Introduction: Robin Carlisle, Deputy DPH, Rotherham PCT

1
Research Evaluation Mini-conference 28 January
2009

• Introduction Robin Carlisle, Deputy DPH,
  Rotherham PCT

2
Introduction

• Introduction to the Mini-conference
• Introduction to the aims and process of the
  evaluation project
• Information not discussed elsewhere

3
Death by PowerPoint.!
4
Aims

• Highlight emerging themes
• Cover the scope of the evaluation
• Presentations to form basis of second evaluation
  report
• Feedback from you

http//www.rotherhampct.nhs.uk/healthprofessionals
/breathingspace/evaluation.asp
5
Invitees

• Those involved in the evaluation including
  ScHARR
• Patients and carers
• Breathing Space staff
• Stakeholders including the Coalfields
  Regeneration Trust
• Clinicians from primary and secondary care
• Managers from primary, secondary care social
  services
• Collaborations for leadership in applied health
  research care (CLAHRC)
• Boehringer Ingelheim

6
Breathing Space Programme

• Day patient rehabilitation - May 2007
• In patient rehabilitation/respite care - October
  2008
• Funding for the current Breathing Space pilot is
  identified until March 2011

7
Success criteria

• 5 original success criteria unchanged
• Breathing Space has impact on whole system - not
  only direct contacts

8
Success criteria

• Substantially improved care for patients and
  their carers
• Improved outcomes for patients and carers who
  have direct contact with Breathing Space
• Improved outcomes for chronic respiratory
  disease patients and carers at population level
• The changes in the whole system costs for
  chronic respiratory disease in Rotherham provide
  value for money for the outcomes that have been
  achieved
• Rotherham Health and Social Care Community will
  have successfully managed the changes in costs
  and resources needed to ensure the long-term
  sustainability of the programme

9
Components of the evaluation
Target population All 5600 people with COPD,
their carers and undiagnosed COPD cases
10
Evaluation timetable
11
Research questions

• Whole system health economics of making
  pulmonary rehabilitation comprehensively
  available
• Equity who takes up pulmonary rehabilitation,
  who does not and why
• Sustainability individuals system
• British Lung Foundation patient documentation
  user carer control over condition and care

12
Questions not covered elsewhere

• Robin Carlisle, Deputy DPH, Rotherham PCT

13
4 questions

• What do we know about the impact on smoking and
  COPD in Rotherham?
• Are we identifying more people with COPD ?
• What is the impact on primary care contacts for
  COPD patients ?
• What is the impact on secondary care ?

14
1. Impact on Smoking in people with COPD
Number of BS patients set a quit date April to
Oct 2008 - 23 Number of BS patients quit April to
October 2008 - 8
15
Conclusions on smoking
Data Dont have reliable before and after
Breathing Space smoking data Results Very few
formal quitters attributable to Breathing
Space If we accept the audit prevalence data
there are around 150 less smokers in Rotherham
with COPD.
16
Impact on case finding
17
Conclusions on case finding
Data We can use QOF registers for this Results
After an initial drop numbers of identified
cases are rising. These data are before the
impact of the spirometry Locally Enhanced
Service.
18
Impact on primary care activity
2008 primary care audit Of 718 patients 577 had
Rotherham COPD records for the 3 years preceding
the audit
19
Conclusions on impact on primary care
No evidence of a meaningful impact on primary
care consultation rates We are planning to
collect no additional information on this
20
Impact on secondary care

• Predictions and post opening data on Rotherham
• Admission rate
• Length of stay
• Bed days
• Re-admissions
• Cost
• Comparisons with Doncaster and Barnsley
• Admission rates
• Length of stay

21
COPD admissions by month All providers
22
(No Transcript)
23
(No Transcript)
24
Conclusions on activity

• Will have the data but a considerable time lag
• A lot of noise and factors other than Breathing
  Space affecting admissions
• Dont have any data yet post opening the beds
• Might be some evidence that Breathing Space is
  contributing to ongoing decrease in COPD bed days

25
(No Transcript)
26

• Prescribing Update
• Govinder Bhogal
• Prescribing Support Pharmacist
• January 2009

27
Breathing Space PCT Prescribing Data

• Aim
• To assess the effect of BreathingSpace on
  Prescribing Costs in Rotherham.
• To demonstrate trends over the last two years in
  prescribing since the opening of Breathing Space.

28
How do Rotherham Respiratory Prescribing Costs
compare with neighbouring PCTs?
29
How have local respiratory prescribing costs
changed over the last 2 years?
30
Limitations of the data

• ePACT data is not condition specific
• COPD Asthma share some drug therapy.
• Changes in PCT configurations
• There were eight neighbouring PCTs in the South
  yorkshire SHA before BreathingSpace opened. There
  are now 4 PCTs in South Yorkshire, and we are
  now compared against the 13 Yorkshire and Humber
  PCTs.

31
Which groups of drugs are involved?

• Short acting bronchodilators
• Long acting bronchodilators
• Inhaled corticosteroids
• Antimuscarinics
• Mucolytics
• Oxygen

32
How does PCT bronchodilator use compare?
33
How has local bronchodilator prescribing changed
over the last 2 years?
34
How does PCT inhaled corticosteroid use compare?
35
How does PCT inhaled corticosteroid cost compare?
36
How has local inhaled corticosteroid prescribing
changed over the last 2 years?
37
How has local inhaled corticosteroid cost changed
over the last 2 years?
38
Mucolytics

• Available on NHS prescription from
  2003.(previously blacklisted)
• Change followed a Cochrane review.
• Useful in patients who have repeated, prolonged,
  or severe exacerbations, or with particularly
  viscous sputum.

39
Mucolytic cost quarter by quarter 2006-2008
40
Anti-muscarinic inhalers and combivent cost
quarter by quarter
41
Anti-muscarinic and combivent nebs cost quarter
by quarter
42
Oxygen prescribing

• National change to oxygen contract, Feb 2006.
• No longer prescribed on FP10.
• Not routinely prescribed by GPs.
• Assessment by specialist.
• More patient choice of oxygen,e.g. ambulatory,
  holiday.

43
Oxygen costs quarter by quarter
44
Summary

• Effect of Breathing space on total respiratory
  prescribing costs impossible to see due to large
  asthma prescribing.
• Reduction in nebulised anti-muscarinics could be
  attributed to breathing space.
• Increase in inhaled anti-muscarinic prescribing
  will be due to BreathingSpace and GP prescribing.
• Rate of increase in oxygen cost will decrease
  with improved assessment and better monitoring.

45
(No Transcript)
46
Compliments

• Qtr 1 7 compliments
• Qtr 2 2 compliments
• Qtr 3 14 compliments
• many many verbal compliments

47
Complaints

• 1
• A system change was made to prevent a recurrence.

48
Comments from patients, carers, families

• This has given me my life back
• Youre magic
• Im a person not a number
• What a wonderful place
• My stay was relaxed and stress free
• Absolutely fantastic
• Couldnt wish for any better staff and treatment
• Etc etc.

49
Education

• All education offered is open to all Health Care
  Professionals within the Rotherham area with a
  view to wider networking
• Education Activity 2007- 2009(courses accessed)
• ARTP/BTS Foundation Course in Spirometry
• Spirometry Study Day
• Foundation Course Asthma
• Foundation Course COPD
• Spirometry Diploma
• Asthma Diploma
• COPD Diploma
• World COPD Day
• In 2008 an Educational Forum was established for
  Health Care
• Professionals

50
Education

• Education programme for BreathingSpace staff
• Support Workers
• Competency Portfolios developed at different
  levels for band 2,3, and 4
• Respiratory Nurses
• Six weeks Specialist in-house training
• All respiratory nurses are either commencing on
  Respiratory Master modules or
• Respiratory Degrees and have completed/on-going
  COPD Diploma, Asthma Diploma, Heart Failure
  Diploma courses and have regular up-dates
• MDT are encouraged and supported with their
  on-going learning
• Administration Staff are encouraged and attending
  on-going
• courses to meet their own and BreathingSpaces
  professional needs

51

• Rehab Inpatient Activity Finance Analysis.

52
Inpatients

• Investment Capacity in BS Inpatient facility
• 2008/09 495k 3500 bed nights.
• 2009/10 990k 7300 bed nights.
• 2010/11 495k 3650 bed nights.
• 2008/09 Investment equates to 19,800 a week or
  141 a night.

53

Inpatient Admissions into BS.
54

Inpatient Bed Days Activity vs Capacity.
55
Inpatients

• Value for Money Comparisons
• Cost per Admission at BS is currently 1343.
• Average cost per Admission at RFT is currently
  1546.
• Current cost per night at BS 244.
• Average cost per night at RFT 364.
• True cost per admission 2253.
• True cost per night at BS 409.

56
Rehab

• Investment Capacity in BS Outpatient Rehab
• Programme
• 2008/09 1005k 400 Rehab packages.
• 2009/10 2010k 800 Rehab packages.
• 2010/11 1005k 400 Rehab packages.
• 2008/09 Investment equates to 2513 per Rehab
  package.

57
Rehab Activity vs Purchased Capacity
58
Rehab

• Rehab Finance Analysis
• Expected 2008/09 cost of delivering Rehab -
  1370k
• 2008/09 average cost per Rehab package - 5115.
• Shortfall to Breathing Space in cost of
  delivering Rehab - 365k.
• Difference between average cost of Commissioned
  Rehab package and current average cost of
  providing Rehab package - 2602.

59
Conclusion

• Activity Summary
• Inpatient underperformance to date - 884 Bed
  nights
• Rehab underperformance to date -
• Finance Summary
• Expected cost in 08/09 to deliver 20 bed service
  - 791k
• Investment in 08/09 in 20 bed service - 495k.
• Expected cost in 08/09 to deliver Rehab service -
  1397k
• Investment in 08/09 to deliver Rehab service -
  1020k.

60
2008 Primary Care COPD Re-audit

• Robin Carlisle, Deputy DPH, Rotherham PCT

61
Purpose of the presentation

• To summarise results from the 2006/7 and
  summer 2008 Rotherham primary care audits
• To answer 2 questions
• What do the audit say about overall standards of
  COPD care in Rotherham?
• What evidence is there of change between 2006/7
  and summer 2008?

62
Methods
11 standards assessed in both audits (some minor
differences between audits) standards mainly from
NICE
63

• BREATHING SPACE PRIMARY CARE STANDARDS
• By March 2009 we aim to achieve
• We will have maximised the number of patients
  with COPD in Rotherham who have been accurately
  diagnosed by the active use of spirometry
• All patients diagnosed with COPD will be
  accurately categorised into the NICE definitions
  of mild, moderate and severe airways obstruction.
• There will be a continuing reduction in the
  number of COPD patients who smoke.
• Pulmonary rehabilitation, to the standard
  provided within the Breathing Space Programme, to
  be offered to all patients with COPD.
• Information required for audit will be
  electronically recorded using standard COPD
  templates.
• All exacerbations of COPD will be Read Coded.
• All patients with COPD will have been given an
  individualised self-management plan
• Self management plans for all patients with
  moderate and severe airways obstruction will
  include standby antibiotics and steroids.
• Medicine usage will be appropriate to patients
  NICE airways obstruction severity category.
• All patients with moderate or severe airways
  obstruction who have 2 or more exacerbations in
  any year should be prescribed inhaled steroids
• All patients with moderate or severe airways
  obstruction will have been assessed for oxygen
  using pulse oximetry.

64
Audit criteria
65
Criteria 4 COPD patients should be categorised as
mild, moderate or severe in accordance with NICE
Guidance
Of 497 records with recent spirometry, 289 had
the 2 criteria recorded to produce a NICE
severity categorisation of these 232 had been
categorised by the practice, 192 correctly
Correctly classified patients
66
Out of 497 records with recent spirometry, 289
had the 2 criteria recorded to produce a NICE
severity categorisation of these 232 had been
categorised by the practice, 192 correctly
1 person classified as being At Risk - FEV1
Pred 55, FEV1/FVC 64
67
Medication

• A different analysis was used this time, only
  COPD patients without a co-diagnosis of asthma
  audited.
• Substantial variations from the guidelines were
  found
• High use of separate inhaled steroids in mild
  COPD
• High use of combined inhaled steroids in mild
  COPD
• High use of nebules (especially in mild
  moderate)
• Low use of both short long acting
  anticholinergics
• 40 of antibiotics used in exacerbation not
  concordant with Rotherham guidelines
• 50 of steroid scripts were non concordant in
  some aspect of dose, duration or frequency

68
Implication of the audits for Breathing Space
Evaluation

• Rotherham benchmarks well on COPD QOF
• Limitations of records audit
• Still a lot that should be done to improve
  community management of COPD
• A substantial improvement over the last 2 years
  we can not be certain this is due to Breathing
  Space but it is encouraging