64128

Idiopathic pulmonary fibrosis

Published: June 2013 http://guidance.nice.org.uk/CG163

Costing report

National costing report: Idiopathic pulmonary fibrosis (June 2013) 2 of 32

This costing report accompanies the clinical guideline: ‘Idiopathic pulmonary fibrosis: the diagnosis and management of suspected idiopathic pulmonary fibrosis’ (available online at http://guidance.nice.org.uk/CG163).

Issue date: June 2013

This report is written in the following context

This report represents the view of NICE, which was arrived at after careful consideration of the available data and through consulting with healthcare professionals. It should be read in conjunction with the NICE guideline. The report and template are implementation tools and focus on the recommendations that were considered to have a significant impact on national resource utilisation.

The cost and activity assessments in the report are estimates based on a number of assumptions. They provide an indication of the likely impact and are not absolute figures. Assumptions used in the report are based on assessment of the national average. Local practice may be different from this, and the template can be amended to reflect local practice.

Implementation of the guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this costing tool should be interpreted in a way that would be inconsistent with compliance with those duties.

National Institute for Health and Care Excellence Level 1A City Tower Piccadilly Plaza Manchester M1 4BT

www.nice.org.uk

© National Institute for Health and Care Excellence, 2013. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.

NICE clinical guideline XX


Contents

Executive summary .......................................................................................... 5

Significant resource-impact recommendations ........................................ 5

Net resource impact ................................................................................ 6

Benefits and savings ............................................................................... 6

Local costing template ............................................................................. 6

1 Introduction .............................................................................................. 7

1.1 Supporting implementation ........................................................... 7

1.2 What is the aim of this report? ...................................................... 7

1.3 Epidemiology of idiopathic pulmonary fibrosis .............................. 8

1.4 Current service provision .............................................................. 9

2 Costing methodology ............................................................................. 10

2.1 Process ...................................................................................... 10

2.2 Scope of the cost-impact analysis .............................................. 11

2.3 General assumptions made ....................................................... 15

2.4 Basis of unit costs ...................................................................... 16

3 Significant resource-impact recommendations ...................................... 16

3.1 Diagnosis ................................................................................... 16

3.2 Interstitial lung disease specialist nurse ..................................... 22

3.3 Pulmonary rehabilitation ............................................................. 23

3.4 Benefits and savings .................................................................. 26

4 Sensitivity analysis ................................................................................ 26

4.1 Methodology ............................................................................... 26

5 Impact of guidance for commissioners .................................................. 27

5.1 Expenditure on idiopathic pulmonary fibrosis will fall under the

Programme Budgeting category of 11X - Problems of Respiratory

System – Other...................................................................................... 27

6 Conclusion ............................................................................................. 27

6.1 Estimated cost per 1,500,000 population ................................... 27

6.2 Next steps .................................................................................. 27

Appendix A. Approach to costing guidelines .................................................. 29

Appendix B. Cost of multidisciplinary team meetings for idiopathic pulmonary

fibrosis ........................................................................................................... 30


Appendix C. Cost of pulmonary rehabilitation for idiopathic pulmonary fibrosis

....................................................................................................................... 32


Executive summary

This costing report looks at the resource impact of implementing the NICE

guideline ‘Idiopathic pulmonary fibrosis’ in England. The diagnosis and

management of idiopathic pulmonary fibrosis is assumed to be delivered

through a series of interstitial lung disease networks, with each network being

responsible for an estimated population of 1.5 million people. The costing

template that accompanies this report has also been prepared on the basis of

a default population of 1.5 million people.

The costing method adopted is outlined in appendix A; it uses the most

accurate data available, was produced in conjunction with key clinicians, and

reviewed by clinical and financial professionals.

Significant1 resource-impact recommendations

This report focuses on the recommendations that are considered to have the

greatest resource impact nationally, and therefore require the most additional

resources to implement or can potentially generate the biggest savings. They

are:

Diagnosis of idiopathic pulmonary fibrosis (recommendation 1.2.2)

Interstitial lung disease specialist nurse (recommendations 1.3.3, 1.3.1,

1.2.2 ,1.2.3,1.5.16,1.5.18)

Pulmonary rehabilitation (recommendation 1.5.1)

1 The following impacts have been defined as significant:

where the number of people affected by the guidance recommendations is estimated to be over 300 (equivalent to 1 patient per 170,000; in practice, smaller populations may have no patients or possibly more than 1, particularly if it is a disease that runs in families and there is a cluster in 1 area)

where initial costing work indicates that the national cost is more than £1 million (equivalent to £2000 per 100,000 population).

.


Net resource impact

The annual change in resource use arising from implementing the

recommendations considered in the costing analysis for a standard interstitial

lung disease network population of 1.5 million is summarised below.

Recommendation Current practice

Future practice

Difference

Diagnose IPF with the consensus of the multidisciplinary team

£11,400 £21,500 £10,100

Pulmonary rehabilitation £2,300 £3,500 £1,200

Interstitial lung disease specialist nurse £7,300 £36,300 £29,000

Total £21,000 £61,300 £40,300

Benefits and savings

Implementing the clinical guideline may result in the following savings and

benefits.

Improved awareness of idiopathic pulmonary fibrosis will lead to an earlier and

more accurate diagnosis, with a resultant improvement in disease

management and improved quality of life for patients.

Diagnosis of idiopathic pulmonary fibrosis may be delayed in a significant

proportion of patients because the signs and symptoms can be attributed to

more common conditions, such as heart failure or chronic obstructive

pulmonary disease (COPD). This can result in inappropriate treatments,

deprive the patient of appropriate advice and support and delay the

identification of reversible causes of fibrosis.

Local costing template

The costing template produced to support this guideline enables organisations

in England, Wales and Northern Ireland to estimate the impact locally and

replace variables with ones that depict the current local position. A sample

calculation using this template showed that additional costs of £40,300 could

be incurred for a standard interstitial lung disease network population of 1.5

million. This equates to £2700 per 100,000 population.


1 Introduction

1.1 Supporting implementation

1.1.1 The NICE clinical guideline on idiopathic pulmonary fibrosis is

supported by the following implementation tools available on

our website http://guidance.nice.org.uk/CG163:

costing tools

a costing report; this document

a local costing template; a spreadsheet that can be used to

estimate the local cost of implementation

podcasts; about the importance of the guideline for GPs

baseline assessment tool; assess your baseline against the

recommendations in the guidance in order to prioritise

implementation activity, including clinical audit

shared learning examples

clinical audit tool; measure current practice against the guidance

and identify areas in which practice can be improved

self-assessment tool; determine to what degree your

organisation meets the recommendations in the guidance and

plan future activity based on the recommendations, monitoring

progress over time.

1.2 What is the aim of this report?

1.2.1 This report provides estimates of the national cost impact

arising from implementation of guidance on idiopathic

pulmonary fibrosis in England. These estimates are based on

assumptions made about current practice and predictions of

how current practice might change following implementation.

1.2.2 This report aims to help organisations plan for the financial

implications of implementing NICE guidance.


1.2.3 This report does not reproduce the NICE guideline on

idiopathic pulmonary fibrosis and should be read in

conjunction with it (see http://guidance.nice.org.uk/CG163.

1.2.4 The costing template that accompanies this report is designed

to help those assessing the resource impact at a local level in

England, Wales or Northern Ireland.

1.3 Epidemiology of idiopathic pulmonary fibrosis

1.3.1 Idiopathic pulmonary fibrosis is a chronic, progressive fibrotic

interstitial lung disease of unknown origin. It is the most

common of the many interstitial lung diseases and it must be

distinguished from the interstitial lung diseases which have

known causes or associations such as asbestosis, lung

disease associated with connective-tissue disease,

hypersensitivity pneumonitis and drug-induced lung disease.

1.3.2 The incidence of IPF is approximately 10 per 100,000

population aged 18 years and over, which means more than

4200 new cases occur in the England each year. It is rare in

people younger than 45 and the median age of presentation is

70 years. The prevalence is around 15 to 25 per 100,000 and

increases with age. The average hospital with a catchment of

500,000 will have 40 to 45 new cases a year and the average

GP surgery of 10,000 patients will have 2 to 3 new cases

every three years. Around two-thirds of people with IPF are

smokers and IPF often co-exists with chronic obstructive

pulmonary disease (COPD).

1.3.3 Idiopathic pulmonary fibrosis is a difficult disease to diagnose

and often requires the collaborative expertise of a consultant

respiratory physician, radiologist and histopathologist to reach

a consensus diagnosis. Most people with idiopathic

pulmonary fibrosis experience symptoms of breathlessness,

which may initially be only on exertion. Cough, with or without


sputum, is a common symptom. Over time, these symptoms

are associated with a decline in lung function, reduced quality

of life and ultimately death. Specific pharmacological

therapies for idiopathic pulmonary fibrosis are limited

highlighting the importance of other forms of treatment

including lung transplantation and best supportive care such

as oxygen therapy, pulmonary rehabilitation and palliation of

symptoms.

1.4 Current service provision

1.4.1 Idiopathic pulmonary fibrosis is one of several interstitial lung

diseases that tend to present in a similar manner with

breathlessness, bilateral inspiratory crackles’ and diffuse

chest X-ray changes. Idiopathic pulmonary fibrosis has the

poorest prognosis of these disorders, so establishing a timely,

confident diagnosis is important. A confident diagnosis needs

careful integration of clinical, radiological (high-resolution CT

scans) and pathological data and there is evidence that this is

best achieved in a specialist multidisciplinary setting.

1.4.2 To manage idiopathic pulmonary fibrosis, there is evidence to

support a role for some types of best supportive care, such as

smoking cessation, pulmonary rehabilitation, withdrawal of

ineffective therapy, oxygen therapy and palliation of

symptoms.

1.4.3 There is no conclusive evidence to support the use of any

drugs to increase the survival of people with idiopathic

pulmonary fibrosis. The guideline identifies a number of drugs

including azathioprine and prednisolone that have been used

in the past for lung fibrosis and are still used for some types of

interstitial lung disease .But following a review of the evidence

they are no longer recommended to modify disease

progression in idiopathic pulmonary fibrosis. Currently, there


is no proven effective drug therapy for idiopathic pulmonary

fibrosis.

1.4.4 However, Pirfenidone for treating idiopathic pulmonary fibrosis

(NICE technology appraisal guidance 282) recommends the

use of pirfenidone for people with mild to moderate idiopathic

pulmonary fibrosis, who meet the criteria in the

recommendations. Pirfenidone is an immunosuppressant that

is thought to have anti-inflammatory and antifibrotic effects,

although the mechanism of action is not fully understood.

1.4.5 Lung transplantation is suitable for only a minority of patients

with idiopathic pulmonary fibrosis. The number of patients that

die waiting for a lung transplant is proportionately higher than

any other patient group. Efforts should be made to identify

which patients would benefit most.

1.4.6 Access to pulmonary rehabilitation services and palliative care

for idiopathic pulmonary fibrosis is not uniform. The past few

years have seen several ad hoc specialist centres emerge,

often with limited or no resource support.

2 Costing methodology

2.1 Process

2.1.1 We use a structured approach for costing clinical guidelines

(see appendix A).

2.1.2 We have to make assumptions in the costing model. These

are tested for reasonableness with members of the Guideline

Development Group (GDG) and key clinical practitioners in

the NHS.

2.1.3 Local users can assess local cost impact, using the costing

template as a starting point, and update assumptions to

reflect local circumstances.

http://guidance.nice.org.uk/TA282


2.2 Scope of the cost-impact analysis

2.2.1 The guideline offers best practice advice on idiopathic

pulmonary fibrosis.

2.2.2 The guideline does not cover:

Children and young people (younger than 18).

People with a diagnosis of pulmonary fibrosis as a complication

of:

connective tissue disorders (for example, systemic lupus

erythematosus, rheumatoid arthritis, scleroderma,

polymyositis and dermatomyositis)

a known exogenous agent (for example, drug-induced

disease or asbestosis).

Therapies for pulmonary hypertension as a complication of

idiopathic pulmonary fibrosis.

Treatment of lung cancer as a complication of idiopathic

pulmonary fibrosis.

Lung transplantation, other than timing and referral.

Therefore, these issues are outside the scope of the costing work.

2.2.3 We worked with the GDG and other professionals to identify

the recommendations that would have the most significant

resource-impact (see table 1). Costing work has focused on

these recommendations.


Table 1: Recommendations with a significant resource impact

Recommendation Recommendation number

Guideline key priority?

Diagnose idiopathic pulmonary fibrosis only with the consensus of the multidisciplinary team (listed in table 1 of the NICE guideline), based on:

o the clinical features, lung function and radiological findings (see recommendation 1.2.1)

o pathology when indicated (see recommendation 1.2.4).

1.2.2

An interstitial lung disease specialist nurse should be available at all stages of the care pathway to provide information and support to people with idiopathic pulmonary fibrosis and their families and carers. (1.3.3)

1.3.3 , 1.3.1 , 1.2.2 , 1.2.3,1.5.16.1.5.18

Assess people with idiopathic pulmonary fibrosis for pulmonary rehabilitation at the time of diagnosis. Assessment may include a 6-minute walk test (distance walked and oxygen saturation measured by pulse oximetry) and a quality-of-life assessment.

1.5.1

2.2.4 Ten of the recommendations in the guideline have been

identified as key priorities for implementation, and 3 of these

are considered to have a significant resource impact.


Table 2: Summary of key priorities for implementation recommendations not considered to have a significant resource impact

Recommendation number

Recommendation Reason not anticipated to have a significant resource impact

1.1.1 Be aware of idiopathic pulmonary fibrosis when assessing a patient with the clinical features listed below and consider requesting a chest X-ray or referring to a specialist:

age over 45 years

persistent breathlessness on exertion

persistent cough

bilateral inspiratory crackles when listening to the chest

clubbing of the fingers

normal spirometry or impaired spirometry usually with a restrictive pattern but sometimes with an obstructive pattern.

This recommendation is not anticipated to have a significant resource impact because it is about raising awareness of IPF by clinicians. There may be an increase in the number of people referred for a chest X-ray for suspected IPF, but this (small) cost will be more than offset by the decrease in the use of inappropriate treatments for patients misdiagnosed with asthma or COPD.

1.3.1 The consultant respiratory physician or interstitial lung disease specialist nurse should provide accurate and clear information (verbal and written) to people with idiopathic pulmonary fibrosis, and their families and carers with the person’s consent. This should include information about investigations, diagnosis and management.

This recommendation is unlikely to have a significant resource impact because expert opinion suggests that accurate and clear information is already available. For example, there are good patient leaflets available from the British Thoracic Society and Breathe Easy. The British Lung Foundation also provides written advice and a helpline.

1.5.5 Offer best supportive care to people with idiopathic pulmonary fibrosis from the point of diagnosis. Best supportive care should be tailored to disease severity, rate of progression, and the person’s preference, and should include if appropriate:

information and support (see recommendation 1.3.1)

symptom relief

management of

This recommendation reinforces good clinical practice and is not anticipated to have a significant resource impact.


comorbidities

withdrawal of therapies suspected to be ineffective or causing harm

end of life care.

1.5.6 If the person is breathless on exertion consider assessment for:

the causes of breathlessness and degree of hypoxia and

ambulatory oxygen therapy and long-term oxygen therapy and/or

pulmonary rehabilitation.


1.5.11 Do not use any of the drugs below, either alone or in combination, to modify disease progression in idiopathic pulmonary fibrosis:

ambrisentan

azathioprine

bosentan

co-trimoxazole

mycophenolate mofetil

prednisolone

sildenafil

warfarin.

This recommendation is expected to lead to a decrease in the use of the drugs listed. Any potential savings are not anticipated to be significant because these drugs are either not used in current practice or have a low cost per person. (NICE technology appraisal guidance 282: pirfenidone gives the cost of current drug therapy as £269 [triple therapy] or £159 [N-acetylcysteine monotherapy]).

1.5.16 Refer people with idiopathic pulmonary fibrosis for lung transplantation assessment if they wish to explore lung transplantation and if there are no absolute contraindications. Ask the transplant centre for an initial response within 4 weeks.

This recommendation is likely to lead to an increase in the number of people with IPF who will be referred for a lung transplant. While this may lead to an increase in the number of people on the waiting list for transplantation, the overall number of lung transplants will not change because this is limited by the number of donor organs available.

1.6.1 In follow-up appointments for people with idiopathic pulmonary fibrosis:

assess of lung function

assess for oxygen therapy






assess for pulmonary rehabilitation

offer smoking cessation advice, in line with Smoking cessation services (NICE public health guidance 10)

identify exacerbations and previous respiratory hospital admissions

consider referral for assessment for lung transplantation in people who do not have absolute contraindications (see recommendations 1.5.15 and 1.5.16)

consider psychosocial needs and referral to relevant services as appropriate

consider referral to palliative care services

assess for comorbidities (which may include anxiety, bronchiectasis, depression, diabetes, dyspepsia, ischaemic heart disease, lung cancer and pulmonary hypertension).

2.2.5 We have limited the consideration of costs and savings to

direct costs to the NHS that will arise from implementation.

We have not included consequences for the individual, the

private sector or the not-for-profit sector. If applicable, any

realisable cost savings arising from a change in practice have

been offset against the cost of implementing the change.

2.3 General assumptions made

2.3.1 The guideline states that there are around 5000 new cases of

idiopathic pulmonary fibrosis identified in the UK each year,

which equates to 4200 new cases in England. This gives an

incidence of approximately 10 new cases per year per

100,000 population aged 18 years and over.

http://guidance.nice.org.uk/PH10

http://guidance.nice.org.uk/PH10


2.3.2 The costing is based on a suggested service model of an

interstitial lung disease network that serves a population of

1.5 million people. The costs shown in this report (and the

accompanying costing template) are for a standard interstitial

lung disease network population of 1.5 million.

2.4 Basis of unit costs

2.4.1 If a national tariff price or indicative price exists for an activity

this has been used as the unit cost. This has then been

inflated by the national average market forces factor.

2.4.2 Using these prices ensures that the costs in the report are the

cost to the clinical commissioning group (CCG) of

commissioning predicted changes in activity at the tariff price,

but may not represent the actual cost to individual trusts of

delivering the activity.

2.4.3 For new or developing services for which there is no national

average unit cost, organisations already undertaking this

activity have been asked their current unit cost.

3 Significant resource-impact recommendations

3.1 Diagnosis

Recommendation 1.2.2

3.1.1 Diagnose idiopathic pulmonary fibrosis only with the

consensus of the multidisciplinary team (listed in table 1 of the

NICE guideline), based on:

the clinical features, lung function and radiological findings (see

recommendation 1.2.1)

pathology when indicated (see recommendation 1.2.4).


Background

3.1.2 Specialist input at an early stage of the diagnostic pathway is

likely to lead to increased certainty of diagnosis.

3.1.3 The Guideline Development Group agreed that the inclusion

of the multidisciplinary team in the diagnostic pathway was

likely to result in a greater number of people accurately

diagnosed with idiopathic pulmonary fibrosis.

Assumptions made

3.1.4 The Guideline Development Group proposed that

multidisciplinary team involvement in the diagnosis of

idiopathic pulmonary fibrosis would evolve within an interstitial

lung disease network configuration of specialist tertiary

centres and local satellite centres in secondary care. The

composition of the multidisciplinary team and the time needed

for the multidisciplinary team meeting will vary between the

specialist and local centres. The composition and associated

costs are shown in appendix B2.

3.1.5 The multidisciplinary team meetings will discuss all interstitial

lung disease patients, not just those with

suspected/diagnosed idiopathic pulmonary fibrosis.

3.1.6 The health economic analysis accompanying the guideline

was based on a proposed model for an interstitial lung

disease network:

One specialist and 6 local multidisciplinary teams in each

network.

Each network was assumed to serve a population of

approximately 1.5 million people.

2 See chapter 5.3.4 and 5.4 (Multidisciplinary Team) in the full guideline [add hyperlink] for

more information on the expertise of the multidisciplinary team.


The multidisciplinary team meeting will discuss all interstitial lung

disease patients. It has been assumed that idiopathic pulmonary

fibrosis patients will form one-third of the interstitial lung disease

patients presenting.

Specialist multidisciplinary team

meet weekly

need an estimated 2 hours of staff time for each clinical staff

member

review an estimated 9 patients in each meeting, of which 2–3

would be diagnosed with idiopathic pulmonary fibrosis

Local multidisciplinary teams

responsible for reviewing the care management of all

diagnosed interstitial lung disease patients within their

catchment area in addition to diagnosing new cases

an interstitial lung disease patient’s management plan is

reviewed on average 3 times per year

meet fortnightly

need an estimated 3 hours of staff time for each clinical staff

member

review an estimated 25 interstitial lung disease patients per

multidisciplinary team meeting.

3.1.7 Where the local configuration of services differs from this

proposed model, costs will vary from those shown.

Organisations are encouraged to check practice in their local

area and amend the costing template to reflect local

circumstances and estimate the resource impact of

implementing this recommendation.

3.1.8 The involvement of some of the specialist staff in the

multidisciplinary team, for example, thoracic surgeon,

interstitial lung disease specialist nurse and histopathologist,

are envisaged as a shared resource across the network, so

the cost of their involvement is included only as part of the

specialist team.


3.1.9 The multidisciplinary team coordinator is assumed to be

employed to coordinate the multidisciplinary team meetings at

a tertiary level and to provide support for local satellite

centres. The salary costs have been apportioned to local and

specialist multidisciplinary team meetings on the basis of

resource use (see appendix B for further details).

3.1.10 The cost per patient has been estimated to be 1 local and 3

specialist multidisciplinary team meetings per person.

3.1.11 The specialist multidisciplinary team cost includes an element

for an interstitial lung disease specialist nurse. The Guideline

Development Group estimate that each specialist centre

would have 1 interstitial lung disease specialist nurse. It has

been assumed that these interstitial lung disease specialist

nurses will work as a shared resource across the interstitial

lung disease network, so the cost of a local multidisciplinary

team does not include a cost for interstitial lung disease

specialist nurses.

Cost summary

3.1.12 The estimated cost of diagnosing idiopathic pulmonary

fibrosis only with the consensus of the multidisciplinary team

is £10,100 for a standard interstitial lung disease network

population of 1.5 million. This equates to £700 per 100,000

population.

Other considerations

3.1.13 In addition to staff time for attending the multidisciplinary team

meetings, there are likely to be other costs, for example,

teleconferencing facilities. As many centres already use

multidisciplinary teams for other conditions (for example,

cancer) rooms may already be set up for multidisciplinary

team meeting purposes. It has been assumed that the

interstitial lung disease network could also use these facilities


for their multidisciplinary team meetings. These costs are not

included in appendix B. It has been assumed that the use of

teleconferencing facilities has negated the need for travel

between sites in the interstitial lung disease network, so the

time and cost of travel is also excluded from the costings.

3.1.14 The Guideline Development Group felt that the involvement of

a multidisciplinary team may reduce the potential health risk

to patients by reducing the need for further more expensive

and invasive procedures, for example surgical lung biopsy,

because of the increased certainty of diagnosis achieved with

specialist input at an early stage of the diagnostic pathway.

Diagnostic accuracy and precision is increased when there is

discussion at multidisciplinary team meetings.

3.1.15 A patient’s quality of life may be decreased through increased

anxiety or potentially depression if their diagnosis remains

uncertain or if they have little confidence that the diagnosis

achieved was correct. The Guideline Development Group

discussed that such patients may continue to seek a more

confident diagnosis with further GP contacts and secondary

care consultations, which would be at a cost to the NHS.

Thus, an increased certainty of diagnosis may also result in a

decrease in the number of GP contacts and secondary care

consultations and associated costs.

3.1.16 Improved diagnosis of idiopathic pulmonary fibrosis may also

result in potential savings from a reduction in inappropriate

treatments given because of incorrect diagnosis, for example,

inhalers given for asthma. It is not possible to quantify these

potential savings.

3.1.17 The incremental cost of the involvement of a multidisciplinary

team in the diagnostic pathway of an interstitial lung disease

patient is likely to be comparable to or lower than other


diagnostic tests. However, the actual incremental cost of the

involvement of a multidisciplinary team in the diagnostic

pathway is likely to be influenced by use of clinical network

arrangements already in place, local need and commissioning

arrangements. The Guideline Development Group

acknowledged that local expertise would influence the number

of cases being referred to, and time needed for, the specialist

multidisciplinary team. Therefore, the most cost-effective

arrangement is potentially highly influenced by local factors.


3.2 Interstitial lung disease specialist nurse

Recommendations 1.3.3/1.3.1/1.2.2/1.2.3 /1.5.16/1.5.18

Throughout the guideline, the role of the interstitial lung disease

specialist nurse is highlighted as being a key role in the diagnosis

and management of idiopathic pulmonary fibrosis.

Background

3.2.1 Expert opinion suggests that there is a national shortage of

interstitial lung disease specialist nurses. Organisations are

advised to check the availability of interstitial lung disease

specialist nurses locally. If there is a need to recruit additional

interstitial lung disease specialist nurses, there will be an

estimated additional cost of £36,300 (Agenda for change

2013-14, mid-point band 6, including oncosts) per specialist

nurse per year.

3.2.2 The Guideline Development Group felt that existing

respiratory nurses could be trained up to be interstitial lung

disease specialist nurses. If this is possible, there would be

the need to recruit to backfill the respiratory nurse post plus

the cost of training for the interstitial lung disease specialist

nurse which may be less costly than recruiting an experienced

interstitial lung disease specialist nurse. The interstitial lung

disease specialist nurse salary cost can be amended in the

costing template to reflect any differences in cost.

Assumptions made

3.2.3 As outlined in section 3.1, the Guideline Development Group

proposed that the diagnosis of idiopathic pulmonary fibrosis

would be managed within an interstitial lung disease network

configuration of specialist tertiary centres and local satellite

centres in secondary care. The model further proposes that

each network serves a population of 1.5 million and would

need 1 specialist and 6 local centres in each interstitial lung


disease network. The interstitial lung disease specialist nurse

is considered to be a shared resource working across the

whole interstitial lung disease network.

3.2.4 Expert opinion suggests that 1 interstitial lung disease

specialist nurse is needed for each specialist centre, which

equates to 34 nurses nationally. There are approximately 8

interstitial lung disease specialist nurses in England at

present.

Cost summary

3.2.5 The estimated cost of increasing the number of interstitial lung

disease specialist nurses is £29,000 for a standard interstitial

lung disease network population of 1.5 million, which equates

to £1900 per 100,000 population.


3.2.6 Expert opinion suggests that the involvement of an interstitial

lung disease specialist nurse in the care of people with

idiopathic pulmonary fibrosis would help to ensure

consistency of care because they would be the clinical lead

for best supportive care. This would improve the quality of life

for patients due to better symptom control and may result in a

reduction in hospital admissions, GP contacts and out-of -

hours care.

3.3 Pulmonary rehabilitation

Recommendation 1.5.1

3.3.1 Assess people with idiopathic pulmonary fibrosis for

pulmonary rehabilitation at the time of diagnosis. Assessment

may include a 6-minute walk test (distance walked and

oxygen saturation measured by pulse oximetry) and a quality-

of-life assessment.


Background

3.3.2 Pulmonary rehabilitation aims to reduce disability in people

with lung disease and improve their quality of life. Provided by

a multiprofessional team, pulmonary rehabilitation comprises

physical training, education, dietetics, occupational therapy,

psychology and social support. The benefits include

improvements in exercise performance, health status,

dyspnoea, and reduction in usage of health services.

3.3.3 Currently in the UK, pulmonary rehabilitation designed and

provided specifically for idiopathic pulmonary fibrosis patients

is not known to exist. Patients are either not offered

pulmonary rehabilitation, or offered places on courses

designed for patients with COPD. Content in a programme

designed for COPD patients may be inappropriate for

idiopathic pulmonary fibrosis patients, who need different

clinical advice in managing expectations in end of life care

and psychosocial support.

3.3.4 Expert opinion suggests that there is limited funding of

pulmonary rehabilitation for idiopathic pulmonary fibrosis

patients, with most current provision being for COPD and

asthma patients. Commissioners are advised to review

practice in their local area.

Assumptions made

3.3.5 Expert opinion suggested that the exercise element of

pulmonary rehabilitation programmes are already tailored to

the needs of the individual patient

3.3.6 However, expert opinion also suggested that it is the clinical

advice that differs for idiopathic pulmonary fibrosis and COPD

patients. It is anticipated that existing pulmonary rehabilitation

programmes can be adapted to meet the needs of people with

idiopathic pulmonary fibrosis,.


3.3.7 The typical duration of a pulmonary rehabilitation course is 6–

8 weeks. The costs in appendix C are based on a model by

Nishiyama which proposes a 9-week course with twice weekly

group sessions for 10 people per session.

3.3.8 There will always be a number of patients who are assessed

for pulmonary rehabilitation who will not continue with the

rehabilitation programme due to disease deterioration or

patient preference. Thus, the proportion of patients who

receive an initial assessment will be slightly more than those

who go on to receive rehabilitation. The costing template

allows the number of assessment and rehabilitation sessions

per patient to be amended to reflect this.

Cost summary

3.3.9 The estimated cost of increasing the number of people with

idiopathic pulmonary fibrosis who receive pulmonary

rehabilitation is £1200 for a standard interstitial lung disease

network population of 1.5 million, which equates to £80 per

100,000 population.


3.3.10 Expert opinion suggests that the use of pulmonary

rehabilitation may lead to a reduction in the number of

healthcare contacts made by patients, for example, the

number of GP surgery visits, because patients learn how to

manage their symptoms.

3.3.11 Expert opinion suggests that approximately 10% of patients

participating in a pulmonary rehabilitation course would need

transport. This cost has been excluded from the costs shown

in appendix C.

3.3.12 The number of times that rehabilitation is offered to a patient

will depend on the individual. Expert opinion suggests that


approximately one-third of people will need more than 1

assessment for pulmonary rehabilitation because of failure to

attend or to complete the session. The costing template

allows the number of assessment and rehabilitation sessions

per patient to be amended to reflect this.

3.4 Benefits and savings

Implementation of this guideline is expected to have the following

benefits and savings:

Improved awareness of idiopathic pulmonary fibrosis will lead to an

earlier and more accurate diagnosis, with a resultant improvement

in disease management and improved quality of life for patients.

Diagnosis of idiopathic pulmonary fibrosis may be delayed in a

significant proportion of patients because the signs and symptoms

can be attributed to more common conditions, such as heart failure

or COPD. This can result in inappropriate treatments, deprive the

patient of appropriate advice and support and delay the

identification of reversible causes of fibrosis. Thus, appropriate

diagnosis, use of oxygen (where appropriate), the involvement of

an interstitial lung disease specialist nurse, pulmonary rehabilitation

and appropriate information and support are likely to improve the

timeliness of seeking assistance. There is also the potential to

reduce costs by not offering drugs inappropriately.

4 Sensitivity analysis

4.1 Methodology

4.1.1 As the local costing template which accompanies this report

contains indicative figures for activity levels, the key drivers of

cost may vary widely. Organisations are advised to carry out a

sensitivity analysis to determine the key cost drivers for their

local area.


5 Impact of guidance for commissioners

5.1 Expenditure on idiopathic pulmonary fibrosis will fall under the

Programme Budgeting category of 11X - Problems of Respiratory

System – Other.

6 Conclusion

6.1 Estimated cost per 1,500,000 population

6.1.1 Using the significant resource-impact recommendations

shown in table 1 and assumptions specified in section 3 we

have estimated the annual impact of implementing these

recommendations in England to be a cost of £40,300 for a

standard interstitial lung disease network population of 1.5

million, which equates to £2700 per 100,000 population. Table

3 shows the breakdown of cost of each significant resource-

impact recommendation.

Table 3: Summary of estimated costs for recommendations with a significant resource impact for a standard interstitial lung disease network population of 1.5 million

Recommendation Current practice

Future practice

Difference

Diagnose IPF with the consensus of the multidisciplinary team

£11,400 £21,500 £10,100

Pulmonary rehabilitation £2,300 £3,500 £1,200

Interstitial lung disease specialist nurse £7,300 £36,300 £29,000

Total £21,000 £61,300 £40,300

6.1.2 The costs presented are estimates and should not be taken

as the full cost of implementing the guideline.

6.2 Next steps

6.2.1 The local costing template produced to support this guideline

enables organisations such as clinical commissioning groups

or health boards in Wales and Northern Ireland to estimate


the impact locally and replace variables with ones that depict

the current local position. A sample calculation using this

template showed that a population of 100,000 could expect to

incur costs of £2700. Use this template to calculate the cost of

implementing this guidance in your area.


Appendix A. Approach to costing guidelines

Guideline at first consultation stage

Analyse the clinical pathway to identify significant recommendations and population

cohorts affected

Identify key cost drivers – gather information

required and research cost behaviour

Develop costing model – incorporating

sensitivity analysis

Draft national cost-impact report

Determine links between national

cost and local implementation

Develop local costing template Internal peer review by

qualified accountant

within NICE

Circulate report and template to cost-impact panel and GDG for comments

Update based on feedback and any changes following

consultations

Cost - impact review meeting

Final sign-off by NICE

Prepare for publication in conjunction with guideline


Appendix B. Cost of multidisciplinary team meetings

for idiopathic pulmonary fibrosis

Cost element Cost per hour

Local MDT time needed4

Specialist MDT time needed4

Salary cost for local MDT

Salary cost for specialist MDT

Consultant respiratory physician1

£70 3 2 £210 £140

Consultant radiologist1

£70 3 2 £210 £140

Consultant histopathologist1,5

£70 n/a 2 n/a £140

Thoracic surgeon1 £70 n/a 2 n/a £140

Interstitial lung disease specialist nurse2,5

£23 n/a 2 n/a £46

Multidisciplinary team coordinator3

n/a – see below

n/a n/a £130 £86

Total cost per MDT meeting

£550 £692

Number of ILD patients discussed per meeting6

25 9

Cost per patient £22 £77

1. Hourly rate is calculated as maximum basic salary (2013/14 rates) of £101,451A plus 21% oncosts of £21,305=£122,756. Assuming a working time of 44 weeks per year and a working week of 40 hours (1760 hours per year), this equates to an hourly rate of £69.74.

A) Salary obtained from http://www.nhsemployers.org/Aboutus/Publications/PayCirculars/Pages/PayCircular-MD1-2013.aspx accessed on 22 April 2013

2. Hourly rate is calculated as Agenda for change Band 6 mid-point salary 2013-14 of £36,306 (including oncosts). Assuming a working time of 42 weeks per year and a working week of 37.5 hours (1575 hours per year), this equates to an hourly rate of £23.05.

3. The multidisciplinary team coordinator annual salary is calculated as Agenda for change Band 4 mid-point salary 2013-14 of £24,766 (including oncosts). They are assumed to be employed to coordinate MDT meetings at a tertiary level and to provide support for local satellite centres. The salary costs have been apportioned to local and specialist MDT meetings on the basis of resource use (see calculations below).

4. The Guideline Development Group proposed a model for an interstitial lung disease (ILD) network within which MDTs will evolve. The model suggests a specialist tertiary care referral hub and local secondary care satellite centres. The health economics analysis accompanying the guideline was based on a proposed model of 1 specialist MDT and 6 local MDTs in each ILD network.


5. The involvement of a histopathologist, thoracic surgeon and ILD specialist nurse are envisaged as a shared resource across the ILD network. Thus, these costs are not included in the local MDT meeting cost.

6. The health economic analysis for NICE clinical guideline 163 : idiopathic pulmonary fibrosis estimates that a specialist MDT meeting will review 9 ILD patients per meeting and a local MDT meeting 25 ILD patients per meeting. (tables 111 and 112).

Apportionment of multidisciplinary team coordinator salary across interstitial lung disease network

MDT coordinator annual salary (see note 3 above) £24,766

Local MDT

No of local MDT meetings per year -fortnightly 26

No of local MDT centres per network 6

No of local MDT meetings annually per network 156

No of hours per local MDT meeting 3

No of hours annually for local MDT meetings per network

468 = 82% of workload

Specialist MDT

No of specialist MDT meetings per year -fortnightly

52

No of specialist MDT centres per network 1

No of specialist MDT meetings annually per network

52

No of hours per specialist MDT meeting 2

No of hours annually for specialist MDT meetings per network

104 = 18% of workload

Salary split on the basis of workload

Local MDT 82% £20,263.00

Specialist MDT 18% £4,503.00

Cost per MDT meeting

Local MDT =20263/156 £130.00

Specialist MDT =4503/52 £86.00


Appendix C. Cost of pulmonary rehabilitation for

idiopathic pulmonary fibrosis

Cost element Unit cost per hour

Time needed per session

(hours)

Cost per patient per session

Assessment (individual)

Clerical coordinator1 £15.72 0.16 £2.52

Physiotherapist3 £22.73 1.50 £34.10

Total cost of assessment £36.61

Rehabilitation programme2

Physiotherapist3 £22.73 0.05 £1.14

Nurse3 £23.05 0.05 £1.15

Hospital-based allied health professional4×2

£18.47 0.01 £0.18

Registrar4 £26.64 0.01 £0.27

Total cost of rehabilitation £2.74

1. Clerical coordinator hourly rate is calculated as Agenda for change Band 4 mid-point salary 2013-14 of £24,766 (including oncosts). Assuming a working time of 42 weeks per year and a working week of 37.5 hours (1575 hours per year), this equates to an hourly rate of £15.72.

2. Time needed details are taken from that health economics analysis accompanying the guideline, appendix L -Table 140. These times are based on a 9-week group rehabilitation programme run twice weekly (18 sessions) for 10 patients. This is based on the model proposed by Nishiyama 2008.

3. Hourly rate is calculated as Agenda for change Band 6 mid-point salary 2013-14 of £36,306 (including oncosts). Assuming a working time of 42 weeks per year and a working week of 37.5 hours (1575 hours per year), this equates to an hourly rate of £23.05.

4. One registrar and 2 allied health professionals (AHP) are needed to undertake a 1 hour educational programme per course programme. Thus, cost calculated as 2 hours AHP time (1 hour each for 2 AHPs) and 1 hour registrar time over 9-week course, twice weekly sessions (18 sessions) for 10 patients = 3 minutes registrar time and 6.5 minutes AHP time (for 2 AHPs) per session. Hourly rate for AHP is calculated as Agenda for change Band 5 mid-point salary 2012-13 of £29,101 (including oncosts). Assuming a working time of 42 weeks per year and a working week of 37.5 hours (1575 hours per year), this equates to an hourly rate of £18.47. The costs in the table above are for 2 AHPs. Hourly rate for registrar is calculated as midpoint of specialty registrar salary (MN37 pay scale code) - £38757.50 (available from http://www.nhsemployers.org/Aboutus/Publications/PayCirculars/Pages/PayCircular-MD1-2013.aspx) plus oncosts of 21% (£8139) = £46896.50. Assuming a working time of 44 weeks per year and 40 hours per week (1760 hours per year), this equates to an hourly rate of £26.64.

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