breakout 4. 2 benefits of implementing medicines optimisation in a copd and asthma clinic - clare...
DESCRIPTION
Breakout 4. 2 Benefits of implementing medicines optimisation in a COPD and asthma clinic - Clare Watson Medicines Management Pharmacist (NHS Hampshire) Independent Prescriber (Victoria Practice, Aldershot) Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programmeTRANSCRIPT
1
Benefits of Implementing
Medicines Optimisation
in a COPD and Asthma Clinic
Clare Watson
Medicines Management Pharmacist (NHS Hampshire)
Independent Prescriber (Victoria Practice, Aldershot)
The Victoria practice participated in a
National Improvement programme to improve
management of patients with COPD and
Asthma, by providing a patient centred
service focusing on
Use of Motivational Interviewing techniques
Adherence
Inhaler technique
Implementing Evidence based cost effective
prescribing in line with current national guidance eg.
Nice, BTS/SIGN
Regular patient review and follow up
Reducing waste
2
What is Medicines Optimisation?
Medicines optimisation is a more patient-focused
approach to getting the best from medicines.
Focused on the patient and their experience, it can
help more patients take their medicines correctly,
reduce waste of medicines, avoid patients taking
unnecessary medicines and improve medicines
safety. Ultimately it can help encourage patients to
take more ownership of their treatment.
Royal Pharmaceutical Society – Good Practice Guidance for
Healthcare Professionals Sept 2012
Why Medicines Optimisation?
Suboptimal prescribing and/or patient adherence
affects patients’ ability to self manage, use of primary
care, admissions, A&E attendance and medicines cost
Current cost of all asthma and COPD medication:
£1.17billion pa
Choice and cost of medicines
How do patients really use medicines?
3
BMJ October 2012….
“45 million prescriptions for respiratory inhalers were
dispensed in 2011 in England alone—at a cost of
£900 million to the NHS—everyone needs to be more
clued up on correct inhaler technique to make sure
these drugs work well for patients and offer the best
value for money for the NHS”
BMJ October 2012….
“45 million prescriptions for respiratory inhalers were
dispensed in 2011 in England alone—at a cost of
£900 million to the NHS—everyone needs to be more
clued up on correct inhaler technique to make sure
these drugs work well for patients and offer the best
value for money for the NHS”
Designing and commissioning services
for adults with asthma: A good practice
guide. PCC 2012
http://www.pcc.nhs.uk/asthma-guide
Many patients do not lead lives free of symptoms and
this is despite the availability of well-constructed
guidelines and good medicines
When patients do take their medication, many do it
incorrectly, which will have an impact on the cost of
treatment and lead to suboptimal outcomes
4
How did we know if we had made an
improvement?
Indicated by cost of respiratory prescribing, medicines
mix, admissions and patient CAT score / ACT score
before and after the intervention
CAT: COPD assessment test: www.catestonline.co.uk
ACT: Asthma control test: www.asthmacontroltest.com
Context
Practice list size: 8476
5 partners (4.5 whole time equivalents)
135 COPD patients
378 Asthma patients
Annual reviews offered scope to address medicines
use and optimisation
Pharmacist led Asthma & COPD clinic (Independent
prescriber and Medicines Management Pharmacist,
COPD Diploma, Clinical Diploma, Community
pharmacy background
5
Approach
1 x 5 hour session per week
30 minute appointments
Understanding the patient’s attitude to and actual use
of medication
Encouraging realistic goal setting and behaviour
change
Using technical knowledge to optimise prescribing
(clinical benefit/cost effectiveness)
Patient reviews
Review compliance, exacerbations, control and
medicines ordering over last 12 months
Patient consultation incorporating:
Understanding current attitudes & motivation
Good things/Not so good things – decisional balance
Eliciting self sufficiency & patient responsibility
Optimisation of treatment
Follow up
6
Understanding current attitudes and
motivation using open questions Tell me some more about that
What are your thoughts about…?
In what ways does that concern you?
Describe what it’s like when?
How do you feel about….?
Tell me what you like about X
Tell me some of the things you don’t like about X
Goal Setting
Where does this leave you?
What’s your plan?
Given all we’ve talked about today, where would you
like to go from here?
What do you want to do next?
What are the difficulties/benefits of taking your
medicine?
7
Commitment
On a scale of 0 to 10 (where 0 = not at all and 10 = very much):
How much do you want to start/continue this treatment?
How important is it to you to start/continue this treatment?
How ready do you feel you are to start/continue this treatment?
How much better do you think your life would be if you start/continue this treatment?
Wrapping Up
How confident do you feel that you will be able to do this?
One a scale of one to 10, how confident do you feel?
If patient is negative, ask how can you get it up to an 8?
Confidence building: Why 7 and not 5?
In a month’s time, what is going to be different now that you are
taking your medicines?
If patient is negative say, “Some people find that…..”
If there is no response say, “So nothing is going to change at all?”
8
Availability
Is the patient on the “right” treatment (medication and
device) for their needs?
Is it a clinically effective choice?
Is it a cost effective choice? Cost comparison tables
available on the website below
http://www.nyrdtc.nhs.uk/Services/presc_supp/presc_sup
p.html
Evidence based? Cost effective?
Right choice of medication for condition and severity of
disease?
Able to use it?
Cost effective choice?
Examples:
Adding on an aerochamber®
to MDI device
Adding LAMA / LABA
Substituting Seretide Acculaher® for Evohaler ®
Smoking cessation / pulmonary rehabilitation
9
Knowledge
Inhaler technique – maintaining own skills as well as
checking others
In-Check Dial to achieve optimal inspiratory flow
(http://www.clement-clarke.com/products/in-check-dial)
2Tone device for MDI users (Now replaced by In-
Check Flo-Tone http://www.flo-tone.com)
Follow up calls or appointments to check progress &
understanding
New medicines not added to repeats until impact
assessed
Victoria Practice Prescribing cost
0
2000
4000
6000
8000
10000
12000
14000
16000
Apr-07
May
-07
Jun-07
Jul-0
7
Aug
-07
Sep
-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb
-08
Mar-08
Apr-08
May
-08
Jun-08
Jul-0
8
Aug
-08
Sep
-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb
-09
Mar-09
Apr-09
May
-09
Jun-09
Jul-0
9
Aug
-09
Sep
-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb
-10
Mar-10
Apr-10
May
-10
Jun-10
Jul-1
0
Aug
-10
Sep
-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb
-11
Mar-11
Apr-11
May
-11
Jun-11
Jul-1
1
prescribing cost
£
£ The Mean (Average) Upper Control Limit Lower Control Limit
10
Change in consecutive CAT score by patient
0
5
10
15
20
25
30
35
1 2 3 4 5 6 7 8 9 10
Patient
CA
T s
co
re
Original CAT score
Second CAT score
Key Learning
30 minute appointments allow time to establish rapport with the patient and understand issues affecting adherence
Follow up reinforces patient understanding and behaviour
Telephone calls in advance can reduce DNAs.
Synchronise repeats where possible to reduce waste, patient inconvenience and surgery work load
Relationships are key
Pharmacist skills can provide a cost effective approach to improving medicines optimisation in the management of any long term condition and enhance the skill mix in the practice team
11