siân williams nhs london respiratory team programme manager creating a case for a 1% shift...
TRANSCRIPT
Siân Williams NHS London Respiratory Team Programme Manager
Creating a case for a 1% shift
Improving value in programme budgets
Imagine we used the value framework
Health OutcomesPatient definedbundle of care
CostValue=
Health Outcomes Cost of delivering
Outcomes
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
To invest appropriately in interventions for people with COPD
Jiminez Ruiz et al Nicotine and Tobacco Research 2011
~500 smokers with severe COPD
Mean age 58 years60 pack-years of smokingHigh nicotine dependence
10 intensive behavioral interventions with medication:233 Nicotine Replacement Therapy & 190 Varenicline
48.5% abstinence at 6 months61% with Varenicline and 44% with NRTSafe
Even those with severe disease
Because even before that paper we knew enough to proceed at a clinical
level‘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.’
NICE 2010
J Health Serv Res Policy. 2011 Jul;16(3):133-40.Emergency respiratory admissions: influence of practice, population and hospital factors. Purdy S et al. Academic Unit of Primary Health Care, Bristol
• For every 1% increase in prevalence of smoking in your COPD population there is a 1% increase in COPD admission rates
• For every 1% increase in prevalence of smoking in your asthma population there is a 1% increase in asthma admission rates
And at a population level
Either from a zero base, or to add to existing interventions
Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psychiatry 2004;161:2317-2319 0
200 out-patients with SMI• 60% current smokers (mean age 44)• 23% COPD prevalence (self-reported)• Only 36% reported having COPD treatment
147 Medicaid patients with SMI• 31% COPD prevalence; 50% as co-morbidity• Annual costs for SMI and COPD were 4 x higher• 45% (5/11) deaths due to respiratory disease
Jones DR, Macias C, Barreira PJ et al Psychiatric Services 2004;55:1250-1257
And there is still unmet need in primary care eg Southwark dashboard 2013
Prevalence of current smoking where status
recorded in last 15 months
1550/3335 = 46.5%
COPD smokers in last year receiving evidence based stop smoking support – 17.5%
So what if we reduced smoking prevalence by 1%.....
So what if we did this by shifting resources to where the people are?
Where are the people?
Sick smokers in hospital beds
Smokers in mental health services
In prisons
Quietly stoical at home
Multiple prescriptions
Would it tackle….
• Premature mortality
• Optimising bed days
• Waste – human spirit, staff resources, time, prescriptions
Asymptomatic smokers: Tobacco control policies, very
brief advice, education, smoke-free environments, community-based stop smoking services,
quitlines, self-referral,
Primary care management of tobacco dependence and
long term conditions, ongoing, sustained, LES,
QOF
Supporting sick smokers:
CQUIN, NRT, stop smoking
champions
Fall in children's asthma admissions equivalent to 6802 fewer hospital admissions in 3 years after smoking ban .http://pediatrics.aappublications.org/content/early/2013/01/15/peds.2012-2592.abstract …
http://jpubhealth.oxfordjournals.org/content/34/1/37.long 200 public health interventions analysed for cost-effectiveness 15% were cost -saving 85% were under 20k per QALY
Martin McShane, NHS CB Lead for Long Term Conditions Care (Domain 2), December 2012
If we had £1200 per person per year, the gearing is:• £100 – GP, • £200 community, • £600 acute, • £300 specialist
If acute goes up by 4% have to take 24% out of primary or 12% out of community; £300 specialist won’t change!
Why shift? It’s all about value….
Programme budget illustrationsRespiratory as proportion of total -
Southwark illustration 2010-11
Total respiratoryTotal programme budgets (ex GMS and miscellenous)
Respiratory categories as proportion of total respiratory
COPDAsthmaRespiratory other
11X
Respiratory programme budget
Spend by care setting Southwark illustration 2010-11 (note nothing coded as health promotion)
%Primary prescribing & pharma services
_x001F_Inpatient: Elective and Daycase
_x0017_Inpatient: Non-elective
Outpatient
_x0014_Other secondary care
Ambulance
_x0014_A&E (inc. MIU & WIC)
_x0004_Care
& social care provided in other setting
_x000c_ social care
Tariffs 2013-14 (* non-mandatory)1st single
1st multi
FU single
FU multi Non face to face*
Spell Trim-point (days)
Respiratory medicine OP 189 245 104 145 23
COPD or bronchitis with NIV without intubation with CC emergency admission
2771 24
Stop smoking West Midlands (2012-13*)
General pop’n no Rx
Targeted pop’n no Rx
General pop’n with Rx
Targeted pop’n with Rx
(4 week quitter 94 136 166 214)
12 week quitter – verified in primary care
129 271 228 427
What does 1% look like - in Southwark?
• 1% of respiratory OP spend £18,940• 1% of total respiratory secondary care £136,
090• 1% of respiratory primary care prescribing £40,470
2010/11 Programme budget –usual caveats about coding
Imagine we shifted some of that to where the people are– eg a mental health stop smoking adviser, or a system-wide education and training programme or a joined up stop smoking service– would we achieve greater value?