3. Has your PCT explored the need for a community based multi-disciplinary specialist team for COPD?

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1 PCT Prescribing Report Asthma and COPD Discussion Points 1. Has your PCT audited compliance with new safety advice from the Commission on Human Medicines covering prescribing of long-acting beta-agonists to people with asthma? 2. Is there a local integrated care pathway for patients who have chronic obstructive pulmonary disease (COPD)? Does the pathway cover smoking cessation and guidance on prescribing in accordance with the NICE clinical guideline for COPD? 3. Has your PCT explored the need for a community based multi-disciplinary specialist team for COPD? 4. Has your PCT taken steps to improve access to physiological measurement for COPD? For example, providing or commissioning open access spirometry or pulse oximetry? 5. Is there a local system for tracking unplanned admissions for ambulatory care sensitive conditions and feeding back information to GPs? Respiratory diseases account for 10% of all expenditure on medicines in primary care. With the exception of antimuscarinic and compound bronchodilators, used for COPD, all the drugs shown in charts 1 and 2 are routinely prescribed for both asthma and COPD. Combination products containing a long-acting beta-agonist plus a steroid (Seretide and Symbicort ) accounted for 46% of items and 75% of expenditure on inhaled steroids for respiratory disease in the quarter to June Apart from the statin, atorvastatin, no single drug accounts for a greater proportion of primary care drug costs than the most commonly prescribed long-acting beta-agonist plus steroid combination, Seretide. Concerns have been expressed recently regarding possible adverse effects of the components of such combination products. These concerns focus on the effects of long-acting beta-agonists in asthma and the effects of steroids in COPD. Both NICE COPD guidelines and British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) Asthma guidelines highlight the importance of reviewing the effectiveness of therapy and discontinuing drugs not producing measurable improvements.

2 PCT s could use the criteria set out by the Commission on Human Medicines to conduct audits on the use of long-acting beta agonists. The advice is provided for the management of chronic asthma, long-acting beta agonists should; be added only if regular use of standard-dose inhaled corticosteroids has failed to control asthma adequately; not be initiated in patients with rapidly deteriorating asthma; be introduced at a low dose and the effect properly monitored before considering dose increase; be discontinued in the absence of benefit; be reviewed as clinically appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved. Growth in the prescribing of long-acting beta agonist / steroid fixed dose combination products has led to a reduction in the volume of corticosteroids prescribed as separate inhalers. There is no proven difference between the efficacy of inhaled steroids with long-acting beta agonists given via fixed dose combination inhalers or via separate inhalers. Nor have combination devices been shown to improve compliance in the medium to long-term. Fixed dose combinations may have advantages for individual patients, however, and may be less expensive at lower doses. Figure 1: Trends in Prescribing of Drugs for Asthma and COPD in General Practice in England Items (Millions) Quarter to Jun-02 Sep-02 Dec-02 Mar-03 Jun-03 Sep-03 Dec-03 Mar-04 Jun-04 Sep-04 Dec-04 Mar-05 Jun-05 Sep-05 Dec-05 Mar-06 Jun-06 Sep-06 Dec-06 Mar-07 Jun-07 Short-acting beta agonists Antimuscarinic bronchodilators Corticosteroids Long-acting beta agonists Compound bronchodilators Symbicort & Seretide

3 Figure 2: Trends in Spending on Drugs for Asthma and COPD in General Practice in England NIC ( Millions) Quarter to Jun-02 Sep-02 Dec-02 Mar-03 Jun-03 Sep-03 Dec-03 Mar-04 Jun-04 Sep-04 Dec-04 Mar-05 Jun-05 Sep-05 Dec-05 Mar-06 Jun-06 Sep-06 Dec-06 Mar-07 Jun-07 Short-acting beta agonists Antimuscarinic bronchodilators Corticosteroids Long-acting beta agonists Compound bronchodilators Symbicort & Seretide Although the recorded prevalence of asthma is higher (5.4% of registered population versus 1.4% for COPD quality and outcomes framework registers 2006) and most respiratory drug prescribing in primary care is for asthma, COPD has by far the greater impact in terms of hospital admissions and deaths. It was the second most important cause of preventable death in 2005 and is responsible for up to 12.5% of all emergency admissions to hospital. There are striking social inequalities in prevalence and outcomes. A National Service Framework for COPD is due in Both asthma and COPD have been identified as ambulatory care sensitive conditions (i.e. long term conditions where good case management, and timely and appropriate care outside hospital can reduce the need for admissions) for which services might be improved and/or augmented via practice based commissioning. According to figures from the NHS Institute for Innovation and Improvement, 25% of emergency admissions attributable to ambulatory care sensitive conditions are for asthma or COPD. In England during 2005/06 there were 14.3 unplanned hospital admissions for COPD for every 100 people with a recorded diagnosis. The Healthcare Commission has identified an urgent need to improve diagnosis and care for people with Chronic Obstructive Pulmonary Disease (COPD). Core care for COPD has been identified as having the following components: smoking cessation; vaccination against flu and pneumonia;

4 access to an Expert Patient Programme; support for self-management, including a plan for worsening symptoms; screening for depression; and exercise advice and support. In Clearing the air, a national study published in 2006, the Commission urged a greater emphasis by PCTs, in their role as commissioners of services, on ensuring that people with COPD receive appropriate structured care. The following actions were highlighted: Continue to pursue initiatives which aim to reduce the number of people who smoke and, in particular, the number of young people who start smoking Improve diagnosis of COPD, especially in areas with higher levels of deprivation, by improving support for those carrying out spirometry testing Commission services that improve access to pulmonary rehabilitation for all people with COPD, in accordance with guidance by NICE, and improve access to palliative care for those who can benefit from this approach Work with clinicians in respiratory networks to review rates of emergency admission to hospital for people with COPD and explore the reasons for admission and the availability of alternative services to support people at home Work with clinicians in respiratory networks to ensure that structured care is available for people with COPD this includes ensuring that registers of people with COPD are accurate, that the care and treatment of people with COPD is reviewed regularly, and that there is support available to help people to care for themselves. Sources of further information 1. Information on prescribing for the PCT is available using epact.net and the Prescribing Toolkit. 2. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE Clinical Guideline 12, February British Guideline on the Management of Asthma. British Thoracic Society / Scottish Intercollegiate Guidelines Network. Revised edition July Disease Management Information Toolkit DH Longtermconditions/DH_ Clearing the air: A national study of chronic obstructive pulmonary disease Commission for Healthcare Audit and Inspection rt1.pdf 6. Department of Health. Avoiding and diverting admissions to hospital - A good practice guide

5 7. Commissioning Toolkit for Long-term Conditions 8. Asthma Exemplar, National Service Framework for Children, Young People and Maternity Services s/asthma_exempla.pdf 9. Health Inequalities Intervention Tool - London Health Observatory on behalf of the Association of Public Health Observatories ol.aspx 10. Statistics on Smoking in England 2007 The Information Centre