Dr Sarah Wikeley sarahwikeley1nhsnet Supporting highquality lowcarbon asthma care HF Prim ary Care SIG Tuesday 30 th November What is the problem that needs addressing Asthma care and outcomes in the UK need improvement ID: 1040164
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1. Dr Aarti Bansalaarti.bansal1@nhs.netDr Sarah Wikeleysarah.wikeley1@nhs.netSupporting high-quality low-carbon asthma care.HF Primary Care SIGTuesday 30th November
2. What is the problem that needs addressing?Asthma care and outcomes in the UK need improvementReduction in the use of MDI inhalers as part of Net Zero NHS
3. What are the current resources and incentives?
4. What are the current resources and incentives?
5. Incentive from October 2021Incentive from April 2022
6. These resources tell clinicians what to do…How do I do this?
7. This project aims to make the implementation high-quality and low-carbon asthma care safe, effective and easy.
8. Two elements to the QI resources
9. Structure of educational slide pack
10. Example slides around ‘drug’ and ‘device’
11. Drug
12. Drugs NRAD found widespread issues with the quality of asthma care amongst those who died, with several areas of key findings including:excessive prescribing of reliever medication under-prescribing of preventer medicationinappropriate prescribing of long-acting beta agonist (LABA) bronchodilator inhalers. 2/3rds of asthma deaths were preventable Dr Aarti Bansal. Net-zero GP Lead. HCV ICS
13. Drugs: Current real-world UK Asthma management574,913 asthma patients SABA Short-acting beta agonist (salbutamol) only195,311 (34%)171,000 (88%)24,311 (12%)Inhaled CorticoSteroids (ICS) +SABA 177,945 (31%)100,432 (56%)77,513 (44%)High ICS, ICS+LABA, + additional201,657 (35%)29,133 (46%)116,541 (54%)Low SABA useHigh SABA use ≥3/yrBloom CI, et al. Asthma-Related Health Outcomes Associated with Short-Acting β2-Agonist Inhaler Use: An Observational UK Study as Part of the SABINA Global Program. Adv Ther. 2020 Oct;37(10):4190-4208. Two-thirds have treatment dominated by Ventolin MDI“mild asthma”. Low adherence with ICSHigh rates of SABA use.
14. Drugs: SABA over-reliance increases risk of severe attack & in extreme cases, death>2-fold risk hospitalisation/ED visit 3+ SABAs vs 0-2 per year1ƗSchatz M, et al. J Allergy Clin Immunol. 2006;117:995-1000; Low-Dose Inhaled Corticosteroids and the Prevention of Death from Asthma Samy Suissa, N Engl J Med 2000; 343:332-336
15. Drugs: SABA over-reliance is commonIn UK, 70% of all inhalers prescribed are SABAPotential overuse of SABA in 50% of patientsAverage of 6.51 prescriptions of SABA in population of patients with over-relianceUK SABA use GHG emissions treble most European countriesWilkinson A, Menzies-Gow A, Sawyer M, et al S26 An assessment of short-acting β2-agonist (SABA) use and subsequent greenhouse gas (GHG) emissions in five European countries and the consequence of their potential overuse for asthma in the UK Thorax 2021;76:A19.
16. Device
17. Device: Inhaler technique often poor leading to poor controlMany asthma patients use a DPI technique with their MDI inhaler -> poor drug delivery. Haughney J, Lee AJ, McKnight E, Pertsovskaya I, O'Driscoll M, Usmani OS. Peak inspiratory flow measured at different inhaler resistances in patients with asthma. The Journal of Allergy and Clinical Immunology: In Practice. 2021 Feb 1;9(2):890-6.
18. Device: UK is out of step with Europe in device choice and has high asthma mortalityWHO European Health Information GatewayLavorini 2011 Resp MedicineUK
19. Device: Examples of DPI and MDI Devices. *Best with spacersFrom NICE Patient Decision Aid 2019
20. Carbon footprint of inhalersDr Aarti Bansal. Net-zero GP Lead. HCV ICSMDIs account for 13% of GP carbon footprint and almost a 1/4 of our prescribing footprint. Low Carbon FootprintHigh Carbon FootprintHighest Carbon FootprintDPIsSMIsHFA 134a MDIsHFA227ea MDIs1kg CO2e/ inhaler 9 to 28kgCO2e/ inhaler36.5kg CO2e/inhalerWhy? Propellant gases in MDIs are 1000-3000x more powerful than CO2eVentolin has more than twice the carbon footprint of other salbutamol MDIs (Salamol, Airomir)
21. SABA relievers represent the majority of inhaler use in the UK and other European countriesSABA relievers drive the majority of GHG emissions from inhaler devices in the UK and other European countries Tackling SABA over-reliance will improve asthma control and reduce inhaler carbon footprint in UK*Inhaler sales data from IQVIA™. CO2, carbon dioxide; GHG, greenhouse gas; SABA, short-acting β2-agonist; UK, United Kingdom.Inhaler sales* (doses x 1,000)SABA relieverMaintenance2,000,0004,000,0006,000,0008,000,00010,000,000ItalySpainGermanyFranceUK0GHG emissions (CO2 equivalent in tonnes)0200,000400,000600,000800,0001,000,0001,200,0001,400,000ItalySpainGermanyFranceUKSABA relieverMaintenanceInhaler sales by countryGHG emissions associated with inhaler sales by country21Wilkinson A, Menzies-Gow A, Sawyer M, et al S26 An assessment of short-acting β2-agonist (SABA) use and subsequent greenhouse gas (GHG) emissions in five European countries and the consequence of their potential overuse for asthma in the UK Thorax 2021;76:A19.
22. if refilledReferences:doi:10.1136/bmjopen-2018-028763doi:https://doi.org/10.1016/j.jclepro.2019.117733doi:10.1136/bmjresp-2020-000571doi:10.1136/thorax-2020-BTSabstracts.330doi:10.3390/su13126657doi:10.1136/thoraxjnl-2019-213744doi:10.1007/s12325-019-01028-y
23. QI pack
24. Structure of QI packIntroSusQI driver diagram for context, brief tips on successful QI in primary care QI: step-by-step project guides, clinician resourcesIT: searches, asthma review templates, prescription templatesComms: SMS/ email/ letter templates, patient informationResourcesResources
25. QI pack examples:These projects address Short-acting beta agonist (SABA) over-reliance and other drug-related markers of poor asthma controlAims are to improve asthma care and therefore reduce carbon footprints by:reducing SABA pMDI usereducing number of exacerbations improving patient understanding and self-care Six example projects shown:Identify SABA over-reliance in prescription requestsIdentify SABA over-reliance in medication reviewsAddress SABA over-reliance in asthma reviewsAuditing SABA over-reliance and other risk factorsUsing prescription label to give informationPatient information campaignDrug
26. Drug: Addressing SABA over-reliance in daily clinical practiceIIF
27. Tool: How to check SABA use (SystemOne) Once patient record open, go to Medicines screenRight-click on last SABA prescriptionChoose “Information”Choose “Issue history”All historical issues will be listed – count how many in the past 12months Add SNOMED Code: Number of prescriptions for reliever inhaler per year (observable entity)
28. Add patient to Waiting List for recallHas the patient been issued 6 or more SABA prescriptions in the last 12 months?YESNOIssue prescription with script noteIssue prescription with script noteSend SMSResource: Flowsheet for SABA prescription requestsSearch for SNOMED Code: Number of prescriptions for reliever inhaler per year (observable entity) Script note: Did you know that needing more than 2 reliever (blue) inhalers per year, or using it more than 2 times per week, might be a sign that your asthma is not well controlled? If this occurs, see your GP or nurse for an asthma review as soon as you can.SMS: The number of inhalers you have needed this year shows your asthma may not be well controlled and you could be at risk of an asthma attack. Please book an asthma review as soon as you can.
29. Drug: Addressing SABA over-reliance and other high risk medication use through audit
30. SMS inviteEmail/ letter inviteSMS infoOur records show that your asthma may not be well controlled & you may be at risk of an asthma attack. Please book a review with your GP or asthma nurse as soon as you can. Dear Patient,Our records show that your asthma may not be well controlled & you may be at risk of an asthma attack. This could be because:You’ve used less than 3 preventer inhalers in the last 12 months (this is the inhaler you take every day to control your symptoms)You’ve used more than 5 reliever (blue) inhalers in the last 12 months (this is the inhaler you take when you have symptoms)You’ve needed 2 or more courses of oral steroids in the last 12 monthsPlease contact the surgery to book a review with your GP or asthma nurse as soon as you can.For more advice on asthma and how to make the most of your asthma review, see:What to do if your asthma's getting worse | Asthma UK (for letter, enclose leaflet printout)Many thanks,Your GP Surgery For more advice on asthma and how to make the most of your asthma review, see:What to do if your asthma's getting worse | Asthma UK
31. Drug: Addressing SABA over-reliance through patient activation
32. Information about inhalers and carbon footprint
33. Structure of QI packIntroSusQI driver diagram for context, brief tips on successful QI in primary care QI: step-by-step project guides, clinician resourcesIT: searches, asthma review templates, prescription templatesComms: SMS/ email/ letter templates, patient informationResourcesResources
34. DeviceQI pack examples:These projects target choice of inhaler device and reduce carbon footprint by facilitating move to lower carbon pMDIs or DPIs. NB: there is only one safe bulk switch – other projects will show how to identify & support patients who could change inhalers One example project shown:Switch from Ventolin/ Generic pMDI to Salamol or Airomir
35. Device: switch Ventolin/ generic pMDI to lower carbon Salamol or Airomir
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37. Hosting and DisseminationAudienceLinking to Toolkit
38. Your Feedback please!Dr Aarti Bansalaarti.bansal1@nhs.netDr Sarah Wikeleysarah.wikeley1@nhs.net