Alison McMinnRespiratory Lead PharmacistMMT, Liverpool Community Health (LCH)Alison.McMinn@liverpoolCH.nhs.uk

Medicines optimisation can help reduce COPD related hospital admissions and exacerbations - LCH MMT Approach

Brief overview of COPDMedicines OptimisationLiverpool priorityProcessOutcomesLessons Learnt along the way

Objectives of the session

0

Chronic obstructive pulmonary disease

Implementing NICE guidance

NICE clinical guideline 101

About 3 million people have chronic obstructive pulmonary disease (COPD) in the UK

Nearly 900,000 people in England and Wales are diagnosed as having COPD and an estimated 2 million people have COPD which remains undiagnosed

Most patients are not diagnosed until they are in their fifties

Epidemiology1

COPD is predominantly caused by smoking and is characterised by airflow obstruction that:

- is not fully reversible- does not change markedly over several months- is usually progressive in the long term

Exacerbations are commonly see, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations requiring a change in treatment

Background1

Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7)

If FEV1 is ≥ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough

COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction.

Definition of COPD1

Consider a diagnosis of COPD for people who are:– over 35, and– smokers or ex-smokers, and– have any of these symptoms:

- exertional breathlessness

- chronic cough

- regular sputum production,-frequent winter ‘bronchitis’ -Wheeze

Diagnose COPD1

Diagnose COPD: assessment of severity1

• Assess severity of airflow obstruction using reduction in FEV1

NICE clinical

guideline 12 (2004)

ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101

(2010)

Post-bronchodilato

r FEV1/FVC

FEV1 % predicted

Post-bronchodilato

r

Post-bronchodilator

Post-bronchodilator

< 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)*

< 0.7 50–79% Mild Moderate Stage 2 (moderate)

Stage 2 (moderate)

< 0.7 30–49% Moderate Severe Stage 3 (severe) Stage 3 (severe)

< 0.7 < 30% Severe Very severe Stage 4 (very severe)**

Stage 4 (very severe)**

* Symptoms should be present to diagnose COPD in people with mild airflow obstruction** Or FEV1 < 50% with respiratory failure

Managing stable COPD: inhaled therapies1

Smoking Cessation Vaccination Accurate diagnosis

Accredited post bronchodilator spirometry Pulmonary Rehabilitation

Breathlessness management Other symptoms

Anxiety Management Low BMI Low oxygen saturations (<92%)

Palliative Care

COPD Management1

Two main clinical priorities…Reduce Exacerbations Reduce Breathlessness

Minimise impact of exacerbations by:-– giving self-management advice on responding

promptly to symptoms of exacerbation– starting appropriate treatment with oral steroids

and/or antibiotics – (Rescue Pack – 8bmw)– use of non-invasive ventilation when indicated– use of hospital-at-home or assisted-discharge

schemesThe frequency of exacerbations should be reduced by

appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations

Managing exacerbations1

MRC Scale – Breathless score1

GRADE Degree of breathlessness related to activities

1 Not troubled by breathlessness except on strenuous exercise

2 Short of breath when hurrying or walking up a slight hill

3 Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when

walking at own pace.

4 Stops for breath after walking about 100m or after a few minutes on the level

5 Too breathless to leave the house, or breathless when dressing or undressing

CAT Score

• Read coded on clinical systems – 38Dg

• www.catestonline.co.uk/index.htm

• Improvement of > 2 shows improvement in quality of life

Medicines OptimisationReduce Exacerbations and Admissions

Identify: All patients with ≥ 2 exacerbation or ≥ 1 admission in the last 12 months

•Check inhaler technique, concordance prior to further optimisation•Consider rescue pack (8bmw)•Self Management Plan

Improve breathlessness

Identify: All patients with an MRC ≥ 3 and ensure their long acting bronchodilators are optimised

•Check inhaler technique, concordance prior to further optimisation•Refer to pulmonary rehabilitation•Check pulse oximetry•Self Management Plan

Pharmacist Medicines OptimisationCOPD Medicines

OptimisationInhaler TechniqueHolistic Medication

ReviewSmoking CessationPulse Oximetry (<92%)Weight/BMI checkDepression Screening

MRC ScoreReferral for Pulmonary

RehabilitationVaccinationSelf Management PlanRescue Pack (8bmw)EducationFollow up

Why was the management of COPD so important in Liverpool?

British Lung Foundation 20072

Liverpool PCO was ranked 3rd worst COPD ‘hotspot’ in the UK

‘People in Liverpool are 43% more likely to be admitted to hospital with COPD than the UK average”.

“Six Steps”*

Accurate diagnosis Optimal stable management Referral to Pulmonary Rehabilitation Acute management Oxygen assessment End of life *Devised by Steve Callaghan (formerly of Liverpool PCT)

North Mersey COPD QIPP Overall Aim: Reduce non elective COPD admissions by 10%

3 Key priorities

Patient access to clinician at time of exacerbation (4hours)

Nursing team (redesign)

Optimisation of medication

In Liverpool the Medicines Management work was rolled

out across the city

Reduction in Admissions Reduction in Exacerbations Pharmacist Medicines Optimisation Patient Education and Self Management Supporting Healthcare Professionals

MMT Objectives

How Practices where Selected?

Admission data was obtained & reviewed for all

practices

The priority practices (based on actual admissions and

practice need) were identified and MMT worked with

each practice as per the 6 steps as a framework

MMT had a project lead & a clinical lead for the COPD

optimisation work

How the MMT worked through the 6 steps

Band 4 - COPD register validation

Accredited post bronchodilator spirometry

Severity of COPD

Determine if under specialist respiratory team

Smoking Status

Housebound status

Band 6 registered pharmacy technician

Triaged all those patients with confirmed diagnosis

Identified patients that required ‘optimisation of

medications’ if they had over a 12 month period 2 or

more exacerbations or 1 or more hospital admissions

From April 2015, we are now also looking at MRC ≥ 3

and not on optimal bronchodilators

Identify & address any over ordering of respiratory

medication (cost saving)

How the MMT worked through the 6 steps

Review Criteria Doctor

Consider Secondary Care/Case Management Referral

Palliative Care issues – end of life register

Differential diagnosis e.g. heart failure, anaemia

Nurse (from April 2015 - Pharmacy Technician)

Nurse already has a rapport with the patient, so may find it easier to address

concordance and inhaler technique issues

Developmental role for the technician and also a way of ensuring

concordance checks have been reviewed

Pharmacist

Optimisation of COPD medications + full medication review

Triage for Review

Triage for review

Prescribed Optimal Therapy

Medicines to be Optimised

Inhaler technique/ compliance to be checked

Unclear diagnosis/ referral

GP    

Nurse /Technician    

Pharmacist      

Pharmacist Medicines Optimisation Review

6 week and 12 month outcomes

Continuous need for education and training Realistic goal Setting for patients Telephone/Face to Face follow up after interventions Outcomes – showcases the benefits of a pharmacy

team Multidisciplinary working Improved engagement with neighbourhood working

Register Validation ‘Missing Millions’ – how MMT can help

Emis Web – advanced searches/reports

Lessons Learnt on our journey

Outcomes

Total Results of Triage for 7884 patients across 52 practices

12 month outcomes

Exacerbation Data– Compare 12 month prior to the pharmacist review to

12 month post pharmacist review Admission Data

– Compare 12 month prior to the pharmacist review to 12 month post pharmacist review

Admissions reduced from* – 194 to 127 36% reduction

Exacerbations reduced from*– 2620 to 1942 26% reduction

* For the cohort of patients seen by a pharmacist

Long Term Impact of Medicines Optimisation over 3 years

Long Term Impact in Liverpool

19% reduction in admissions since North Mersey QIPP 2010/11

Objective Outcomes

Reduction in Admissions 36% Reduction (12 months post pharmacist review)

Reduction in Exacerbations 26% Reduction (12 months post pharmacist review)

Pharmacist Medicines Optimisation

1,004 patients 3125 Respiratory interventions 1622 Non-respiratory interventions

Patient Education and Self Management

Consultation and information Self management/rescue pack

Supporting Healthcare Professionals

Development of local guidelines Education/training/advice

Our Achievements

Liverpool working together Consistent results Holistic Approach

Quality of care for Patients Innovative approach to service delivery Prevention of COPD admissions and exacerbations Productivity - optimisation

“WIN WIN”

References

1. http://guidance.nice.org.uk/CG101

2. British Lung Foundation: Invisible Lives COPD – finding the missing millions (accessible via www.lunguk.org)

COPD Guidelines

http://www.panmerseyapc.nhs.uk/guidelines/documents/G17_flowchart.pdf

http://www.panmerseyapc.nhs.uk/guidelines/documents/G17_information.pdf