Virtual clinics in COPD and high
dose ICS step down
Dr Azhar Saleem
GP Respiratory Lead, Lambeth CCG
GP Lead London Procurement Partnership
GP and Lung co-lead TOHETI, Guys & St Thomas’ Hospital
www.toheti.org
Oct 2015
Disclosures for Dr Azhar Saleem
I never do promotional speaking
Research Support/P.I.
No relevant conflicts of interest to declare
Employee
No relevant conflicts of interest to declare
Consultant
No relevant conflicts of interest to declare
Major Stockholder
No relevant conflicts of interest to declare
Speakers Bureau
No relevant conflicts of interest to declare
Honoraria
TEVA, Pfizer
Scientific Advisory Board
No relevant conflicts of interest to declare
What the difference between
COPD and True Love?
COPD lasts forever
NHS best in the world
Worst crisis in 20 years?
Value based interventions
APPROPRIATE
Health outcomes
True Value
=
Cost
+
COST OF WASTE
Value based pyramid
WISDOM STUDY
• 2485 patients with moderate to severe COPD with
exacerbations
• Randomised after 6 week run in to either ICS continuation
or stepwise withdrawal to dual bronchodilatation with
LAMA/LABA (tio/salm) over 52 weeks
• Mean FEV1 34% Mean mMRC 1.8
• Primary end point – time to first moderate or severe COPD
exacerbation
• Magnussen H et al. NEJM Sept 2014 DOI: 10.1056/NEJMoa1407154
WISDOM STUDY RESULTS
• 2027 patients completed study
• No difference in exacerbation rate between 2 groups (HR 1.06
CI 0.94-1.19)
• At week 18, ICS group had 38ml greater trough FEV1 (p<0.001)
and week 52 - 43 ml (p<0.001)
• Slight difference in SGRQ at weeks 52 in favour of ICS
continuation (1.22 difference p=0.047)
• CONCLUSION
• Many patients with severe to very severe COPD and
exacerbations may not benefit from addition of ICS on top
of LAMA+LABA
Evidence from UK
White P et al. PLoS One. 2013 Oct 23;8(10):e75221. doi: 10.1371/journal.pone.0075221. eCollection 2013.
Applying medicines optimisation
principles
• 35% of patients on COPD
registers did not have spirometry
consistent with this diagnosis
Principle 1 :
Understanding
the patient
experience
• 38% of patients were receiving
inhaled corticosteroid (ICS)
therapy outside national guidance
• lack of focus on high value
interventions like quit smoking
support and pulmonary
rehabilitation
Patrick White et al, 2013. 41 London general
practices (population 310,775)
- Population 366,574
- Densely populated and ethnically
diverse borough
- 48 General Practices
- 3 Locality Care Networks
- North Lambeth
(95,816)
- SE Lambeth
(113,701)
- SW Lambeth
(157,054)
Lambeth & Southwark IRT
Pulmonary
rehabilitation
SECONDARY
CARE
Chest clinic
Integrated Respiratory Team
Oxygen
assessment &
review
Virtual clinics
PRIMARY
CARE
Tier 3
smoking
cessation
Advanced
lung
function
One referral
form
IRT Structure
Respiratory
physio team
GSTT
GSTT Chest
clinic
GP Lambeth
Respiratory nurses
GSTT & KCH
Respiratory physio
team KCH
50% SECONDARY
CARE
Consultant Chest Physician
KCH Chest
clinic
50% PRIMARY
CARE
Respiratory
pharmacist
GP Southwark
The joint MO and IRT plan
• COPD: Review of Inhaled Corticosteroid in
mild & moderate
• Asthma: Step down clinics for pts on high
dose ICS (at step 4)
• Metric. Reduction in high dose ICS as a %
of all ICS items
What is a virtual clinic?
Virtual clinics
Virtual Clinics – a model for change
• Delivered in GP practice by an integrated
respiratory consultant and/or respiratory
pharmacist or GP respiratory lead.
Principle 4:
Making
medicines
optimisatio
n part of
routine
practice
• 2-hour structured sessions for practice
clinicians to discuss optimal patient
management on a case by case basis.
• Pre-work – searches and templates
• Follow up – sustainability (GP/nurse
actions) and patient engagement in the
plan; ideally within 2 weeks.
19
Why Virtual Clinics ?
• Information alone doesn’t
change behaviour
• Asthma and COPD registers are
currently quite inaccurate for many
different reasons
• Diagnostic spirometry is not
performed well in primary care
• COPD is often incorrectly staged
and there are ‘false’ Asthma
diagnoses
• Respiratory prescribing is often
poorly understood
20
21
22
23
VCs - Typical changes
• Many patients on high dose LABA/ICS but not on a LAMA
• Many patients had not had PR or smoking cessation prior to
being on high dose ICS
• Many patients on high dose ICS with FEV1 % predicted
above 50%
• Some patients on high dose ICS didn’t even meet diagnostic
criteria for Asthma or COPD
• Poor understanding between different devices and doses of
equivalent steroid eg Accuhaler vs Evohaler
24
Evaluation of an ICS withdrawal
programme in patients with Mild/Mod
COPD in Lambeth CCG
Grainne d’Ancona, National Institute of Health Research (NIHR)
Irem Patel, Consultant Respiratory Physician, KCH
Dr Azhar Saleem, GP Respiratory Lead, Lambeth CCG
Cathrine McKenzie, Consultant Pharmacist, GSTT
Vanessa Burgess, Chief Pharmacist Lambeth CCG
Tariq Sethi, Head of Respiratory Medicine, KCH
26
Lambeth CCG ICS stepwise
withdrawal programme
• Feasibility study in one CCG (48 practices)
• withdrawal by GP upon recommendation by the
multidisciplinary Integrated Respiratory Team in a virtual
clinic
• 370 patients with FEV1 >50% reviewed – 320 had COPD
• 2/3 patients had a change in medicines recommended
• Of these, 76% to gradually stop or step down ICS dose
• 60% attempted (95% patient acceptance)
Lambeth ICS prescribing
Percentage high-dose ICS prescribing (of all ICS)
34%
2012-13
2013-14
2014-15
33%
32%
31%
30%
29%
28%
Launch of Respiratory
Virtual Clinics
27%
26%
25%
24%
Q1 2012- Q2 2012- Q3 2012- Q4 2012- Q1 2013- Q2 2013- Q3 2013- Q4 2013- Q1 2014- Q2 2014- Q3 201413
13
13
13
14
14
14
14
15
15
15
Lambeth ICS prescribing pattern
17% reduction in high dose ICS
Tiotropium items, Lambeth CCG
3,400
Tiotropium Items
3,300
3,200
3,100
3,000
2,900
2,800
Tiotropium Items
2,700
2,600
2,500
2,400
1st Quarter
2013/2014
2nd Quarter
2013/2014
3rd Quarter
2013/2014
4th Quarter
2013/2014
1st Quarter
2014/2015
2nd Quarter
2014/2015
3rd Quarter
2014/2015
30
PR referrals increased by 40%
1000
Pulmonary Rehabilitation – referrals
900
800
700
600
GP Referrals,
Lambeth CCG
500
400
All referrals incl
hospital referrals
300
200
100
0
Total referrals for
2012
1st & 2nd Q’s 2013
3rd & 4th Q’s 2013
Total Referrals for
2013
31
Lambeth ICS prescribing
Q2 2014/2015
Q2 2013/2014
Admissions data
• Between 2011/12 and 2013/14 COPD admissions in
Southwark decreased by 6%, saving £37,016 and
£43,926 per year. Lambeth has shown a smaller
impact to date.
• From 2011/12 to 2013/14 neither borough had an
increase in COPD admissions attributable to the ICS
“step down.
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It can be done!
!
What now?
• Lambeth and Southwark CCG are now targeting Asthma
with the high quality Asthma pyramid
• Lambeth and Southwark have developed two algorithms for
use by primary care to work up patients presenting with
breathlessness and cough.
• London Procurement Partnership in conjunction with UKMI
and the ABPI are developing an NHS digital inhaler resource
to be free at the point of use for all NHS HCPs and to be
editorially managed and control by the NHS
The high quality asthma pyramid
Key
SABA = short-acting B-agonist
ICS = Inhaled Corticosteroid
QST = Quit Smoking Treatment
PAAP = asthma action plan
VBA = Very Brief Advice (smoking
cessation)
The reality of how it’ll look
Key
SABA = short-acting B-agonist
ICS = Inhaled Corticosteroid
QST = Quit Smoking Treatment
PAAP = asthma action plan
VBA = Very Brief Advice (smoking cessation)
Breathlessness Algorithm
Cardiac
Respiratory
Mental Illness
/Addiction
Fitness/Lifestyle
Anaemia/Kidney
disease
Breathlessness Algorithm
NHS Lambeth Clinical Commissioning Group
NHS Southwark Clinical Commissioning Group
NHS Lambeth Clinical Commissioning Group
NHS Southwark Clinical Commissioning Group
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Common(Causes(of(
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Further(Examinations/Tests(
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