The Victoria practice participated in a program to improve management of COPD and asthma patients through a patient-centered service focusing on motivational interviewing, adherence, inhaler technique, evidence-based prescribing, and regular reviews. The pharmacist-led asthma and COPD clinic aimed to optimize prescribing through 30-minute appointments to understand patients' medication use and encourage behavior change. Results showed a reduction in respiratory prescribing costs, improved COPD and asthma control scores, and lower exacerbation rates through a medicines optimization approach.

1. Benefits of Implementing
Medicines Optimisation
in a COPD and Asthma Clinic
Clare Watson
Medicines Management Pharmacist (NHS Hampshire)
Independent Prescriber (Victoria Practice, Aldershot)
The Victoria practice participated in a
National Improvement programme to improve
management of patients with COPD and
Asthma, by providing a patient centred
service focusing on
 Use of Motivational Interviewing techniques
 Adherence
 Inhaler technique
 Implementing Evidence based cost effective
prescribing in line with current national guidance eg.
Nice, BTS/SIGN
 Regular patient review and follow up
 Reducing waste
1

2. What is Medicines Optimisation?
Medicines optimisation is a more patient-focused
approach to getting the best from medicines.
Focused on the patient and their experience, it can
help more patients take their medicines correctly,
reduce waste of medicines, avoid patients taking
unnecessary medicines and improve medicines
safety. Ultimately it can help encourage patients to
take more ownership of their treatment.
Royal Pharmaceutical Society – Good Practice Guidance for
Healthcare Professionals Sept 2012
Why Medicines Optimisation?
 Suboptimal prescribing and/or patient adherence
affects patients’ ability to self manage, use of primary
care, admissions, A&E attendance and medicines cost
 Current cost of all asthma and COPD medication:
£1.17billion pa
 Choice and cost of medicines
 How do patients really use medicines?
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3. BMJ October 2012….
“45 million prescriptions for respiratory inhalers were
dispensed in 2011 in England alone—at a cost of
£900 million to the NHS—everyone needs to be more
clued up on correct inhaler technique to make sure
these drugs work well for patients and offer the best
value for money for the NHS”
Designing and commissioning services
for adults with asthma: A good practice
guide. PCC 2012
http://www.pcc.nhs.uk/asthma-guide
 Many patients do not lead lives free of symptoms and
this is despite the availability of well-constructed
guidelines and good medicines
 When patients do take their medication, many do it
incorrectly, which will have an impact on the cost of
treatment and lead to suboptimal outcomes
3

4. How did we know if we had made an
improvement?
 Indicated by cost of respiratory prescribing, medicines
mix, admissions and patient CAT score / ACT score
before and after the intervention
 CAT: COPD assessment test: www.catestonline.co.uk
 ACT: Asthma control test: www.asthmacontroltest.com
Context
 Practice list size: 8476
 5 partners (4.5 whole time equivalents)
 135 COPD patients
 378 Asthma patients
 Annual reviews offered scope to address medicines
use and optimisation
 Pharmacist led Asthma & COPD clinic (Independent
prescriber and Medicines Management Pharmacist,
COPD Diploma, Clinical Diploma, Community
pharmacy background
4

5. Approach
 1 x 5 hour session per week
 30 minute appointments
 Understanding the patient’s attitude to and actual use
of medication
 Encouraging realistic goal setting and behaviour
change
 Using technical knowledge to optimise prescribing
(clinical benefit/cost effectiveness)
Patient reviews
 Review compliance, exacerbations, control and
medicines ordering over last 12 months
 Patient consultation incorporating:
 Understanding current attitudes & motivation
 Good things/Not so good things – decisional balance
 Eliciting self sufficiency & patient responsibility
 Optimisation of treatment
 Follow up
5

6. Understanding current attitudes and
motivation using open questions
 Tell me some more about that
 What are your thoughts about…?
 In what ways does that concern you?
 Describe what it’s like when?
 How do you feel about….?
 Tell me what you like about X
 Tell me some of the things you don’t like about X
Goal Setting
 Where does this leave you?
 What’s your plan?
 Given all we’ve talked about today, where would you
like to go from here?
 What do you want to do next?
 What are the difficulties/benefits of taking your
medicine?
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7. Commitment
On a scale of 0 to 10 (where 0 = not at all and 10 = very
much):
 How much do you want to start/continue this
treatment?
 How important is it to you to start/continue this
treatment?
 How ready do you feel you are to start/continue this
treatment?
 How much better do you think your life would be if you
start/continue this treatment?
Wrapping Up
 How confident do you feel that you will be able to do this?
 One a scale of one to 10, how confident do you feel?
 If patient is negative, ask how can you get it up to an 8?
 Confidence building: Why 7 and not 5?
 In a month’s time, what is going to be different now that you are
taking your medicines?
 If patient is negative say, “Some people find that…..”
 If there is no response say, “So nothing is going to change at all?”
7

8. Availability
 Is the patient on the “right” treatment (medication and
device) for their needs?
 Is it a clinically effective choice?
 Is it a cost effective choice? Cost comparison tables
available on the website below
http://www.nyrdtc.nhs.uk/Services/presc_supp/presc_sup
p.html
Evidence based? Cost effective?
 Right choice of medication for condition and severity of
disease?
 Able to use it?
 Cost effective choice?
 Examples:
 Adding on an aerochamber®
 to MDI device
 Adding LAMA / LABA
 Substituting Seretide Acculaher® for Evohaler ®
 Smoking cessation / pulmonary rehabilitation
8

9. Knowledge
 Inhaler technique – maintaining own skills as well as
checking others
 In-Check Dial to achieve optimal inspiratory flow
(http://www.clement-clarke.com/products/in-check-dial)
 2Tone device for MDI users (Now replaced by In-
Check Flo-Tone http://www.flo-tone.com)
 Follow up calls or appointments to check progress &
understanding
 New medicines not added to repeats until impact
assessed
Victoria Practice Prescribing cost
16000
14000
12000
10000
8000
£
6000
4000
2000
0
Jac- 0 7
Jac- 0 8
Jac- 0 9
Jac- 1 0
AJul-0 7
M b-0 8
Au l-0 8
M b-0 9
Auul-0 9
M b-1 0
A u l- 0
M b-1 1
l-1 1
A ar- 08
M pr- 08
A ar- 09
M pr- 09
A ar- 10
M pr- 10
A ar- 11
M pr- 11
Sug- 07
Seg- 08
Seg- 09
Seg- 10
1
ep 7
t- 0 7
Fen-0 7
Ocp- 08
No t- 8
Fen-0 8
Ocp- 09
No t- 9
Fen-0 9
Ocp- 10
No t- 0
Fen-1 0
Jay-07
Juy-08
Juy-09
Juy-10
ay 1
un 7
Ju -08
J n- 9
Ju -10
Ju -11
De v- 7
De v-08
De v-09
De v-10
1
0
0
1
Oc - 0
M pr- 0
a 0
a 0
a 1
Ju -1
-
n
n
n
No
A
£ prescribing cost
The Mean (Average) Upper Control Limit Lower Control Limit
9

10. Change in consecutive CAT score by patient
35
30
25
CAT score
20 Original CAT score
15 Second CAT score
10
5
0
1 2 3 4 5 6 7 8 9 10
Patient
Key Learning
 30 minute appointments allow time to establish rapport
with the patient and understand issues affecting
adherence
 Follow up reinforces patient understanding and
behaviour
 Telephone calls in advance can reduce DNAs.
 Synchronise repeats where possible to reduce waste,
patient inconvenience and surgery work load
 Relationships are key
 Pharmacist skills can provide a cost effective approach
to improving medicines optimisation in the
management of any long term condition and enhance
the skill mix in the practice team
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