Transcript Dr Vince Mak Value Prescribing - VM

VALUE IN
RESPIRATORY
PRESCRIBING
Dr Vince Mak, Consultant Physician, NWLH Trust
Value Framework
Health
Outcomes
Value
=
Health Outcomes
Cost of delivering
Outcomes
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
Cost
QUALITY vs VALUE paradigm
Quality and Value are not mutually exclusive
RIGHT CARE
Do the right thing
Do the right thing right
Doing the right thing right first time should deliver
quality and value
Source: NHS Information Centre
What are the top 5 costliest drugs to
NHS (June 2012)?
5.
4.
3.
2.
1.
Seretide 125 evohaler Seretide 500 accuhaler Symbicort 200 Tiotropium Seretide 250 evohaler -
£81 million/yr
£85 million/yr
£90 million/yr
£120 million/yr
£180 million/yr
Thus, of the top 5 costliest drugs to the NHS currently,
ALL ARE RESPIRATORY INHALERS
Source: www.drugtariff.co.uk
WHY IS SERETIDE 250 THE NO.1
COMBINATION INHALER
Position in BTS/SIGN Asthma Guidelines
Does this mean majority of asthmatics
are at Step 4+ of BTS guidelines?
COPD Value Pyramid
What we know…. Cost/QALY
Triple Therapy
(£7000£187000/QALY
LABA
£5-8000/QALY
Tiotropium
£7000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with pharmacotherapy
£2,000/QALY
Flu vaccination? £1000/QALY in “at risk” population
London Respiratory Team
ARE WE GETTING THE MOST OUT
OF OUR INHALER SPEND?
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 may be easier to use and can increase
deposition to 30%
• If used incorrectly – most of the drug from MDI is wasted –
Seretide 250 is £60/month
*Thorax 2010;65:A117
PRIMARY CARE PRACTITIONERS SAY
THAT PRESCRIBING IS LED BY
SECONDARY CARE
Can that be true?
In NWLH Trust over 2011/12 What were the top 10 costliest drugs in
Emergency Medicine Directorate?
Top 30 Drugs for Emergency Medicine Directorate - NWLH
April, May, June, July, August, September, October, November, December, January 2011/12
Drug Name
2011/12
DALTEPARIN
£29,297.29
SERETIDE
£28,763.14
OPTIUM H
£20,761.34
OCTAPLEX (KEPT IN BLOOD TRANSFUSION EXT 2746)
£19,040.00
MEROPENEM
£15,683.04
TIOTROPIUM (SPIRIVA)
£13,711.00
TETANUS, Low Dose Diphtheria & POLIO (REVAXIS)
£12,855.98
DALTEPARIN (GRADUATED SYRINGE)
£12,605.43
CLARITHROMYCIN
£12,006.87
SYMBICORT
£11,594.38
£350,000
London Acute Trusts Total spend on inhaled respiratory medicines
2011/12
£300,000
£250,000
£200,000
Anticholingeric total
Bronchodilator total
ICS single total
£150,000
Combinations total
£100,000
£50,000
£0
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WHAT CAN WE DO?
ENCOURAGE RESPONSIBLE
RESPIRATORY PRESCRIBING
“clinicians will need to accept that they are
responsible for the stewardship of resources and
not just their use” Sir Muir Gray BMJ Oct 6 2012
RIGHT CARE - Responsible Respiratory Prescribing
• Often – use of high potency inhaled corticosteroid not
appropriate for stage of disease for asthma and COPD
• Poor inhaler technique often cause for treatment failure and
not “fixed” by increasing the dose
• In COPD – possible to use evidence based lower potency
alternative with less risk
• Treatment rarely stepped down when stable or not effective
Optimise – not Maximise
7 Key COPD Prescribing Messages
1. Respiratory medications are expensive
Doing the Right Things:
2. When prescribing any new respiratory inhaler, ensure that the patient has undergone NICErecommended 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 (>1000ug BDP equivalent?), ensure that
the patient is issued with an inhaled steroid safety card
7. No Prednisolone EC prescribing without good clinical reason
Minimise Risk : Patient Safety
•
Warn about potential for
adrenal suppression on high
doses of ICS
•
Warn about not stopping high
dose ICS suddenly
Minimise Risk : Minimise waste : Maximise Value
•
Warn about high dose ICS side effects:
– Pneumonia
– Diabetes
– Bone Loss
•
In COPD – moderate dose ICS (800µg BDP equivalent)
same clinical efficacy as very high dose ICS (2000µg
BDP equivalent).
•
In asthma – little evidence for efficacy of ICS above
800µg/day (BTS/SIGN Grade D evidence)
•
Checking inhaler technique, using ICS through a spacer
or changing inhaler device may be more effective than
increasing the dose or stepping up treatment
•
If dose of ICS has been stepped up in the treatment of
asthma and patient is well controlled – consider
stepping down after 3 months.
Minimise Risk : Increase awareness
•
Traffic light reference card
•
BDP dose equivalence
•
Which inhalers and at what
dose may deliver >1000µg BDP
equivalent/day
•
Also gives some idea of cost for
BDP equivalent doses of
different brands of inhaler
WHAT CAN AND WILL YOU DO TO
ENCOURAGE RESPONSIBLE
RESPIRATORY PRESCRIBING IN
YOUR TRUSTS?
Optimise – not Maximise