Transcript What is “State of the Art” COPD Care?

Are there ways of improving
care and achieving QIPP?
Colin Gelder & Sandy Walmsley
Respiratory Leads
West Midlands SHA
PCT Revenue Limits £bn
PCT Revenue Limits £bn
PCT Revenue Limits £bn
1.6-2.0
1.0-1.3
0.55
PCT Revenue Limits £bn
Summary of Patient Priorities
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Better Information
Respect
Support for Self Management
Pulmonary Rehabilitation
Improved Access
End of Life Care
Summary of Secondary Care
Recommendations
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Integrated Commissioning
Integrated Care
Better Diagnosis/Registers
Increased Access to Pulmonary Rehabilitation
Oxygen Services
Self Management
End of Life Care
……..so what do we have to do? Is it
Plan is to…………………..
Are there better ways to deliver care?
• Quality and productivity: IMPRESS's More for
Less
• Keep up to date with NHS Policy: summary of
Operating Framework and Outcomes
Framework
• www.impressresp.com
May 2011
COPD Care
Prevention & Identification
Finding the ‘missing millions’
High quality care and support
End of life care
1. Active Support For Self
Management
COPD & Self Management
• Advice on how to stay healthy
• Advice on how to recognise onset of
exacerbation
• Advice as to when to seek further support
• Telehealth
Self-Management of Exacerbations
Encourage people at risk of having an
exacerbation to respond quickly to the symptoms
of an exacerbation by:
• adjusting bronchodilator therapy to control
symptoms
• starting oral corticosteroid therapy (unless
contraindicated)
• starting antibiotic therapy if their sputum is
purulent
2. Primary Prevention
COPD & Primary prevention
• Public Health approach
• Starts early in life
• Promote “lung health” rather than lung
disease
Long-term effectiveness & cost-effectiveness
of smoking cessation interventions
in patients with COPD
Tiotropium £7,112/QUALY
Eur J Health Econ.
2007; 8(2): 123135
1 year abstinence
%
QALY
£
Usual care
1.4
Minimal counselling
2.6
14,735
Intensive counselling
6
7,149
Intensive counselling +
pharmacotherapy
12.3
2,092
Pulmonary Rehabilitation £2,000-8,000/QALY
Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH
Thorax 2010: 65:711-718
3. Secondary Prevention
Secondary Prevention
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Smoking cessation
Opportunistic case finding
Self management
Pulmonary rehabilitation
4. Effective Medicines Management
COPD and Medicines Management
• Oxygen
• Appropriate prescribing in line with NICE/ COPD
Strategy
• Appropriate for individual patients: Inhaler
technique
• Integration with other therapies e.g. Pulmonary
rehabilitation
Current Overview
• Home Oxygen Service provides O2 therapy to ~85,000
people in England
• In some areas there is no quality assured assessment
• 60% have COPD
• NHS cost £110 million
• 25% of little or no clinical benefit
• 300 NPSA alerts/SUIs, 44 deaths
• Current contracts expire in Jan 2011 (exc. South West)
• Services need to be fully integrated into the whole
patient pathway
Potential Savings
• In PCT with formal review of oxygen
registers coupled with introduction of
oxygen assessment services up to
£400,000 /year has been saved
• Potentially £10-20 million savings in
England per year
Optimising pharmacological maintenance treatment
for COPD in primary care
Rupert Jones, Anders Ostrem
Primary Care Respiratory Journal 2011; 20(1): 3345
IMPRESS GUIDE TO INFORMATION ABOUT USE OF MEDICINES IN THE NHS
A SECTION OF THE IMPRESS GUIDE TO INFORMATION
This document is not about best practice prescribing or information about
medicines for patients, but about the information available to help clinicians,
commissioners and managers to know what is being prescribed by whom, for
whom, at what cost, and at what benefit and how this compares to other
geographic and disease areas. It draws together the information available
across the primary, community and secondary care system. It focuses on
respiratory care, but many of the lessons are of wider relevance to the
management of long term conditions.
Right Care Respiratory Prescribing
London Respiratory Team
NICE 2010
‘Ensure
all patients with COPD
are on the appropriate therapy for
the severity of, and symptoms
from, their disease.’
Right Care Respiratory Prescribing
London Respiratory Team
NICE 2010
‘‘Offer
nicotine replacement
therapy, varenicline or bupropion
(unless contraindicated)
combined with a support
programme to optimise quit
rates… to all people with
COPD who still smoke at every
opportunity.’
Total cost of Respiratory Medication
by BNF Chapters 2008 and 2009 for England
£ millions
~£1 billion on respiratory
medication not including
antibiotics…
Source: NHS Information Centre
Volume of Respiratory Medication
by BNF Chapters 2008 and 2009 for England
Number of prescriptions (millions)
but a relatively low volume of
respiratory prescriptions ...
Source: NHS Information Centre
Item cost of Respiratory Medication
by BNF Chapters 2008 and 2009 in England
Average net ingredient cost per prescription item £
Respiratory items are the most
expensive category of item
prescribed .....
…… inhalers
Source: NHS Information Centre
NHS budget & respiratory meds
Of the top 5 costliest drugs to the NHS currently 3 are inhalers
Seretide (all) is the highest cost drug
Seretide 250 Evohaler is the most expensive
individual item (second is atorvastatin): Switch to
accuhaler
Symbicort 200 is 5th most expensive item
Source: NHS Information Centre
5. Managing Ambulatory Care
Sensitive Conditions
Ambulatory care in COPD
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Quality assured diagnosis
Accurate registers
Empower patients to understand condition
Self management plans with written
instructions
• Quality assured Pulmonary Rehabilitation
• Integrated care across whole health and socail
care economy
Pulmonary Rehabilitation
Pulmonary rehabilitation available to all
• Post discharge
• MRC3 or above/symptomatic
COPD and Urgent Care
• Assessing to admit NOT admitting to assess!
• Integration between Acute & Community Care
can reduce admissions
• Self management plans & rescue medications
• EoL planning with Advance Care Plans
6. Care co-ordination through
integrated health & social care teams
Integrated health care in COPD
Teams should be fully integrated across health &
social care, enabling
• Right care, right place, right time, right person
• Communication across integrated team VITAL
• Leading to reduced inappropriate admissions
BUT……we need to make sure that we are doing
the right things, right!
7. Managing elective activity
-referral quality
COPD and Elective Referral
• Networks to improve standards and reduce
secondary care referrals, integrated working
• Genuine integrated care pathways across health
economy
• Intermediate/community clinics either Nurse or
Consultant led will lead to reduced referrals to
secondary care
Managing Emergency Activity
-Urgent care
8. Improving the management of
patients with both mental & physical
health needs
Anxiety & Depression
• Be alert to the presence of depression in individuals with
COPD
• Patients found to be depressed should be treated with
conventional pharmacology
• Antidepressant therapy should be supplemented by
explanation of why depression needs to be treated
alongside the physical disorder
9. Improving primary care
management of end of life care
Organ system failure: end of life trajectory
High
Function
Occasions of
discontinuity of care
Low
Death
Frequent admissions,
self-care becomes difficult
Time
2-5 years
but death often
“unexpected”
No clinical service is designed to routinely meet the needs
of this pattern of decline
Palliative
care
End of
life care
Terminal
care
Advanced Care Planning – why?
“ACP is about ensuring that futile treatments are not
continued to the exclusion of appropriate end-of-life
care”.
“ACP is not about abandonment – it is about ensuring
that abandonment does not happen. Futile
interventions can lead to abandonment”.
Changing the professional approach
CEILING OF CARE / RESUSCITATION PREFERENCES
documentation
Please indicate which of the following “CEILING OF CARE” goals
/ interventions are appropriate. Circle each response. More
than one YES response may apply.
- SYMPTOM RELIEF: LOW FLOW OXYGEN / BRONCHODILATORS
/ OPIATES / BENZODIAZEPINES / HALOPERIDOL
Select as appropriate for the patient’s needs
ALWAYS
- PREDNISONE / AMINOPHYLLINE
YES / NO
- ANTIBIOTICS
YES / NO
- NON-INVASIVE VENTILATION (BIPAP)
YES / NO
- ICU ADMISSION AND POSSIBLE VENTILATION
YES / NO
- CPR FOR CARDIO-RESPIRATORY ARREST
YES /NO
The Journey
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A map – idea of route and destination
An informed guide
Companions
Appropriate travel equipment
Supplies
Comfort breaks
End destination
The Journey
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Starts with noticing symptoms and being given a
diagnosis
This is the point of no return...
A story with no beginning
A middle that is a way of life
An uncertain and unlooked for end
Patients with COPD
information needs
DIAGNOSIS
SYMPTOM CONTROL
WHAT DYING MIGHT
BE LIKE
INCLUDING
SPIRITUAL ISSUES
COPING MECHANISMS
DISEASE
PROCESS
TREATMENT
PRACTICAL ADVICE
ADVANCE CARE
PLANNING
CONTINUITY IN CARE
(Scullion, 2010)
We need companions too!
Third Sector
BLF, Asthma UK
Pharma Alliance
MSD, Pfizer, Novartis, Glaxo Smithkline, Astra
Zeneca, Teva
Why are we here?
2 key reasons for
involvement;
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We all supply medicines for
COPD and Asthma
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Strategic steer from the DH to
encourage dialogue and joint
working between the NHS and
industry
Vision and Mission
“To ensure that all individuals with COPD in
the West Midlands receive state of the art,
patient focused, cost effective care”
The WIN/WIN
By industry and the NHS working together
to achieve ‘state of the art’ evidencebased appropriate use of medicines, we
will help reduce in-patient care; resulting
in health, social and economic benefits
What have we achieved?
…We continue to support the journey of
strategy through to implementation…
Examples of work undertaken with support of the Alliance;
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Stakeholder mapping
Data project
COPD needs assessment
Access to an independent external facilitator
Support for World Spirometry Day
Raising awareness of cluster meetings
The Future
We can offer;
 Expertise
 Resources
BUT the real value is;
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Working together
Hierarchy
Network