Use of Inhalers

Medicines Optimisation
workshop
14th September 2015, Holiday Inn Gatwick
Aim
To optimize the use of inhalers across Kent
Surrey Sussex, to reduce the cost burden to the
NHS and maximise patient benefit of such
medications through effective and appropriate
high quality care
Objectives of this workshop
1. To move forwards with optimising the use of inhalers
across KSS
2. To agree specific ways forward and scope pieces of
work
3. To share examples of good practice
4. To identify volunteers and partners for project work
that is agreed
The story so far…..
• NHSE set a medicines optimisation priority to all
AHSN regions
• KSS AHSN hosted a MO event 19th May 2015
covering:
– National view from NHSE
– Polypharmacy
– AF and HF medications
– Inhalers
• Agreed to work up strategies and projects
Agreed Priorities
1. Need for spirometry competencies to be increased
across all kinds of professionals, for accurate earlier
diagnosis and ongoing effective monitoring
2. Need for improved effective use of inhalers by patients
and their carers, through improved inhaler
technique capabilities and training
3. Need for appropriate, effective and responsible
inhaler prescribing in terms of both medication
and devices
 Quality Assured Spirometry

Vikki Knowles
Respiratory Nurse
Consultant
G & W CCG
Setting the scene
● Spirometry is the recommended objective test
performed to identify abnormalities in lung
volumes and air flow .
1

● It is used in conjunction with physical

assessment, history taking, blood tests and x-
rays, to exclude or confirm particular types of
lung disease, enabling timely diagnosis and
treatment.
The Global view
● Standardisation of spirometry (2005)
Eur Resp Journal 26: 319-338
● BTS NICE QS 10 (2011) COPD
STANDARDS DOCUMENT
Diagnostic Spirometry in Primary Care

Proposed standards for general practice compliant with American

Thoracic Society and European Respiratory Society
Recommendations

A General Practice Airways Group (GPIAG)1 document, in association with

the Association for Respiratory Technology & Physiology (ARTP)2 and
Education for Health3
1 www.gpiag.org 2 www.artp.org 3 www.educationforhealth.org.uk

Mark L Levy, Philip H Quanjer, Rachel Booker, Brendan G Cooper, Stephen

Holmes, Iain R Small
Quality Assurance

● Diagnostic spirometry should only be conducted by an

operator trained and assessed to Association for
Respiratory Technology and Physiotherapy (ARTP) or
equivalent standards in the performance of spirometry
by recognised training bodies.
● Interpretation of results may be performed separately.
The interpreter must be trained and assessed to ARTP
or equivalent standards in the interpretation of
spirometry by recognised training bodies2.
Other useful educational information
Pitfalls in Spirometry: An Educational Piece
Jo Congleton, Consultant Physician, Clinical Co-lead
South of England (east) SHA
Breathing Matters Nov 2010
Restrictive Spirometry: An Educational Piece
Jo Congleton, Consultant Physician, Clinical Co-lead
South of England (east) SHA
Breathing Matters Sept 2011

QA Diagnostic spirometry for COPD. Ten minute

tutorial (2013)
www.copdexchange.co.uk
Issues re training
ARTP certification Gold standard but:
● Significant cost and time implications
● Practices may disengage with spirometry training
● Increased referrals to separate spirometry service
QA Spirometry training
● Silver standard training
● Alternative way of achieving a safe and cost effective
service
● Practical to achieve across a CCG
● Starting point for those practices wishing to achieve the
ARTP certification
Risk of poor quality spirometry
● Incorrect diagnosis
● Poor patient outcomes
● Inappropriate use of inhaled
treatment with increased risk of side
effects for no benefit.
COPD in KSS
68,000 people diagnosed; 55,000 undiagnosed

KSS spend £46.6m on inhaled corticosteroids in 2010

49,504 bed days

1,891 deaths in 2010

equating to a DSR of 21.92 (against England rate of 25.19)

1,557 years of life lost

Standardised LoS 6.3 days

below national average 6.4,
however, reducing to best area’s (London) could save 3,196 bed days
Spirometry in Primary Care
● Unlike many medical tests during which the patients
remain passive, spirometry testing requires co-
operation and an almost athletic breathing manoeuvre.
● With submaximal effort, the results are erroneous
(false positive and false negative for disease or change
in severity).
● The misclassification rate is about 5% in most research
and sub-speciality settings , but has been shown to be
higher in primary care settings.
● The most common cause of error is inadequate
spirometry training and experience of the person
performing the test
Common Errors
● Sub maximal inhalation
● Excessive extrapolated volume
● Slow start
● Cough
● Early termination
● Variable effort
● Cessation of airflow – glottis closure
● Leak
● Extra breaths
Local spirometry provision
● How does your service stack up?
● Have you used a QA checklist to
assess the quality of the service
being provided.
● Who carries out spirometry?
● What training have the HCP’s
providing spirometry undertaken?
What happens in other areas
● Leicester ask practices to submit 10 traces
to RCT lead for approval.
● Stockport had a spirometry LES initially but
this created problems when the HCP
leading it left.
● Moved towards accrediting a limited
number of local practitioners (ARTP) and
maintaining register but reaccreditation
proving a problem.
Supportive documents
● Commissioning Toolkit
● Service Specifications
● Read costing tool for spirometry
Spirometry and Assessment Service
Model
Number of patients
referred

Case finding diagnoses

patients earlier than
they would otherwise
have been diagnosed

Increase in cost of on- Reduction in cost of

Cost of service going treatment in treatments for
primary care exacerbations

Net cost QALY Gains

Commissioning pack cost benefit model
Summary of costs and benefits: COPD commissioning pack

Back to Contents

Select your PCT from the drop down box Click here to enter additional local costs

COPD diagnosis rate (your PCT) 46% Diagnosis rate = Number of people diagnosed with COPD
COPD diagnosis rate (national) 50% as % of estimated total number of people with COPD

Choose services to commission Net costs

Spirometry and Assessment Service Net cost of S&A Service over 20 years £ 8,480,608

Pulmonary Rehabilitation Service Net cost of PR Service in Year 1 £ -

Spirometry and Assessment Service

Key inputs Costs and benefits over 20 years

Enter local
Default
data here
% of GP practices which agree to participate 100% Cost of running S&A Service in Year 1 £ 2,160,348

% of those invited likely to turn up 30% Discounted net cost of healthcare £ 6,320,260

Proportion of population over 35 who smoke 19.7% Number of patients diagnosed by S&A 8,574

Proportion of population over 35 who are ex-smokers 29.9% Discounted QALY benefits 122

% of current smokers who quit on diagnosis 10% Cost per QALY gained £ 69,600

Year-by-year costs and benefits Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7

Cost of S&A running service in Year 1 £2,160,348

Discounted cost of additional treatment £1,113,971 £940,078 £776,672 £623,243 £555,673 £491,960 £431,921

Discounted savings from reduced exacerbations -£140,194 -£117,541 -£96,260 -£76,284 -£67,114 -£58,477 -£50,347

Discounted net cost of healthcare £973,777 £822,537 £680,412 £546,959 £488,559 £433,483 £381,573

Discounted QALY benefits 2.94 2.54 2.15 1.77 1.59 1.41 1.24

Cost per QALY gained £331,459 £324,183 £316,785 £309,116 £307,461 £306,665 £307,000
Achieving QA Spirometry
Silver standard
● 2 full days attendance
● Submission of portfolio
● Local assessment
● Annual half day attendance to
maintain QA
Morning session – Day 1

● Introduction in to the rationale for performing spirometry

followed by:
● Practical session on performing spirometry to include:
● Preparation of equipment
● Review of different spirometers (Attendees asked to bring
along spirometer they use where possible.
● Calibration techniques
● Patient preparation
● Information on Contraindications
● Practical Assessment
Afternoon session – Day 1
● Introduction into interpretation
● Review all the spirometry strips from the
morning assessment (QA)

● Within 6 weeks submit portfolio, 5 cases,

calibration log and pre test check list.
Day 2 Interpretation day
● GP and PN to attend with portfolio containing 3 spirometry
tracings.
● GP part of protected learning QA: One GP per practice to
attend
● Morning session
● Introduction to interpretation of spirometry results with link
to diagnosis.
● Review of spirometry tracings brought to day; Assess
quality of tracing and interpretation of results
● Afternoon session
● Assessment of 5 cases to complete the day
● Certificate of attendance if passed
Maintaining QA Spirometry
● Annual half day attendance for all
staff who have completed initial QA
spirometry sessions.
● Submission and review of 5 cases
● Information / signposting - ARTP
Gold standard accredited spirometry
courses.
The Next Step
● How would you define a QA spirometry
service?
● Do you think the silver standard level offers
a robust first step to achieving QA
spirometry?
● What is your preferred model of delivery?
● Should we be insisting on ARTP
qualification across the CCG within all GP
practices?
Follow us on Social Media

@PCRSUK

https://www.facebook.com/PCRSUK
 Inhaler Technique
How do we get it right and improve
technique, knowledge and
understanding of both HCP’s and
patients?

Jo Wookey KSS AHSN Respiratory programme co

lead.
Why is so important?

4 of the top 5 costliest drugs to

the NHS are Respiratory inhalers
 Top 5 costliest drugs in the NHS ?
(Mar 2014)
5. Sitagliptin 100mg - £5.8 million/mo
4. Seretide 500 accuhaler - £8 million/mo
3. Symbicort 200 - £8.5 million/mo
2. Tiotropium - £12 million/mo
1. Seretide 250 evohaler - £12.5 million/mo

Thus, of the top 5 costliest drugs to the NHS currently,

4 ARE RESPIRATORY INHALERS

Total for high potency Seretide approx £260 million/yr

Source: www.drugtariff.co.uk = last accessed

Sep 2014
Why is it so important?
• 90% of patients have the wrong technique.
• Poor technique means patients aren’t getting the dose they
require
• Think its ineffective
• Doesn’t help symptom management
• Keep changing inhalers or stepped up onto inappropriate regimes
• Studies have shown between 70-94% of HCP’s unable to
demonstrate ability to use inhale correctly
• If we can’t do it right how can the patient??
Therefore, it is a costly mistake to both the patient and the
NHS getting it wrong!
What do we need to do?
• Improve the knowledge of all HPC’s
• Understanding the different devices, how they work, pro’s &
con’s
• Patient appropriate device selection
• Use of spacers- the correct type for the correct device
• Understanding of the prescribing guidelines
• Improve skills in teaching inhaler technique
• Check and re-check inhaler technique at every opportunity
• Improve patient knowledge and technique
• Provide patients with information about their device
• Ensure carer/partner knows how to use the device
• Involve them in the selection of the device
How do we do this? Examples….
• Train the trainer
• Isle of Wight project-
• HCPs were instructed on how to use the inhalers themselves, and then
trained to measure a patient's ability to use their prescribed inhaler.
• Emergency admissions due to asthma reduced by 50%, and deaths by
75%. PCT
• Bronchodilator spend down by 20%
• Hospital inpatient costs for asthma-related admissions have fallen by
66%
• South West inhaler training project-
• training ambassadors( primary and secondary nurses and pharmacists)
supported by on-line competency and then running further training
sessions locally to other HCP’s
• Consistent messages
• ITT East Sussex
• Trained the trainers
• Learnt that targeting specific groups/ organisation was more effective
than a “mass marketing” approach with better uptake.
• Have delivered workshops to practice nurses, ACNPs, school staff,
domiciliary care workers and housing support workers and more recently
nursing and therapy teams in HWLH.
• Getting engagement is key
Examples…
• Online training
• Greater Manchester inhaler improvement innovation project-
WIRES Podcasts hosted by Wessex AHSN

• Medicines.org.uk- video’s showing use of inhaler + info on

each device and medication

• Pharma websites
Examples
• On-line information/resources

• BLF
• Asthma uk
• Local CCG websites hosting information
• Local pharmacy websites
How shall we do this across KSS?
? Build on Train the trainer
? Agreed standardised training for the region- slide set
? Consistent messages
? Accredited training/competency sets
? combining training with MUR’s- utilise pharmacists
? Develop regional on-line resource- utilising existing
resources
? Patient/carer information

Over to you…………..
 Responsible Respiratory Prescribing
Messages
Draft update for discussion
Helen Marlow, Lead Primary Care Pharmacist and NICE Medicines and
Prescribing Centre Associate

August 2015
Responsible Prescribing in COPD (old
messages)
South East Coast Principles

Do the right things:

 Smoking cessation is the most effective intervention for COPD
 Pulmonary rehabilitation reduces admissions and health care
resource use, improves exercise capacity and health related quality
of life
 Prescribe according to guidelines
Do the right things right:
 Ensure correct inhaler technique most patients don’t know how to
use their inhaler and many health care professionals who teach the
use of MDI cannot demonstrate it correctly
 Use a spacer when using an MDI correctly a max of 15% of the drug
enters the lung. With a spacer this can be increased up to 30%
 Use an ICS patient safety card
 What are we trying to achieve?
Maximise value

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

The challenge for the NHS is to get
more for less in an era of “no more
money”.

To do this, the NHS needs to shift

from lower value interventions
to higher value interventions
 Right Care
“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

 Do the right thing

 Do the right thing right

 Doing the right thing right first time should deliver

quality and value
COPD Value Pyramid (from London RespiratoryTeam)
Cost per QALY*
Telehealth
*Quality Adjusted Life Year £92000/ QALY

Triple Therapy
£7000-
£187000/QALY

Long term Oxygen Therapy

£11-16000/QALY

LABA
£5-8000/QALY

Tiotropium/LAMA
£7000/QALY

Pulmonary Rehabilitation
£2000-8000/QALY

Stop Smoking Support with pharmacotherapy £2000/QALY

Flu vaccination? £1000/QALY in “at risk” population

Responsible Prescribing in COPD (old
messages)
South East Coast Principles

Do the right things:

 Smoking cessation is the most effective intervention for COPD
 Pulmonary rehabilitation reduces admissions and health care
resource use, improves exercise capacity and health related quality
of life
 Prescribe according to guidelines
Do the right things right:
 Ensure correct inhaler technique most patients don’t know how to
use their inhaler and many health care professionals who teach the
use of MDI cannot demonstrate it correctly
 Use a spacer when using an MDI correctly a max of 15% of the drug
enters the lung. With a spacer this can be increased up to 30%
 Use an ICS patient safety card
 Asthma – potential RRP messages
Do the right things:
 Smoking cessation is the most effective intervention for COPD
 Personalised asthma action plans improve outcomes and may
reduce readmission rates
Do the right things right:
 Titrate dose of inhaled preventative therapy to optimise asthma
control and minimise risk of side effects
 Know the equivalent dose of ICS when changing to a combination
inhaler
 Check adherence to and use of preventer and reliever therapy, to
identify patients at risk of severe exacerbations
 Use an ICS patient safety card
 COPD – potential RRP messages
Do the right things:
 Smoking cessation is the most effective intervention for COPD
 Flu vaccination reduces the risk of COPD exacerbations
 Pulmonary rehabilitation reduces admissions and health care resource
use, improves exercise capacity and health related quality of life
 Prescribe according to guidelines
 Provide individualised self management plan and exacerbation rescue
pack, to patients with COPD exacerbations

Do the right things right:

 Encourage a trial of therapy, if it does not work don’t be afraid to stop it
 Use an ICS patient safety card for patients on high dose ICS
 Reserve ICS for more severe COPD and frequent exacerbations to
minimise risk of harm and optimise benefit
 Inhalers - – potential RRP messages
Do the right things:
 With the patient, decide the best device for them assess their ability to
inhale, let them see, touch and feel the inhaler, then describe, show and
provide written information
Do the right things right:
 Ensure correct inhaler technique most patients don’t know how to use their
inhaler and many health care professionals who teach the use of MDI
cannot demonstrate it correctly
 Use a spacer when using an MDI correctly a max of 15% of the drug
enters the lung. With a spacer this can be increased up to 30%
 Prescribe inhalers by brand, so patient receives correct inhaler device
 Rationalise inhaler devices for an individual patient, avoid mixing too many
DPI devices (check evidence)
 Re-check inhaler technique often, inhaler technique deteriorates over time,
and lots of patients think they are using their inhalers correctly when they
are not
 Updating messages
• Do we have any new evidence / important
issues in practice to include?
• Do we need separate messages for asthma
and COPD?
• Messages need to be relevant and valid
• How should they be presented?

What do you think?