and Quality Standards for asthma (e.g. QS25 Statement 3, 4, 5, 6 and 10, people with asthma have action plans, have their inhaler techniques assessed, have a structured review, have their asthma control assessed and have primary care follow up after receiving treatment from hospital or OOH service).
For patients with COPD, the checklist drew on (e.g. QS10 Statement 1, 2, COPD patients have diagnosis confirmed with spirometry, inhaler technique is reviewed) would be assessed and addressed. The reviews included the following assessments:
The reviews included the following assessments:
• Quality of life (QoL): asthma control test (ACT) and COPD assessment tool (CAT) questionnaires
• Adherence to maintenance inhalers based on GP prescription records
• Whether patients were on the correct therapy based on their diagnosis and disease severity
• Whether patients agreed to smoking cessation (defined as stopping smoking for ≥3 months).
Patients were identified for a specialist review based on use of high dose inhaled corticosteroid and bronchodilator preparations and/or presence of previous exacerbations, A&E or hospital admissions.
One of the problems faced within the CCG was around the capacity of the specialist clinical pharmacist undertaking the project. This was addressed by upskilling practice based pharmacists to also undertake medicines optimisation clinics for patients with asthma or COPD.
Educational events were provided by the specialist pharmacist to local clinicians including GPs and Practice Nurses. Costs The CCG reimbursed the acute trust – at a rate of £13K per annum – to allow for a day/week backfill of the respiratory specialist pharmacist’s time. No other investment or set up costs were incurred as the expertise of local and existing NHS staff were harnessed enabling shared learning.
As shown in Table 3 in Appendix 2 of the supporting material, a significant proportion of patients had uncontrolled disease based on their Quality of Life (QoL), use of reliever inhalers and frequency of moderate-severe exacerbations. The use of high dose inhaled corticosteroids in patients reviewed was frequently associated with poor adherence to maintenance inhalers and poor inhaler technique. Interventions were made in all patients, including reducing the beclomethasone dipropionate (BDP) equivalence in the asthma group by 645.4mcg (39.9%).
Follow up reviews showed that despite a reduction in dose of inhaler therapy, measures of asthma and COPD control (QoL, peak flow, night time wakening, and reliever inhaler use) all improved as well as patients’ reported ability to self-manage their disease and achieve smoking cessation. Annual drug cost savings attributed to appropriate step down and cessation of therapy showed that savings of £75K were made (asthma: £49.3K; COPD: £25.7K).
Follow up exacerbation and admission data is ongoing, with 57 patients (16.0%) having been seen at the 6 or 12 month stage. This shows that exacerbations have been significantly reduced from 1.7 to 0.36 and 3.0 to 0.19 per year in asthma and COPD respectively, with no admissions or A&E attendances. With the average cost of an asthma and COPD admission being approximately £0.9K and £2.2K respectively, this amounts to significant reductions in utility.
Prospective data was collected to quantify these savings. These amount to:
• Reductions in outpatient referral due to uncontrolled asthma or COPD:
o Asthma: £30.4K (219 patients x £139/appointment)
o COPD: £15.3K (110 patients x £139/appointment)
• Reductions in asthma and COPD admissions:
o Asthma: £24.8K (26 patients x £953/admission)
o COPD: £74.1K (34 patients x £2180/admission)
• Reductions in asthma and COPD A&E attendances:
o Asthma: £3.5K - £10.8K (46 patients x £77-£235/episode depending on type of episode)
o COPD: £3.9K - £12.0K (51 patients x £77-£235/episode)
We quantified our total annual savings, including drug costs savings as: £215.1K - £230.5K per year
Key learning points
• Medicines optimisation work streams can be identified through assessment of waste / returned medicines
• In terms of medicines optimisation for respiratory patients it is important to prioritise patients who are at higher risk of unscheduled hospital admission; in our case we focused on the group of patients with severe asthma / COPD. Up skilling existing staff to help support legacy planning and maintain capacity within a team or service is essential.
• A critical success factor of this service has been engagement , at the outset, of patients and local stakeholder groups across the primary and secondary care interface. With the patient’s consent, liaising with their community pharmacist helps to support ongoing monitoring of the patient and in particular review of the patient’s inhaler use
• Structured reviews by the respiratory pharmacist in our pilot resulted in reductions in exacerbations and reduced unnecessary over prescribing. However we also found that there were a significant number of relatively ‘simple’ interventions that did not require specialist respiratory knowledge, for which most prescribers / healthcare professionals would and should be able to make, including:
1). Checking patients’ inhaler technique regularly
2). Checking adherence to prescribed treatment particularly for inhaled corticosteroids; in our pilot, many patients, especially those with asthma, were unaware of the need to use ICS regularly, and only used their steroid inhaler when they felt their condition was worsening.
• Raising awareness to amongst healthcare professionals - including practice and community nurses and community pharmacists (as well as non-clinical practice staff involved in repeat prescribing processes to alert clinicians) about identifying instances where excessive quantities of short-acting reliever inhalers (or too few preventer inhalers) are being ordered/ prescribed/ dispensed as advocated by the National Review of Asthma Deaths.
• Regular reviews of individuals’ doses of inhaled corticosteroids and Practice level audits of high dose inhaled corticosteroids (e.g. as per Appendix 3 in the supporting material).