Isle of Wight PCT
Poor inhaler technique was an issue for the Isle of Wight PCT, as across the NHS. Through a simple, patient-led intervention, significant reductions in hospital admissions and the cost of medication have been achieved. So much so that The Isle of Wight now has the lowest standardised admission rate for asthma in the UK.
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
To reduce respiratory deaths, hospital admissions and the cost of respiratory medication.
To reduce resipratory deaths, hospital admissions and the cost of respiratory medication.
Reasons for implementing your project
The Isle of Wight had a high prevalence of long term respiratory conditions combined with a much higher than average, spend on medication for treatment.
Despite the higher spend, clinical outcomes were poor, with a greater number of respiratory related emergency hospital admissions than expected.
Reasoning from the disparity between spend on medication and the high level of emergency hospital admissions that simply investing more money in medication wasn't addressing the issue, the PCT began tackling the effectiveness of inhaler use.
How did you implement the project
When used effectively, 20% of the medication in a metered dose inhaler (MDI) reaches the lungs (the other 80% being swallowed), whereas with a poor technique the percentage drops to between 0 and 10%. Therefore an intervention to improve inhalation techniques was identified as a cost effective way of improving performance.
A review of the training techniques of Health Care Professionals (HCPs) with a role to play in delivering inhaler training, revealed a very low level of performance across the board with 94% of HCPs unable to even demonstrate the ability to use the inhaler correctly for themselves.
Tackling the lack of knowledge in both primary and secondary care inhaler application, a series of communication measures were put in place to make sure HCPs and all patients receive improved and consistent training for MDI and other inhaler applications.
- Training the trainers: HCPs were initially instructed on how to use the inhalers themselves, and then trained to measure a patient's ability to use their prescribed inhaler, rather than the previous less scientific visual assessment.
- Equipping patients: Once properly instructed and able to use their inhaler efficiently, patients were also issued with a training aid for regular use post contact with the HCP in order to avoid slipping back into previous bad habits. This was the first time such aids have been available free of charge from the NHS.
- Patient communication: An advertising campaign was run to advise patients of the new training on offer via their HCP and invite them to be re-trained.
- Holistic working: A more collaborative relationship has been implemented with both primary and secondary care practitioners working closely together, including GPs formally referring patients to their community pharmacist for inhaler technique training.
The training aid carried a cost but this was paid back 7X over with the reduction in cost of bronchodilators within year 1 of the project.
According to Asthma UK, the Isle of Wight standardised admission rates (SAR) for asthma are the lowest in the UK, with an SAR of 52 in 2008/9, having not been listed in the top 23 PCTs in England in the previous report (standardised where 100 would be mean). (Asthma UK figures, released 2009 based on full Hospital Episode Statistics dataset for England).
Reliever therapy (measured by ePACT) showed an immediate drop, and within the first year costs of selective betaagonists fell by 22.7% - a saving greater than seven times the initial investment by the PCT. (measured as NIC/STAR PU - net ingredient cost per specific therapeutic group age-sex prescribing unit) and a decrease against trend of 25.2% in prescription numbers.
Additionally, within 12 months, the Isle of Wight PCT was able to demonstrate through validated hospital data, and Hospital Episode Statistics that emergency admissions due to asthma had reduced by 50%, and deaths by 75%.
Prescribing of selective beta-agonists is still falling, taking the PCT spend for bronchodilators to approximately 20% below the national average for this class of drugs. It is pleasing to note that use of ICS preventers, when compared with the trend for England, is also decreasing.
Hospital inpatient costs for asthma-related admissions have fallen by 66% since the project commenced. (figures from www.hesonline.nhs.uk)
South East Public Health Observatory (May 2009) have quoted IOW COPD admissions data as exceptionally good despite high prevalence and advise other PCTs to copy the IOW.
Local Pharmaceutical Committee have evaluated public and HCP opinion - highly supportive.
Key learning points
Seek public opinion at an early stage and use a multidisciplinary approach across primary and secondary care, local authorities, schools, care homes, prisons etc.
Head of Medicines Management
Isle of Wight PCT
Is the example industry-sponsored in any way?
The project was a true joint project with Pharma using training funded in part by pharma.