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Noel Baxter GP

Co-lead NHS London Respiratory Team

Optimise not maximise for

better value COPD & asthma

care

The VALUE equation

Health

Outcomes Patient defined

bundle of care

Cost Value =

Health Outcomes

Cost of delivering

Outcomes

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

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We know what interventions are good value –

when they are done in the right way

Triple Therapy

£35,000-£187,000/QALY

LABA

£8,000/QALY

Tiotropium

£7,000/QALY

Pulmonary Rehabilitation

£2,000-8,000/QALY

Stop Smoking Support with pharmacotherapy £2,000/QALY

Flu vaccination £1,000/QALY in “at risk” population

1 year abstinence

%

QALY

£

Usual care 1.4

Minimal counselling 2.6 14,735

Intensive counselling 6 7,149

Intensive counselling +

pharmacotherapy

12.3 2,092

Systematic Review of 9 studies Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH. Thorax 2010: 65:711-718

A cost effective intervention in COPD - Stopping Smoking

What works long term and is cost effective?

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The low value pyramid

We know how to allocate resource at

population level http://www.impressresp.com/index.php?option=com_content&view=article&id=167:impressions-28-relative-value-of-copd-interventions&catid=11:impressions&Itemid=3

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COPD in London: What do we know?

Londoners dying from smoking

‘1 in 5 deaths due to

smoking’

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Stop smoking support: Step 1 treatment for

people with asthma who smoke and for

households of children with asthma that

smoke

“ 32.5% of patients admitted to hospital were current smokers …a further 18.8% were ex‐smokers …a significantly greater number of asthmatics reported themselves to be smokers over the general population … … smoking causes steroid resistance in asthma and is associated with other ‘risk’ behaviours, which may make this group more likely to be admitted to hospital

Optimal healthcare for up to 1:4 people with a

long term condition is stop smoking support as

treatment

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Admissions ( asthma and COPD) : What factors

can we influence as health professionals ?

• Bed capacity

• Distance to hospital

• Deprivation of population

• Socioeconomic status

• Prevalence of COPD

• Prevalence of smoking in our practices

Where can we make an impact for people

with COPD and asthma ?

• 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.

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PCT monthly COPD 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%

Quit smoking as treatment Sharing Whittington learning

Health professionals esp doctors need to believe quit smoking

interventions are part of their role & responsibility

Behaviour change: importance, confidence

Make it easy to do

clinical leadership, systems & incentives

• Brief interventions

• Behaviour change skills

• Knowledge of quit smoking services & referral

• Prescribing knowledge & medications available

• Measure outcomes and provide feedback

• Acute Trust and Mental Health Trust CQINs

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Are your hospital staff able, & confident

to, prescribe Quit Smoking medication?

Does your hospital provide nicotine

replacement therapy routinely on

admission for smokers?

How do we make this happen?

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What did we do?

More about LRT and Right Care @ www.londonrespiratoryteamconference.com

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