Chronic obstructive pulmonary disease. Costing report. Implementing NICE guidance

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1 Chronic obstructive pulmonary disease Costing report Implementing NICE guidance February 2011 NICE clinical guideline 101 National costing report: chronic obstructive pulmonary disease 1 of 30

2 This costing report accompanies the clinical guideline: Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) Available online at Guidance issue date: June 2010 Costing tools issue date: February 2011 This guidance is written in the following context This report represents the view of the Institute, which was arrived at after careful consideration of the available data and through consulting healthcare professionals. It should be read in conjunction with the NICE guideline. The report and templates are implementation tools and focus on those areas that were considered to have significant impact on resource utilisation. The cost and activity assessments in the reports are estimates based on a number of assumptions. They provide an indication of the likely impact of the principal recommendations 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 to estimate local impact. National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA National Institute for Health and Clinical Excellence, February 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 the Institute. National costing report: chronic obstructive pulmonary disease 2 of 30

3 Contents Executive summary... 4 Supporting implementation... 4 Significant resource-impact recommendations... 4 Total cost impact... 4 Benefits and savings... 5 Estimated timeframe for implementation... 5 Local costing template Introduction Supporting implementation What is the aim of this report? Background Epidemiology of COPD Models of care Costing methodology Process Scope of the cost-impact analysis General assumptions made Basis of unit costs Cost of significant resource-impact recommendations Managing stable COPD prescribing Benefits and savings Sensitivity analysis Methodology Impact of sensitivity analysis on costs Impact of guidance for commissioners Conclusion Total national cost for England Next steps Appendix A. Approach to costing guidelines Appendix B. Results of sensitivity analysis Appendix C. References National costing report: chronic obstructive pulmonary disease 3 of 30

4 Executive summary This costing report looks at the resource impact of implementing the NICE guideline Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) in England. 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. Supporting implementation The partially updated NICE clinical guideline on chronic obstructive pulmonary disease (COPD) is supported by a range of implementation tools available on our website and detailed in the main body of this report. Significant resource-impact recommendations Because of the breadth and complexity of this guideline this report focuses on recommendations that are considered to have the greatest resource impact and therefore require the most additional resources to implement or can potentially generate savings. They all relate to managing stable COPD with inhaled combination therapy and are detailed in table 2. All recommendations considered in this report were new in 2010 and were not included in Chronic obstructive pulmonary disease (NICE clinical guideline 12). Total cost impact The annual changes in revenue costs arising from fully implementing the identified recommendations are summarised in the table below. National costing report: chronic obstructive pulmonary disease 4 of 30

5 Estimated recurrent costs of implementation Recommendation Costs ( 000s ) Current estimated cost of prescribing 268,543 Predicted future cost of prescribing 320,030 Costs/ savings( 000s) Incremental cost of prescribing 51,487 Current estimated cost of hospital admissions 310,413 Predicted future cost of hospital admissions 294,892 Incremental saving for hospital admissions 15,521 Total incremental cost 35,966 Benefits and savings Implementing the clinical guideline may bring the following benefits: Improvement in the management and effectiveness of treatments for patients with COPD is likely to result in an estimated 5% fewer admissions to hospital, resulting in around 15.5 million savings each year. Increased compliance with treatment and a reduction in the number of visits made to GPs is also likely. More effective management of COPD is also likely to reduce the number of working hours lost as a result of the disease and reduce the costs incurred as a result of this lost productivity. Estimated timeframe for implementation The timeframe for implementation is estimated to be about 3 years. For some areas this could vary so it should be reviewed locally. Prescribing practice will probably take time to change following implementation of the guidance. Figure 1 below shows the cumulative increase in cost according to the national assumptions on how prescribing may change after implementation. National costing report: chronic obstructive pulmonary disease 5 of 30

6 millions Figure 1 Combined incremental costs of prescribing and savings from fewer hospital admissions Year 1 Year 2 Year 3 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 70,219 per year would be incurred for a population of 100,000. National costing report: chronic obstructive pulmonary disease 6 of 30

7 1 Introduction 1.1 Supporting implementation This NICE clinical guideline on COPD is supported by the following implementation tools available on our website costing tools a national costing report; this document a local costing template; a simple spreadsheet that can be used to estimate the local cost of implementation a slide set; key messages for local discussion baseline assessment tool audit support A practical guide to implementation, How to put NICE guidance into practice: a guide to implementation for organisations, is also available to download from the NICE website. It includes advice on establishing organisational level implementation processes as well as detailed steps for people working to implement different types of guidance on the ground. 1.2 What is the aim of this report? This report provides estimates of the national cost impact arising from implementation of the partial update to the original guidance on COPD in England. These estimates are based on assumptions made about current practice and predictions of how current practice might change following implementation This report aims to help organisations plan for the financial implications of implementing NICE guidance This report does not reproduce the NICE guideline on COPD and should be read in conjunction with it (see National costing report: chronic obstructive pulmonary disease 7 of 30

8 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. The costing template may help inform local action plans demonstrating how implementation of the guideline will be achieved. 1.3 Background COPD is characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months and is usually progressive in the long term In the early stages of COPD, patients are largely free of symptoms but, as the disease progresses, patients report symptoms of breathlessness, coughing and chest tightness. COPD primarily affects people aged over 45 and is characterised by a chronic, slowly progressive decline in lung function, usually associated with exposure to cigarette smoke, but occasionally with exposure to air pollution or other noxious particles or gases (Department of Health 2005) The total annual cost of COPD to the NHS is estimated to be over 800 million for direct healthcare costs, which equates to 1.3 million per 100,000 people. In the late 1990s, 24 million working days per year were lost due to COPD, with the cost of lost productivity being estimated at around 2.7 billion (Department of Health 2005). 1.4 Epidemiology of COPD An estimated 3 million people have COPD in the UK. Although for around 2 million of this group their COPD remains undiagnosed (Healthcare Commission 2006) Data from the quality and outcomes framework (QOF) report the prevalence of diagnosed COPD as 1.6% in England, equivalent to an estimated 819,524 people (see table 1). National costing report: chronic obstructive pulmonary disease 8 of 30

9 East Midlands East of England London North East North West South Central South East Coast South West West Midlands Yorkshire and the Humber Unadjusted prevalence Table 1 Recorded prevalence of COPD in primary care in England as reported in the 2008/09 Quality and outcomes framework England population Prevalence in population 51,220, ,524 (1.6%) The QOF data also indicate regional variation in the identified prevalence of COPD throughout strategic health authorities, ranging from 0.9% in London to 2.3% in the North east (see figure 1). Figure 2 Prevalence of diagnosed COPD by strategic health authority as reported in the 2007/08 Quality and outcomes framework 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% National costing report: chronic obstructive pulmonary disease 9 of 30

10 Prevalance Figure 3 Estimated prevalence of diagnosed COPD by age 8% 7% 6% 5% 4% 3% 2% 1% 0% Age (years) Source: IMS Disease Analyzer The prevalence of COPD is also influenced by age, as indicated in figure 2. The diagnosed prevalence for individuals between the ages of years is < 1% increasing to > 5% for individuals aged 65 years and older. 1.5 Models of care Care for COPD patients will be given by primary and secondary healthcare professionals This costing report concentrates on costs in primary care, although savings may be achievable through a reduction in secondary care admissions resulting from improved disease control. 2 Costing methodology 2.1 Process We use a structured approach for costing clinical guidelines (see appendix A) The costing report uses data supplied by the NHS Information Centre for health and social care, which completed an analysis of patient records to establish the current prescribing practice for patients with COPD. National costing report: chronic obstructive pulmonary disease 10 of 30

11 2.1.3 The analysis was based on 982,246 patient records from 113 practices, available from 1 January to 31 December IMS collects data from a sample of GP practice systems. These records are made anonymous and are available for analysis via a tool called the IMS Disease Analyzer To estimate prescribing practice following implementation of the guidance made several assumptions in the costing model. We developed these assumptions and tested them for reasonableness with members of the Guideline Development Group (GDG) and key clinical practitioners in the NHS. 2.2 Scope of the cost-impact analysis Groups that will be covered by the guideline are adults (16 years and older) who have COPD (including chronic bronchitis, emphysema and chronic airflow limitation/obstruction) The guidance does not cover the following groups: people with asthma, bronchopulmonary dysplasia or bronchiectasis, or children. Therefore these issues are outside the scope of the costing work The costing work has concentrated on the new recommendations in the 2010 guidance. Reviewing the uptake of the recommendations made within the 2004 guidance is outside the scope of this costing work Due to the breadth and complexity of the guideline, we worked with the GDG and other professionals to identify the recommendations that would have the most significant resource impact (see table 2). Costing work has focused on these recommendations. National costing report: chronic obstructive pulmonary disease 11 of 30

12 Table 2 Recommendations with a significant resource impact High-cost recommendations Recommendation number Key priority? Offer once-daily long-acting muscarinic antagonist (LAMA) in preference to four-timesdaily short-acting muscarinic antagonist (SAMA) to people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, and in whom a decision has been made to commence regular maintenance bronchodilator therapy with a muscarinic antagonist No In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy: if forced expiratory volume in 1 second (FEV 1 ) 50% predicted: either longacting beta 2 agonist (LABA) or LAMA if FEV 1 < 50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA Yes In people with stable COPD and an FEV 1 50% who remain breathless or have exacerbations despite maintenance therapy with a LABA: consider LABA+ICS in a combination inhaler consider LAMA in addition to LABA where ICS is declined or not tolerated No Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV Yes Consider LABA+ICS in a combination inhaler in addition to LAMA for people with stable COPD who remain breathless or have exacerbations despite maintenance therapy with LAMA irrespective of their FEV No National costing report: chronic obstructive pulmonary disease 12 of 30

13 2.2.5 Ten of the recommendations in the guideline were identified as key priorities for implementation, and two of these are also among the five recommendations considered to have significant resource impact. Of the other eight key priorities for implementation, seven are unchanged from recommendations made in Chronic obstructive pulmonary disease (NICE clinical guideline 12); one new recommendation, relating to pulmonary rehabilitation, was not considered to have a significant resource impact. 2.3 General assumptions made The model is based on the prevalence of COPD and population estimates (see table 1). 1.6% is the national average prevalence for COPD. The costing template allows the user to select specific PCTs and calculate the incremental cost of implementing the guidance using the prevalence specific to that area. 2.4 Basis of unit costs The daily dose for each drug was estimated for the purposes of assessing the potential resource impact of implementing the guideline (see table 3). Pack prices have been taken from the British National Formulary Please note that the prices of drugs fluctuate; the costs quoted in this report were accurate at the time of publication (February 2011) but clearly may change over time. The costing template that accompanies this report allows users to tailor the drug costs and prescribing practice to reflect their local practice. National costing report: chronic obstructive pulmonary disease 13 of 30

14 Table 3 Estimated annual prescribing costs for drugs commonly used in the treatment of chronic obstructive pulmonary disease (COPD) Class Drug formulation and dose Pack price ( ) Daily cost ( ) Annual cost (365 days ) SABA Salbutamol 100 micrograms metered inhalation (generic) ICS Beclometasone 250 micrograms metered inhalation (generic) SAMA Ipratropium 20 micrograms metered inhalation (Atrovent) LABA Salmeterol 25 micrograms metered inhalation (Serevent) SABA Terbutaline 500 micrograms metered inhalation (Bricanyl) LAMA Tiotropium 18 micrograms inhalation capsule (Spiriva) LABA+ICS LABA+ICS LABA+ICS Budesonide 200 micrograms + formoterol 6 micrograms metered inhalation (Symbicort turbohaler) Budesonide 400 micrograms + formoterol 12 micrograms metered inhalation (Symbicort turbohaler) Fluticasone propionate 500 micrograms + salmeterol 50 micrograms metered inhalation (Seretide accuhaler) SABA = short-acting beta 2 agonist. ICS = inhaled corticosteroids. SAMA = short-acting muscarinic agonist. LABA = long-acting beta 2 agonist. LAMA = long-acting muscarinic agonist A hospital admission for COPD is estimated to cost commissioners 1960 (see table 4). This is a weighted average cost calculated from national tariff cost information and activity levels taken from reference cost data. It is only inpatient costs that are included in this average; intensive care unit, high dependency unit and ambulance costs are not included The tariffs for COPD also include people admitted with bronchitis. On the basis of primary diagnosis data extracted from Hospital Episode Statistics, it was calculated that 86% of the total activity in relation to COPD and bronchitis is for COPD Table 4 below shows all the tariffs in relation to COPD. National costing report: chronic obstructive pulmonary disease 14 of 30

15 Table 4 Tariff and activity data for admissions for chronic obstructive pulmonary disease (COPD) HRG code Description Tariff (daycase, elective or non-elective stays; ) DZ21A DZ21B DZ21C DZ21E DZ21F DZ21G DZ21H DZ21J DZ21K COPD or bronchitis with length of stay 1 day or less discharged home COPD or bronchitis with intubation with major complications COPD or bronchitis with intubation with complications COPD or bronchitis with non-invasive ventilation without intubation with major complications COPD or bronchitis with non-invasive ventilation without intubation with complications COPD or bronchitis with non-invasive ventilation without intubation without complications COPD or bronchitis without non-invasive ventilation without intubation with major complications COPD or bronchitis without non-invasive ventilation without intubation with complications Chronic Obstructive Pulmonary Disease or Bronchitis without NIV without Intubation without complications Total activity 86% of activity estimated to relate to COPD ,547 62, ,777 3, , ,006 34, ,870 45,468 1,849 13,448 11,565 Total 184, ,374 Weighted average tariff cost A 5% reduction in the number of hospital episodes is estimated as a result of implementing the guidance in relation to prescribing. This is based on expert medical opinion. National costing report: chronic obstructive pulmonary disease 15 of 30

16 3 Cost of significant resource-impact recommendations 3.1 Managing stable COPD prescribing Recommendations Offer once-daily long-acting muscarinic antagonist (LAMA) in preference to four-times-daily short-acting muscarinic antagonist (SAMA) to people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, and in whom a decision has been made to commence regular maintenance bronchodilator therapy with a muscarinic antagonist [ ] In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy: if forced expiratory volume in 1 second (FEV 1 ) 50% predicted: either long-acting beta 2 agonist (LABA) or LAMA if FEV 1 < 50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA [ ] In people with stable COPD and an FEV 1 50% who remain breathless or have exacerbations despite maintenance therapy with a LABA: consider LABA+ICS in a combination inhaler consider LAMA in addition to LABA where ICS is declined or not tolerated [ ] Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV 1 [ ]. National costing report: chronic obstructive pulmonary disease 16 of 30

17 3.1.5 Consider LABA+ICS in a combination inhaler in addition to LAMA for people with stable COPD who remain breathless or have exacerbations despite maintenance therapy with LAMA irrespective of their FEV 1 [ ]. Background Current prescribing for COPD is difficult to calculate because many of the drugs used to treat COPD are also used for other respiratory conditions including asthma For the purpose of this report current prescribing for COPD has been estimated using data provided by the NHS Information Centre using the IMS Disease Analyzer. The analysis was based on 982,246 patients in 113 practices available from 1 January to 31 December The therapy problem link, a function of the IMS Disease Analyzer, was used in this analysis. This allows a therapy to be linked to a condition, in this case COPD. This finds all patients who were prescribed a certain therapy to treat their condition To identify COPD patients the read codes as defined in the QOF business rules version 17 were used The therapies used in the analysis report are listed below: Beclometasone (Clenil Modulite, QVAR) Budesonide Fluticasone Ipratropium (Atrovent) Salbutamol (Ventolin, Salamol) Salmeterol (Serevent) Fluticasone proprionate + salmeterol (Seretide) Budesonide + formoterol (Symbicort) Terbutaline Tiotropium (Spiriva) National costing report: chronic obstructive pulmonary disease 17 of 30

18 Assumptions made The prescribing data extracted from the IMS Disease Analyzer were refined to remove very small levels of prescribing (< 1%) and this data was then applied pro-rata to the other prescribing options Prescribing amongst the sample group was extrapolated to estimate national prescribing for the 819,524 people diagnosed with COPD (see table 5) Current prescribing costs were estimated by applying the annual costs listed in table 3, multiplied by the number of patients. As shown in table 5, the current annual primary care prescribing costs for COPD is estimated to be million This is similar to data in an impact assessment report released by the Department of Health in 2010, in which the estimated total cost of all drugs used for COPD was million. National costing report: chronic obstructive pulmonary disease 18 of 30

19 Class Table 5 Estimated current prescribing for COPD in primary care Number of preparations Drugs Proportion treated Patients Annual cost ( ) Cost ( 000s) ICS 1 Beclometasone 6.1% 50, LABA 1 Salmeterol 2.1% 17, LABA+ICS 1 Fluticasone proprionate + salmeterol (Seretide) LABA+ICS 1 Budesonide + formoterol (Symbicort) 6.5% 52, , % 18, LAMA 1 Tiotropium 18.0% 147, ,381 SABA 1 Salbutamol 21.3% 174, SABA 1 Terbutaline 1.0% SAMA 1 Ipratropium 4.2% 34, Subtotal 61.4% 107,375 ICS and LABA 2 Beclometasone, salmeterol 1.2% LABA+ICS and LAMA LABA+ICS and LAMA LABA+ICS and SABA 2 Fluticasone proprionate + salmeterol (Seretide), tiotropium 2 Budesonide + formoterol (Symbicort), tiotropium 2 Salbutamol, fluticasone proprionate + salmeterol (Seretide) 4.4% 36, , % 11, , % 27, ,382 ICS and LAMA 2 Beclometasone, tiotropium 1.2% ICS and SABA 2 Beclometasone, salbutamol 3.7% 30, SABA and 2 Salbutamol, tiotropium 9.8% 79, ,660 LAMA SAMA + SABA 2 Ipratropium bromide, salbutamol 4.8% 39, Subtotal 29.9% 102,542 LABA+ICS and SABA and LAMA LABA+ICS and SABA and LAMA SABA and LAMA and ICS 3 Fluticasone proprionate + salmeterol (Seretide), salbutamol, tiotropium 3 Symbicort, Salbutamol, Tiotropium 3 Salbutamol, tiotropium, beclometasone 5.4% 43, , % 13, , % 13, Subtotal 8.7% 58,626 Grand total 100% 819, , Changes in prescribing practice (see table 6) were estimated on the basis of the updated prescribing pathway (see appendix B) and National costing report: chronic obstructive pulmonary disease 19 of 30

20 following discussions with clinical experts. It should be highlighted that predictions made around future prescribing practice are made for financial planning purposes only and should not be taken as recommended practice, or used as targets. Table 6 Estimated changes in prescribing following implementation Number of preparations Class Current prescribing (%) Change in prescribing (%) Future prescribing (%) 1 ICS LABA LABA+ICS LAMA SABA SAMA ICS and LABA LABA+ICS and LAMA LABA+ICS and SABA ICS and LAMA ICS and SABA SABA and LAMA SAMA and SABA LABA+ICS and SABA and LAMA SABA and LAMA and ICS Total The costs for future prescribing practice are shown in table 7 and were estimated by applying the annual costs listed in table 3 multiplied by the number of patients predicted to receive each drug in the future (based on the percentages shown in table 6). National costing report: chronic obstructive pulmonary disease 20 of 30

21 Class Table 7 Estimated future annual prescribing costs for COPD in primary care Number of preparations Preparations Proportion treated Patients Annual cost ( ) Cost ( 000s) ICS 1 Beclometasone 1.6% 13, LABA 1 Salmeterol 2.1% 17, Fluticasone proprionate + 7.4% 60, ,193 LABA+ICS salmeterol (Seretide) 1 Budesonide + formoterol 2.6% 21, LABA+ICS (Symbicort) LAMA 1 Tiotropium 20.2% 165, ,439 SABA 1 Salbutamol 21.3% 174, SABA 1 Terbutaline 1.0% SAMA 1 Ipratropium 2.0% 16, Subtotal 58.2% 117,754 ICS and LABA 2 Beclometasone, salmeterol 0.0% LABA+ICS 2 Fluticasone proprionate + 4.4% 36, ,449 and LAMA salmeterol (Seretide), tiotropium LABA+ICS and LAMA LABA+ICS and SABA 2 Budesonide + formoterol (Symbicort), tiotropium 2 Salbutamol, fluticasone proprionate + salmeterol (Seretide) 1.4% 11, % 65, ,325 ICS and LAMA 2 Beclometasone, tiotropium 0.8% ICS and SABA 2 Beclometasone, Salbutamol 1.8% 14, SABA and 2 Salbutamol,tiotropium 12.6% 103, ,472 LAMA SAMA and 2 Ipratropium, salbutamol 2.0% 16, SABA Subtotal 31.0% 124,660 LABA+ICS and SABA and LAMA LABA+ICS and SABA and LAMA SABA and LAMA and ICS 3 Fluticasone proprionate + salmeterol (Seretide), salbutamol, tiotropium 3 Budesonide + formoterol (Symbicort), salbutamol, tiotropium 3 Salbutamol, tiotropium, beclometasone 7.7% 63, , % 18, , % Subtotal 10.8% 77,617 Grand total 100% 819, ,031 National costing report: chronic obstructive pulmonary disease 21 of 30

22 Cost summary Table 8 Estimated incremental annual costs associated with managing stable COPD inhaled combination therapy Current cost ( 000s) Estimated future cost ( 000s) Change ( 000s) Cost of prescribing 268, ,030 51,487 Cost of hospital admissions 310, ,892 15,521 Total 578, ,922 35, The total estimated annual cost is 36 million (see table 8) A lower number of single preparations are expected to be prescribed to patients because the guidance recommends prescribing ICS in a combined inhaler. 3.2 Benefits and savings Improvements in the management and effectiveness of treatments for patients with COPD are likely to result in a reduced number of admissions to hospital and increased compliance with treatment. There is also likely to be a reduction in the number of visits made to GPs One in eight emergency admissions to hospital is for COPD, making it the second largest cause of emergency admission in the UK, and one of the most costly inpatient conditions treated by the NHS (British Lung Foundation, 2007). An inpatient admission for COPD is estimated to cost 1960 based on a weighted average of the HRG codes applicable to COPD (see table 4) On the basis of expert medical opinion an estimated 5% decrease in the number of hospital episodes for COPD is expected as a result of implementing the guidance. When this reduction of 5% is applied to the total activity of 158,374 episodes (see table 4) the estimated future annual activity is 150,455. This in turn would lead to an annual saving of 15.5 million. National costing report: chronic obstructive pulmonary disease 22 of 30

23 3.2.4 This reduction in hospital admissions may increase further in future years as people receive more effective medication earlier in their treatment pathway More effective management of COPD is also likely to reduce the number of working hours lost as a result of the disease and, hence, reduce the costs incurred as a result of this lost productivity. 4 Sensitivity analysis 4.1 Methodology No empirical evidence exists for several assumptions in the model. Because of the limited data, the model developed is based mainly on discussions of typical values and predictions of how things might change as a result of implementing the guidance and is, therefore, subject to a degree of uncertainty Because the future prescribing was estimated on the basis of clinical opinion, variables were altered by 25% either way, except for the future prescribing rate of beclometasone and salmeterol which was increased to a maximum of 2% from its baseline of 0% It was not possible to arrive at an overall range for total cost of prescribing because the minimum or maximum of individual lines would not occur simultaneously. We undertook one-way simple sensitivity analysis, altering each variable independently to identify those that have greatest impact on the calculated total cost The average cost of a hospital admission was included in the analysis because the calculation of this is subject to variation. The estimated 5% reduction in admissions provided by clinical experts is also included Appendix C contains a table detailing all variables modified and the key conclusions drawn are discussed below. National costing report: chronic obstructive pulmonary disease 23 of 30

24 4.2 Impact of sensitivity analysis on costs Altering the prevalence of COPD has a significant effect on the total cost of the guidance as all costs are driven by the number of patients. Users of the costing template are encouraged to select their local area when using the template as prevalence by area is included The future prescribing rates of the drugs that are expected to result in the most significant changes following implementation of the guidance were adjusted. For each prescribing rate altered, the equal and opposite effect was applied to the drugs recommended to be used instead of, or to no longer be used The main reasons for predicted differences between current and future prescribing rates are considered to be: The recommendation of LAMA (tiotropium bromide) instead of SAMA (ipratropium bromide) under circumstances set out in the guidance. The recommendation to use ICS in a combination inhaler (Seretide or Symbicort) rather than as a single preparation (beclometasone). Therefore, prescribing rates of the above drugs were altered in the sensitivity analysis The variables that resulted in the most significant effect on cost when altered were the drug combinations including tiotropium. This is because it is one of the more expensive drugs and is often used in combination with other expensive drugs The estimated number of admissions of 5% was based on clinical opinion and hence is subject to a degree of uncertainty. Altering the baseline value has a large impact on the total cost. National costing report: chronic obstructive pulmonary disease 24 of 30

25 5 Impact of guidance for commissioners This costing report concentrates on prescribing in primary care which is outside the scope of Payment by results A 5% reduction in the number of annual hospital admissions for COPD from 158,374 to 150,455 is estimated as a result of improved disease control. This falls within the scope of Payment by results. A non-elective inpatient admission for COPD is estimated to cost commissioners 1960 (see table 4 for calculation of weighted average tariff cost) Expenditure on COPD falls under programme budgeting category 211A Problems of the respiratory system obstructive airways disease 6 Conclusion 6.1 Total national cost for England Using the significant resource-impact recommendations shown in table 2 and assumptions specified in section 3 we estimated the annual cost impact of fully implementing the guideline in England to be 36 million We applied reality tests against existing data if possible, but this was limited by the availability of detailed data. We consider this assessment to be reasonable, given the limited detailed data regarding diagnosis and treatment paths and the time available. However, the costs presented are estimates and should not be taken as the full cost of implementing the guideline Because the implementation of the guideline involves a change in prescribing practice, clinicians and patients may have some reluctance to alter their current treatment, implementation is anticipated to take place over a period of more than a year. The National costing report: chronic obstructive pulmonary disease 25 of 30

26 millions graph below shows the cumulative cost of implementation over 3 years. Figure 4 Combined incremental costs of prescribing and savings from fewer hospital admissions Year 1 Year 2 Year Next steps The local costing template produced to support this guideline enables organisations such as primary care trusts (PCTs) 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 with COPD prevalence of 1.6% could expect to incur additional costs of 70,219. Use this template to calculate the cost of implementing this guidance in your area using local data. The template includes prevalence by PCT to provide a more accurate cost for your area. National costing report: chronic obstructive pulmonary disease 26 of 30

27 Appendix A. Approach to costing guidelines Guideline at first consultation stage Identify significant recommendations and population cohorts affected through analysing the clinical pathway 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 Internal peer review by qualified accountant within NICE Develop local cost template 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 National costing report: chronic obstructive pulmonary disease 27 of 30

28 Appendix B. Use of inhaled therapies (NICE 2010) Algorithm 2a: Use of inhaled therapies Please note: This algorithm should be used within the wider context of the management of COPD, including algorithms 1, 2 and 3 Breathlessness and exercise limitation Exacerbations or persistent breathlessness SABA or SAMA as required* FEV1 50% FEV1 < 50% LABA LAMA Discontinue SAMA Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler Consider LABA + LAMA if ICS declined or not tolerated LAMA Discontinue SAMA Offer LAMA in preference to regular SAMA four times a day Persistent exacerbations or breathlessness LABA + ICS in a combination inhaler Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS in a combination inhaler Abbreviations: SABA Short-acting beta agonist SAMA Short-acting muscarinic antagonist LABA Long-acting beta agonist LAMA Long-acting muscarinic antagonist ICS Inhaled corticosteroid * SABA (as required) may continue at all stages Offer therapy (strong evidence) Consider therapy (less strong evidence) National costing report: chronic obstructive pulmonary disease 28 of 30

29 Appendix C. Results of sensitivity analysis Assessment of sensitivity costs to a range of variables Baseline costs ( 000s) Minimum costs ( 000s) Maximum costs ( 000s) Parameter varied Baseline value Minimum value Maximum value Change ( 000s) Prevalence of COPD 1.6% 1% 2.5% 35,966 16,659 64,928 48,269 Future prescribing rate of tiotropium 20.2% 16.2% 24.2% 35,966 24,336 47,597 23,261 Future prescribing rate of beclometasone, salmeterol 0.0% 0.0% 1.0% 35,966 31,770 35,966 4,196 Future prescribing rate of salbutamol, fluticasone proprionate + salmeterol 8.0% (Seretide) 6.0% 10.0% 35,966 32,888 43,776 10,888 Future prescribing rate of fluticasone proprionate + salmeterol (Seretide), 7.7% salbutamol, tiotropium 5.8% 9.6% 35,966 24,360 49,509 25,149 Average cost of a hospital admission ,966 33,274 38,817 5,543 Reduction in the number of admissions 5% 2.5% 7.5% 35,966 28,206 43,727 15,521 National costing report: chronic obstructive pulmonary disease 29 of 30

30 Appendix D. References Admitted patient care & outpatient procedure tariff British Lung Foundation (2007) Invisible lives: chronic obstructive pulmonary disease (COPD) finding the missing millions. Department of Health (2010) Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England impact assessment. London: Department of Health Healthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission. NICE (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). NICE clinigal guideline 101. London: National Institute for Health and Clinical Excellence. Available from Quality and Outcomes Framework (2009/10). Prevalence data tables. Available from information/audits-and-performance/the-quality-and-outcomes-framework/qof /data-tables/prevalence-data-tables National costing report: chronic obstructive pulmonary disease 30 of 30

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