siân williams nhs london respiratory team programme manager
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Improving value in programme budgets. Creating a case for a 1% shift. Siân Williams NHS London Respiratory Team Programme Manager. Imagine we used the value framework. Health Outcomes Patient defined bundle of care. Value = Health Outcomes Cost of delivering Outcomes. Cost. - PowerPoint PPT PresentationTRANSCRIPT
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Siân Williams NHS London Respiratory Team Programme Manager
Creating a case for a 1% shift
Improving value in programme budgets
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Imagine we used the value framework
Health OutcomesPatient definedbundle of care
CostValue=
Health Outcomes Cost of delivering
Outcomes
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
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To invest appropriately in interventions for people with COPD
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Jiminez Ruiz et al Nicotine and Tobacco Research 2011
~500 smokers with severe COPD
Mean age 58 years60 pack-years of smokingHigh nicotine dependence
10 intensive behavioral interventions with medication:233 Nicotine Replacement Therapy & 190 Varenicline
48.5% abstinence at 6 months61% with Varenicline and 44% with NRTSafe
Even those with severe disease
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Because even before that paper we knew enough to proceed at a clinical
level‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’
NICE 2010
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J Health Serv Res Policy. 2011 Jul;16(3):133-40.Emergency respiratory admissions: influence of practice, population and hospital factors. Purdy S et al. Academic Unit of Primary Health Care, Bristol
• 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
And at a population level
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Either from a zero base, or to add to existing interventions
Himelhoch S, Lehman A, Kreyenbuhl J et al. Am J Psychiatry 2004;161:2317-2319 0
200 out-patients with SMI• 60% current smokers (mean age 44)• 23% COPD prevalence (self-reported)• Only 36% reported having COPD treatment
147 Medicaid patients with SMI• 31% COPD prevalence; 50% as co-morbidity• Annual costs for SMI and COPD were 4 x higher• 45% (5/11) deaths due to respiratory disease
Jones DR, Macias C, Barreira PJ et al Psychiatric Services 2004;55:1250-1257
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And there is still unmet need in primary care eg Southwark dashboard 2013
Prevalence of current smoking where status
recorded in last 15 months 1550/3335 = 46.5%
COPD smokers in last year receiving evidence based stop smoking support – 17.5%
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So what if we reduced smoking prevalence by 1%.....
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So what if we did this by shifting resources to where the people are?
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Where are the people?
Sick smokers in hospital bedsSmokers in mental health servicesIn prisonsQuietly stoical at homeMultiple prescriptions
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Would it tackle….
• Premature mortality• Optimising bed days• Waste – human spirit, staff resources,
time, prescriptions
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Asymptomatic smokers: Tobacco control policies, very
brief advice, education, smoke-free environments, community-based stop smoking services,
quitlines, self-referral,
Primary care management of tobacco dependence and
long term conditions, ongoing, sustained, LES,
QOF
Supporting sick smokers:
CQUIN, NRT, stop smoking
champions
Fall in children's asthma admissions equivalent to 6802 fewer hospital admissions in 3 years after smoking ban .http://pediatrics.aappublications.org/content/early/2013/01/15/peds.2012-2592.abstract …
http://jpubhealth.oxfordjournals.org/content/34/1/37.long 200 public health interventions analysed for cost-effectiveness 15% were cost -saving 85% were under 20k per QALY
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Martin McShane, NHS CB Lead for Long Term Conditions Care (Domain 2), December 2012
If we had £1200 per person per year, the gearing is:• £100 – GP, • £200 community, • £600 acute, • £300 specialist
If acute goes up by 4% have to take 24% out of primary or 12% out of community; £300 specialist won’t change!
Why shift? It’s all about value….
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Programme budget illustrationsRespiratory as proportion of total -
Southwark illustration 2010-11
Total respiratoryTotal programme budgets (ex GMS and miscellenous)
Respiratory categories as proportion of total respiratory
COPDAsthmaRespiratory other
11X
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Respiratory programme budget
Spend by care setting Southwark illustration 2010-11 (note nothing coded as health promotion)
%Primary prescribing & pharma services
_x001F_Inpatient: Elective and Daycase
_x0017_Inpatient: Non-elective
Outpatient
_x0014_Other secondary care
Ambulance
_x0014_A&E (inc. MIU & WIC)
_x0004_Care
& social care provided in other setting
_x000c_ social care
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Tariffs 2013-14 (* non-mandatory)1st single
1st multi
FU single
FU multi Non face to face*
Spell Trim-point (days)
Respiratory medicine OP 189 245 104 145 23
COPD or bronchitis with NIV without intubation with CC emergency admission
2771 24
Stop smoking West Midlands (2012-13*)
General pop’n no Rx
Targeted pop’n no Rx
General pop’n with Rx
Targeted pop’n with Rx
(4 week quitter 94 136 166 214)
12 week quitter – verified in primary care
129 271 228 427
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What does 1% look like - in Southwark?
• 1% of respiratory OP spend £18,940• 1% of total respiratory secondary care £136,
090• 1% of respiratory primary care prescribing £40,470
2010/11 Programme budget –usual caveats about coding
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Imagine we shifted some of that to where the people are– eg a mental health stop smoking adviser, or a system-wide education and training programme or a joined up stop smoking service– would we achieve greater value?