1 How to manage… exacerbations of COPD, asthma &… in hospital Delivering high value integrated care with KREDIT? Dr Louise Restrick, NHS London Respiratory Team Lead Consultant Respiratory Physician, Whittington Health & NHS Islington Improving Outcomes Right Care Doing the right things and doing things right Right diagnosis including severity Addressing respiratory failure and breathlessness Structured admission & care planning conferences? Value framework KREDIT
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Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick
Breakout 4.3 How to manage… exacerbations of COPD, asthma and… in hospital - Delivering high value integrated care with KREDIT? Dr Louise Restrick NHS London Respiratory Team Lead Consultant Respiratory Physician, Whittington Health & NHS Islington Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme
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1
How to manage… exacerbations
of COPD, asthma &… in hospital
Delivering high value integrated care
with KREDIT? Dr Louise Restrick, NHS London Respiratory Team Lead
Consultant Respiratory Physician, Whittington Health & NHS Islington
Improving Outcomes
Right Care Doing the right things and doing things right
Right diagnosis including severity
Addressing respiratory failure and breathlessness
Structured admission & care planning conferences?
Value framework
KREDIT
2
Patients present with breathlessness…
Frightening … and disabling
Clinicians focus on respiratory failure
Aligning and sharing
agendas…
Frightening !!!
Breathlessness and hypoxaemia
pathways of care
Breathlessness
Hypoxaemia
=
Low oxygen saturation
Breathless
with normal
oxygen
saturation
Low oxygen saturation
but not breathless
Present to ED
Breathless
and low oxygen saturation
Care at home?
Respiratory failure
treatment in
hospital
3
Right Care for Respiratory Failure
Getting the diagnosis right Exacerbation is not the same as pneumonia …
Assessing severity and prognosis …
Getting oxygen therapy right High flow O2 increases mortality - from 7% to 11%*
Using Non-Invasive Ventilation
appropriately 11% given NIV had metabolic acidosis…*
* Roberts et al NCROP Thorax 2011:66;43-48
Right Care for Respiratory Failure
…NOT EASY
Need clinicians with
respiratory diagnostic
& treatment knowledge,
skills & expertise
Appropriate NIV halves mortality due to respiratory
failure in acute exacerbations of COPD
from 20% to 10%
Getting it right saves lives
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Value Framework
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
NB Outcomes as defined by patients & their families So we have to ask & listen …
What patients & families tell us…
‘I don’t want to die’
‘breathlessness is frightening and
disabling’
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Right Care for disabling
breathlessness…NOT EASY
Need long term condition
clinicians with behaviour
change & motivational
interviewing skills
To deliver evidence-based support for patients
to stop smoking as treatment for sick smokers
To enable patients to
benefit from pulmonary
rehabilitation
Kindness
Respect
Empathy
Dignity
Interest
TRUST
KREDIT* Respiratory Teams’ Shared Values …
*Whittington Health, London Respiratory Team and …
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COPD ‘Value’ Pyramid What we know…. Cost/QALY
Support to stop smoking
is key TREATMENT for
sick smokers …
Where are the sick
smokers?
… in our hospital beds
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
Is current smoking an issue in COPD?
2010 ERS Audit
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Effect of smoking on hospital
admissions for COPD and
asthma ….and???
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
Emergency respiratory admissions: influence of practice,
population and hospital factors Purdey S et al
J Health Services Research Policy 2011;16:133-40
Changing how we think about smoking
Tobacco dependence
Sick smokers are admitted to hospitals - acute and psychiatric
Evidence based quit smoking treatment is the most important
treatment for sick smokers:
Behaviour change support and quit smoking medication
‘Smoking kills, stopping works’ Sir Richard Peto 2012
Delivering value in tobacco dependence
Top 10 Questions …
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Does your hospital have a BTS Quit
Smoking Champion lead?
Do your consultants believe that Quit
Smoking treatment is high value for their
patients?
Does your hospital provide NRT
routinely on admission for smokers?
Are your hospital staff able, & confident
to, prescribe Quit Smoking medication?
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Do you have a Quit Smoking service for
patients and staff in the hospital?
Do your hospital staff know your Quit
Smoking advisors and refer to them?
Services Offered:
• Outpatient Quit Smoking Clinics: for patients and staff
• Inpatient Assessment for Quit Smoking Support
• Special Clinics – Pre-operative Assessment & Maternity Support for smokers to quit
Do your hospital staff routinely offer
‘Very Brief Advice’ to every smoker?
Online training module
WWW.NCSCT.CO.UK/VBA
‘This training is relevant to anyone who comes into
contact with smokers… GPs, practice nurses, hospital
doctors, pharmacists & other healthcare professionals.