Sustainability of Inhaler Prescribing in Primary Care

SusQI project completed as part of the Cwm Taf Morgannwg University Health Board (CTM UHB) and Centre for Sustainable Healthcare Intensive Sustainable Innovation Group Scholar Programme. 

Background:

Short acting beta agonist (SABA) inhalers account for more than half of the inhaler carbon footprint in Wales. Overuse of SABA inhalers is common in the UK and is known to be associated with increased asthma exacerbations and asthma mortality. Reducing the overuse of SABA inhalers through improved patient education and asthma control will improve patient outcomes and reduce carbon footprint.

NHS Wales is committed to increasing the proportion of low GWP inhalers to 80% of all inhalers prescribed by 2025. If low GWP inhalers are not suitable for a patient, then metered dose inhalers can be switched to a brand containing the smallest volume of propellant gas. Salamol inhalers, for example, have less than half the carbon footprint of a Ventolin Evohaler.

At the end of their useful life, inhalers are often disposed of with domestic waste. When used pMDIs are disposed of in this way, the residual gases are likely to be released into the atmosphere and contribute to global warming. There is no national recycling scheme available for inhalers in Wales currently so the most environmentally friendly alternative is to dispose of used or unwanted inhalers at a community pharmacy. This way the inhalers will be incinerated at a high temperature and the gases will be degraded into chemicals with a much smaller global warming potential.

Aims:
1. To reduce the number of SABA prescribed
2. To increase the proportion of low GWP inhalers prescribed
3. To reduce the carbon footprint of inhaler waste

Method / Approach:
This project was piloted in a single practice in a deprived area of CTM UHB. Prescribing data was gathered to identify the inhalers with the greatest carbon footprint in the practice. This showed that Ventolin has by far the greatest contribution to carbon footprint in the practice. For this reason, interventions were focused on prescribing of Ventolin. The following driver diagram was created to identify potential change ideas.

Two change ideas were tested during this project. Firstly, a pharmacist led review clinic was set up to target patients with poor asthma control. Patients were stratified according to the number of SABA inhalers prescribed in the last year as an indicator of potential poor asthma control, using a digital tool created for this purpose, and patients with concomitant COPD were excluded. More than a quarter of patients on the asthma register were found to be prescribed 12 or more SABA inhalers per year.  Secondly, switching Ventolin prescribed on repeat to lower carbon Salamol was completed by a Health Board Pharmacy Technician.

In addition to the above, in collaboration with the ‘Your Medicines Your Health’ campaign, a pilot was set up to promote the return of used inhalers to a selected community pharmacy for incineration. Marketing materials including posters and paper returns bags were provided.

Results:
Environmental benefit:
The total carbon savings for the period September 2022 to February 2023 was 16,425 kgCO2e.  If this reduction is maintained then the estimated reduction for the year will be 32,850 kgCO2e, equivalent to 94,614 miles, a distance greater than the circumference of the earth.

Financial benefit:
In the months before the intervention, the average percentage increase in cost of inhalers was 11.3%, and in the months after the intervention this was reduced to 9.8%. Over a 12 month period this would represent a “saving” of £2,898.43.

Clinical and health outcomes:
Reduction in SABA overuse as indicated by trend to reduction in monthly number of SABA prescribed for patients on the Asthma register at the pilot surgery from September to January.