How to... commission a pharmacist-led COPD service
Community pharmacist Adam Crampsie on how the COPD service he set up under PBC improved patients’ quality of life
Community pharmacist Adam Crampsie on how the COPD service he set up under PBC improved patients' quality of life
As a community pharmacist, I see patients with a wide range of diseases. Monitoring medication compliance is a key aspect of my job. I noticed a rising trend among patients on inhaled medications for COPD, with some patients presenting prescriptions for antibiotics and steroids on a very frequent basis. We were also dispensing vast amounts of salbutamol to these patients. Why were certain patients exacerbating more frequently than others? And more importantly, what could be done to help?
As a result of investigating those questions, we have created a community COPD service that both identifies new patients and aims to improve the care of those with a pre-existing diagnosis.
I started conducting medicine use reviews specifically on patients with COPD and soon saw that there was a wide spectrum of care on offer, ranging from patients with excellent care and control to those who had much less control of their disease. Through conducting inhaler technique checks and discussing patient's perception of their dyspnoea and quality of life, I was able to start designing a service that met the needs of the COPD patients in my area.
This is a disease prevalence of 2.4%. It is predicted that the true prevalence of COPD is around 4.8%, meaning there is large population of patients suffering from COPD who haven't been diagnosed. There is of course a proportion of misdiagnosis resulting from the difficulty of distinguishing COPD from asthma but the vast majority of the reduced prevalence is from straightforward missed cases of COPD.
Armed with this knowledge, a robust COPD screening service was designed alongside a service for pre-existing COPD patients (see box).
At the time the service was conceived, my knowledge of COPD treatment and management was based for the most part on what I had learned at university.
I embarked on a steep learning curve, enrolling on a spirometry course and a COPD treatment and management course, both run by Respiratory Education UK. After completion of this, I felt more confident in conducting and interpreting spirometry but still did not feel I had the depth of knowledge needed to offer a high-quality service. I therefore completed a diploma in respiratory disease management and COPD. This gave me an excellent and well-rounded knowledge in managing COPD patients.
I presented my ideas for the service to the local Pharmacy Development Group to get their feedback. Fortunately the PCT's lead for long-term conditions was at this meeting and she agreed to discuss ways we could get funding as a LES. She proposed that this service would suit the PBC group as COPD was on its list of priorities. A meeting was brokered with the PBC chair, who instantly saw the benefits of the service to both practices and patients.
He did, however, have reservations as it was a novel scheme and he was understandably reticent about funding an unknown entity. It was decided that a three-month pump-priming pilot would be carried out to assess the impact of the service. The only drawback was that this would be an unfunded pilot across six surgeries. This posed serious challenges as equipment and training were needed.
I approached pharmaceutical companies for grants to carry out this pilot and was successful in gaining medical fellowship from the companies to kick-start the service. The initial outlay was relatively low. Training with Respiratory Education UK for the spirometry courses and the diploma cost about £900.
A spirometer and a pulse oximeter were purchased for £1,400. Consumables such as patient training placebos, spirometer mouth pieces and nose clips were provided by the pharmaceutical companies. The pharmacist's time was paid for by the pharmacy on a part-time basis.
The results of the three-month pilot were very promising, with 68 opportunistic screenings performed on patients who had either presented for smoking cessation or had seen posters promoting screening. Some, 26 showed signs of lung obstruction leading to a positive diagnosis of COPD. The levels of obstruction observed varied from mild COPD to one patient who had an FEV1 of 45% predicted and was completely oblivious to his lung condition.
Some 160 pre-existing COPD patients were seen during the three-month pilot. Medication changes were made in the majority of them and in all cases these led to the patient feeling a positive symptomatic improvement after one or two months on the new medication regime. Patient satisfaction and quality-of-life surveys showed excellent results for interventions made by the service.
The most important factor to come to light from the pilot was the number of patients who had missed annual spirometry because they were housebound. As a result of this, the service started carrying out spirometry in the home on housebound patients. These patients were also invariably on the list of those needing a review because they had had two or more exacerbations in the previous year.
Commissioning the service
I presented the pilot data to the PBC group. It was well received and the group was happy to start funding the service. The start-up costs were retrospectively paid and a payment structure was put in place to fund the pharmacist time on a sessional basis. This pays for three days of pharmacist time at £35 an hour. This covers case-finding work done at the GP practice, the opportunistic screening and the review of diagnosed patients.
The prescription intervention service is paid by the PCT as a pharmacist Medicine Use Review payment on a per-patient basis. The MUR is an advanced service within the community pharmacist contract.
It has now been seven months since being commissioned by the PBC group and the service has carried out a further 82 opportunistic screenings with a detection rate of 44%. More than 400 pre-existing patients have been reviewed with patient satisfaction surveys and quality of life improvements echoing those seen in the pilot. From a medicines management point of view, the spending on newly prescribed medicines is roughly cost-neutral when balanced against the savings made by rationalising a patient's inhaled medication.
For example, simple changes such as switching a patient from two puffs daily of a Seretide 250 MDI (unlicensed for COPD treatment but very commonly prescribed) to one puff daily of a Seretide 500 accuhaler (which carries a licence for COPD) can lead to a saving of over £250 per year per patient.
Currently the opportunistic pharmacy-based screening is limited as it is only offered in this pharmacy. The expansion of this screening to multiple pharmacies is in discussion to widen the net of detection across the county. The pharmacies (with pharmacists trained in spirometry) would case find new patients and feed them in to the service for processing and future management should their assessment show positive signs of COPD.
We are now in the process of working out actual reductions in COPD exacerbations and admissions. But anecdotally, GPs say they definitely sense there has been a reduction.
Although positive steps are being made to both detect and manage patients with COPD it is ultimately an uphill struggle and often feels like you are fighting a losing battle. However, experiences over the past year have demonstrated that positive changes can be made to these patients' quality of life and that savings can be made through drug rationalisation and reducing exacerbations that require either admission and/or increased GP involvement.
Pharmacists are an untapped resource for PBC groups, with many pharmacists having novel ideas for services or ideas that can be useful in service redesign. For most pharmacists the processes of PBC are quite alien and there is very little engagement between PBC groups and pharmacists.
I believe that PBC groups that actively engage with pharmacy will reap the benefits.
Adam Crampsie is a pharmacist working in Durham for M Whitfield, a small independent pharmacy chainAdam Crampsie carrying out a spirometry review 60-second summary How the three-part scheme works
The community COPD service consists of the following three aspects:
Opportunistic pharmacy-based screening
The COPD screening service runs alongside the smoking cessation service offered in pharmacies and GP surgeries. Patients over 35 are asked a set of five questions aimed at identifying those who may have COPD. These assess symptoms including wheeze frequency, phlegm without a cold and type of cough. Any patient with potential COPD is offered spirometry and a detailed history is taken to assess their symptoms.
If these point to COPD, the results are forwarded to the patient's GP for assessment. Once the diagnosis has been ‘rubberstamped' by the GP, the patient is treated as per protocol. The newly diagnosed patient is seen again by the pharmacy service to educate them about their disease and reassessed after six months. All information is fed back to the GP.
Managing patients with pre-existing COPD
Patients already diagnosed with COPD are reviewed by the service in an effort to reduce exacerbation rates and admissions.
Each of the nine practices provides details of patients on its COPD QOF register and exacerbation rates. Any patient with two or more exacerbations in the previous year is reviewed. The review can take place at the practice, the pharmacy or the patient's home and covers inhaler technique and suitability, disease education and drug suitability. Spirometry, BMI and smoking history are also taken. Recommendations are then made to the GP and, if accepted, the pharmacy gives the patient any new drugs and/or education.
A review is conducted a month later to assess response. All results are forwarded to the GP. Patients at high risk of exacerbation are also given a rescue pack of oral steroids and antibiotics and a self-management plan.
GPs from the nine practices also make direct referrals to the service if they think a patient may benefit.
Prescription intervention service
When a patient presents in the pharmacy for a inhaled medication for COPD, their technique, compliance and symptomatic control are assessed. If the patient's last spirometry was more than a year ago, then this is also carried out. All details from this review are fed back to the GP.