alison mcminn respiratory lead pharmacist mmt, liverpool community health (lch)...
TRANSCRIPT
Alison McMinnRespiratory Lead PharmacistMMT, Liverpool Community Health (LCH)[email protected]
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
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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