Asthma and chronic obstructive pulmonary disease (COPD) continue to account for a large burden of disease in the UK. Despite comprehensive guidelines, more than 1,000 people die from asthma each year and COPD accounts for a leading cause of emergency admissions in the UK. In a joint initiative between NHS City and Hackney clinical commissioning group and the local tertiary centre for respiratory disease Barts Health NHS Trust, asthma and COPD reviews were undertaken by a specialist respiratory pharmacist in GP practices on a one-day-a-week basis. The impact of the specialist asthma and COPD reviews were assessed in accordance with national guidelines and standards of care. Furthermore, to ensure a lasting legacy, practice support pharmacists (PSPs) were trained by the specialist respiratory pharmacist.
A questionnaire was devised to ensure that the reviews included factors addressed by National Institute for Health and Care Excellence (NICE) quality standards and other national and international guidelines. The reviews included assessments of: level of respiratory control: asthma control test (ACT) and COPD assessment tool (CAT) questionnaires; inhaler technique; smoking prevalence and smoking pack years where relevant; spirometry and peak expiratory flow rates where applicable; and assessing adherence to maintenance inhalers based on GP prescription records.
Patients were identified for review using EMIS Web, with a search conducted to identify patients who had either severe asthma or COPD, or those who were the greatest users of healthcare resources. A total of 567 consultations were undertaken for 364 patients with asthma and 145 patients with COPD. During this time, seven PSPs underwent training to undertake these reviews with ongoing support from the specialist respiratory pharmacist.
The study showed that a significant proportion of patients had uncontrolled disease based on their ACT or CAT scores, use of reliever inhalers and frequency of moderate-severe exacerbations. The use of high dose respiratory medicines, in many of the patients reviewed, was often a result of poor adherence to maintenance inhalers and poor inhaler technique in a large proportion of patients. Interventions were made in all patients, including reducing the beclomethasone dipropionate equivalence in the asthma group by 645.4mcg (40%), from 1617.5mcg daily to 972.1mcg daily. Follow up reviews showed that, despite a reduction in inhaler therapy, measures of asthma and COPD control, such as ACT and CAT scores, peak flow measurements, night time wakening and reliever inhaler use all improved. Furthermore, the study showed that 50% and 52% of asthma and COPD patients were supported to stop smoking successfully, defined as smoking cessation for three months or more.
Annual drug cost savings attributed to appropriate step down and cessation of therapy showed that savings of £75,000 were made. Ongoing follow up data shows that exacerbations were significantly reduced from 1.7 to 0.36 and 3.0 to 0.19 per year in asthma and COPD, respectively, with no admissions or accident and emergency department attendances. Prospective data was collected to quantify utility savings, which equated to up to £230,000 per year.
In summary, the asthma and COPD reviews have shown that a large number of patients have uncontrolled disease despite use of extensive and high dose pharmacological therapy and have a high smoking prevalence. Structured reviews by the pharmacist resulted in significant interventions that improved levels of asthma and COPD control, adherence to therapy, reductions in exacerbations, reduced unnecessary over prescribing and resulted in a large proportion of patients to quit smoking. Furthermore, it showed that appropriate prescribing and disease management in line with national standards of care also resulted in significant drug costs and utility savings. Since this study was undertaken, it has gone on to be a finalist in the Health Service Journal Value in Healthcare awards in 2015 and has recently been shortlisted for a NICE Shared Learning Award for 2016.
More information is available at:
Lead respiratory pharmacist
Barts Health NHS Trust (at the time of the project)
Head of medicines management
NHS City & Hackney CCG
Practice support pharmacist
NHS City & Hackney CCG
Correspondence to: Hasanin Khachi firstname.lastname@example.org