Improving outcomes for respiratory patients

Two Primary Care Networks (PCNs) in Middlesbrough took part in a service evaluation project where the aims were:

  • To significantly reduce the disease burden of patients with asthma
  • To improve system integration and multi-disciplinary team working in respiratory care
  • To reduce the carbon footprint of inhalers used by patients.

Patients were identified by a software package, SENTINEL Plus, provided by Astra Zeneca as a ‘service to medicine’ initiative. Pharmacists from Interface Clinical Services used this to interrogate General Practice (GP) clinical systems to extract the data and identify those patients who, according to pre-set criteria around their medication use, may benefit from a review of their asthma management.

This exercise resulted in 29% of eligible/invited patients attending a GP based pharmacist review and a further 1% attending for a community pharmacy review. Reductions of up to 11% of inhaler usage were reported. There was a significant 2% reduction in carbon footprint of SABA inhalers used and 1% reduction in carbon footprint of ICS inhalers used.

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Project Dates

Project Start 01/02/2021
Project End 30/09/2023

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The NHS Long Term Plan outlined ambitious targets for lower carbon emissions and to reduce its carbon footprint to net zero by 2040.

Medicines account for 25% of emissions within the NHS, with inhalers a significant contributor.1 Inhalers are commonly used in respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Most of the emissions come from the propellant in metered-dose inhalers (MDIs) used to deliver the medicine, rather than the medicine itself. When a patient is poorly controlled in Asthma or COPD, they usually require to use more reliever inhaler, (usually blue ie ‘SABA’).  When SABAs are used in MDI device, they are responsible for higher carbon emissions. Therefore, higher carbon emissions follow the poorly controlled patient.

This project reviewed asthma patients in a multi-site service evaluation across two Primary Care Networks (PCNs) in the Tees Valley.

This was done by identifying high risk/poorly controlled asthma patients through bespoke searches using Sentinel plus. The highest risk patients were seen in GP practices, lowest risk patients were invited to a participating community pharmacy for review.

Those with poor control were reviewed for optimisation; this brought the opportunity to improve control using more environmentally friendly device options such as a Dry Powder Inhaler (DPI). By improving control this reduces the need for a reliever inhaler which is usually delivered in Pressurised Metered Dose inhaler (pMDI), which are associated with higher carbon emissions.

To ensure patients who were called for review throughout the project received high quality care, staff education around asthma best practice was delivered.Patients were identified by a software package, SENTINEL Plus, provided by Astra Zeneca as a ‘service to medicine’ initiative. Pharmacists from Interface Clinical Services used this to interrogate General Practice (GP) clinical systems to extract the data and identify those patients who, according to pre-set criteria around their medication use, may benefit from a review of their asthma management.Activity was undertaken in:• 8 GP practices within the 2 PCNs• 3 community pharmacies were recruited but a very low level of activity in patients presenting was recorded• 711 patients were reviewed overallA combination of face to face and telephone appointments were undertaken. Lower risk patients were invited to a community pharmacy by text message.

The results of this service evaluation have demonstrated that the implementation of a modular education package on asthma best practice improved clinicians’ knowledge/confidence.  Following this, patient asthma reviews by an outsourced pharmacist in GP or by community pharmacist resulted in positive changes across a range of prescribing measures. The most important difference in prescribing trends included a reduction in excess SABA prescriptions reflecting improved asthma control among patients, and an increase in DPI prescribing which resulted in lower carbon emissions, which is a key target within the NHS Long Term Plan.1,2 It is reasonable to assume that the magnitude of these improvements may increase as more asthma patients within the two participating PCNs undergo a review, as at the time of final data collection only 29% (697/2393) of eligible/invited patients had attended a GP based pharmacist review and a further 1% (14/2393) community pharmacy review.

The highest risk patients (poorly controlled) were identified. There was a significant 12% reduction in patients prescribed ≥6 SABA. There was also a significant 11% reduction in patients prescribed 6–10 SABA. There was a smaller, but still significant 1% reduction in patients prescribed 11–15 SABA.  Over use of SABA is a marker of poor control, therefore these reductions have been translated into improved patient outcomes.

There is huge benefit to patients who upon having a review can be reassured they are using the correct medicines in the correct doses for their condition. Optimising medicine usage can improve asthma control which is hugely beneficial for a patient.

The modular training package improved knowledge and confidence levels of both non-clinical and clinical staff in management of asthma including improved awareness of the environmental impact of inhalers.

The NHS will also benefit from this new pathway as it provides improved asthma control which leads to reduced health care utilisation, as well as supporting the NHS agenda for reducing carbon emissions.

There was a significant 2% reduction in carbon footprint of SABA inhalers used, equivalent to a total reduction of 117 tonnes CO2 (equivalent to ~33 flights from London to Perth, Australia for one passenger[i]) across all practices. Similarly, there was a significant 1% reduction in carbon footprint of ICS inhalers used, equivalent to a total reduction of 82 tonnes CO2  (equivalent to ~23 flights from London to Perth, Australia for one passenger4) across all practices

[i]     Foundation myclimate. Calculate and support. Available at: https://co2.myclimate.org/en/flight_calculators/new [Accessed March 2024]

 

Claire Adams of HI NENC provided education to PCNs and co-ordinated all stakeholders involved in the project. This included project management through to final reporting.

Mike Maguire, NHSE, Local Professional Network Chair provided Project Support throughout, and was instrumental in the community pharmacy phase.

This project has significant potential for spread and adoption across the country. The results are currently being shared with:

  • The ICB sustainability group
  • ICB NENC medicines optimisation team and Primary care team
  • Health Innovation Network- national clinical working group for respiratory.