Sustainable COPD Advisory Group Consultation Selection of Content Areas 2012

Sustainable COPD Advisory Group Consultation – selection of content areas 2012

Sustainable COPD 2012

Advisory Group Consultation – selection of content areas for research and implementation projects

A graphic COPD “population pathway” will provide a framework for the programme and a communication tool. Along the pathway, a number of topics appear relevant and interesting for detailed analysis. However, limited resources require that a selection is made so that, for example, we carry out detailed analysis in just one area, but work up and submit research proposals for the others.

This document sets out three possible content areas for projects in 2012: 1. Inhalers 2. Early detection / prevention (by smoking cessation & physical activity) 3. Home oxygen therapy

Input is sought from members of the Advisory Group – both on the selection of a main topic area and on the specific research / implementation projects within it.

Please annotate freely and return to [email protected] by latest Monday 28 May.

17 May 2012

1 Sustainable COPD Advisory Group Consultation – selection of content areas 2012

CONTENT AREA: Inhalers

Background The HFC propellants used in metered dose inhalers (MDIs) are potent greenhouse gases

(GHG) with global warming potentials >1400 * CO2. Although not currently included, these are estimated to account for an equivalent of up to 7% of the total NHS carbon footprint. Alternatives include dry-powder inhalers (DPIs), and the use of non-HFC propellants in MDIs. There is also scope to reduce the GHG emissions associated with manufacture and disposal of inhalers, as well as to improve the targeting of inhaler prescribing and improve compliance.

Sustainability potential: very high Alignment with respiratory care agenda: moderate

Existing projects: Carbon footprinting of inhalers by manufacturers Inhaler recycling pilot 2011 (GSK)

Possible research questions • What is the life-cycle carbon footprint of respiratory inhalers (MDI, DPI)? • What are the carbon and £ cost-benefits of a (X%) shift from MDI to DPI? • What are the carbon and £ cost-benefits of inhaler recycling programmes? • What is the benefit in £ and carbon of using the correct device for each patient. Eg if unable to take DPI, is there still benefit in using MDI but appropriately - this would be hard to capture but is, I think a question which will be raised. • Carbon and £ impact of good vs poor inhaler technique, regardless of device. The alignment with clinical imperative is that better, more effective care is still better even if patient 'can't' use low carbon technology • PLEASE ADD

Possible implementation projects  Project aim: accelerate shift from MDI to DPI o Objective: raise awareness of carbon impact among clinicians & patient groups o Objective: influence guidelines/formularies  Project aim: improve targeting of inhaler prescriptions o Objective: provide primary care education and support  Project aim: increase inhaler recycling o Objective: develop case study/business case for recycling programme o Objective: engage pharmacies and companies to set up programmes o Objective: promote to patients . PLEASE ADD

Key groups – organisations / entry points – PLEASE ADD SPECIFICS Industry – pharma companies, gsk, boeringer, Allen &hanburys Patients – NLF, BLF, asthma uk, Formularies – regional prescribing leads / local guideline developers. Eg City and Hackney (Angshu Bhowmik's patch has local prescribing guidelines. No reason why MDI is default device... Pharmacies – go for big names like Boots, lloyds etc (recycling started at lloyds I think)

Primary Care – CCGs will have cost reduction on their horizon, but engaging with commissioners to put vanilla clauses into contracts around particular services or CQUIN targets may be one way to influence practice. Respiratory Care – Impress, BTS, primary care airways group

Comments Important to guard against conflict of interest (GSK funding) – independent verification of data and methodology, footprint a range of products, present all mitigation strategies (not just DPI)

CONTENT AREA: Early detection / prevention

Background COPD is not measured in the community – approx. 50% of estimated sufferers are not registered. Previously there was no evidence for effective intervention at early stages of the disease, however members of the group have presented recent evidence for 1. Prevalence of current smoking among COPD sufferers, presented alongside evidence for effectiveness of smoking cessation interventions (Noel Baxter) 2. Effectiveness of physical activity as a disease modifying intervention (Nick Hopkinson); effective behaviour change support interventions (Jonathan Fuld) Cost effectiveness of early detection has not been demonstrated to date, and there is uncertainty about the net healthcare resource implications of prolonging life, given that individuals may require ongoing care for COPD and other chronic diseases. However, it is possible that the interventions highlighted here would lead to prolonging of healthy life (“squaring the curve”).

Sustainability potential: unknown/possibly high Alignment with respiratory care agenda: quite good

Existing Projects London Respiratory Team - ?projects PLEASE ADD

Possible research questions • What is the carbon and £ impact of COPD care due to smoking? • What are the carbon and £ cost-benefits of available smoking cessation interventions? (review effectiveness of interventions and conduct top-down analysis using existing data, e.g. use Fletcher-Peto figures to estimate effects of different scenarios) • What is the carbon and £ impact of COPD care due to physical inactivity? • What are the carbon and £ cost-benefits of interventions to increase physical activity? • What is the carbon and £ cost-benefit of increasing early detection of COPD with current care provision? • What is the carbon and £ cost-benefit of increasing early detection of COPD combined with smoking cessation & physical activity interventions? • PLEASE ADD

Possible implementation projects • Project aim: reduce smoking among registered COPD patients o Objective: replication of a successful training programme for target hc professionals (e.g. GPs, practice nurses, ward nurses) • Project aim: increase physical activity among registered COPD patients o Objective: communicate evidence for physical activity as a disease- modifying intervention o Objective: provide tools/training for evidence-based interventions to support sustained behaviour change o Objective: demonstrate carbon savings through reduced admissions / reduced exacerbations in patients undergoing pulmonary rehab. (could be mapped onto existing data sets o Objective: develop a tool for patients to estimate their own carbon footprint reduction through using more sustainable forms of transport as part of

increased physical activity? Eg in early disease, cycling etc and later on, walking to shops etc? • PLEASE ADD

Key groups – organisations / entry points – PLEASE ADD SPECIFICS Health economists / epidemiologists – Jenni Quint is epidemiologist looking at COPD! Suggest input from her here. Primary Care – Respiratory – London Respiratory Team London Mayoral team (do work on air quality and lung disease, may be interested in links between green transport and health

Comments Suggested implementation projects are ambitious / not visibly connected to sustainability.

Toby: is this link not apparent because the research demonstrating it is outstanding?

CONTENT AREA: Home oxygen therapy

Background “Oxygen = bottled electricity” Production and distribution of home oxygen in cylinders may make a significant contribution to the carbon footprint of respiratory care. Cylinders are reportedly returned at 25% capacity and the remaining oxygen is vented to air by BOC. Opportunities to reduce carbon footprint may include better targeting of home oxygen therapy to patients who will benefit, shift to concentrators or to delivery devices which match to patient’s inspiratory phase, use of gauges to give accurate information on residual oxygen in cylinders.

Sustainability potential: unknown/possibly good - could be huge Alignment with respiratory care agenda: good if reduces £ waste

Existing Projects An anaesthetist in London I think calculated rough estimates of carbon per litre of O2 manufactured. PLEASE ADD

Possible research questions • What are the carbon costs of home oxygen therapy for COPD? • What are the relative carbon costs of different delivery devices? • What are the potential carbon savings from targeting home oxygen therapy to those patients who will benefit? Key point is the evidence base here. • What are the potential carbon savings from reducing waste, e.g. through use of accurate gauges on cylinders? • What are the carbon benefits of accurately prescribing oxygen? ( lots is prescribed without evidence of benefit ) - breathlessness is often the precipitant - studies at BTS meetings have shown huge over prescription and ongoing use where not indicated. • PLEASE ADD

Possible implementation projects • Project aim: reduce the residual oxygen discarded from used cylinders o Objective: communicate cost-benefits of accurate gauges to procurers/ commissioners of home oxygen services • Project aim: improve the prescription of oxygen in terms of devices and accuracy of need for oxygen • Objective: communicate the carbon, and cost benefit of safe accurate prescribing of oxygen. Key point being this is simply good, evidence based care. Reducing waste

Key groups – organisations / entry points – PLEASE ADD SPECIFICS Industry – BOC. Try American manufacturers? Or Scandinavian countries where data may be more freely available. Industry – manufacturer of gauges / alternative delivery devices - Air Products / Air Liquide Commissioning / procurement – Christine Mikelsons - Patients – usual patient charities, think also of cardiac charities, cf, Healthcare - oxygen champions - for London Christine Mikelsons I think has a list. Consider engaging palliative care who may be able to help with clinician resources around breathlessness to help with alternatives to oxygen when faced with v breathless patients in primary care.

Comments Access to industry data may be a barrier if BOC not on board? Will be nigh on impossible to get data. Could do internal study at a trust looking at returns.