Swindon PCT/CCG - Cost based ASTRO-PU variance to the England average prescribing spend by month

Transcription

1 Appendix x Swindon CCG Primary Care Prescribing Costs and Patient Outcomes Variance to the England average % Swindon PCT/CCG - Cost based ASTRO-PU variance to the England average prescribing spend by month % % % % % 99.00% 98.00% 97.00% 96.00% Nov-10 Jun-11 Dec-11 Jul-12 Jan-13 Aug-13 Mar-14 Sep-14 Apr-15 Oct-15 May-16 The chart above shows significantly monthly variation compared to the England average over the past 6 years, the trend shows a small increase in prescribing cost variance, but the trend in the last months is downwards. Prescribing Growth The chart above shows CCG growth has been above the England growth rate since June 2015, but in recent months the gap is narrowing Page 1 of 16

2 Growth by BNF sorted total actual growth cost descending; May April 2016 V May April 2015 Chapter Total cost last year Total cost this year Actual growth cost % growth cost England % growth cost Diff to national growth cost Endocrine System 4,879,466 5,527, , % 10.84% 2.45% Cardiovascular System 3,528,769 3,969, , % 6.65% 5.84% Central Nervous System 6,763,843 7,065, , % 1.54% 2.92% Stoma Appliances 853, , , % 5.82% 9.19% Appliances 1,047,508 1,122,000 74, % 8.52% -1.41% Obstetrics,Gynae+Urinary Tract Disorders 1,251,269 1,319,828 68, % 2.71% 2.77% Skin 918, ,453 57, % 2.85% 3.43% Respiratory System 4,012,408 4,054,636 42, % 1.16% -0.11% Eye 432, ,464 38, % 9.27% -0.45% Malignant Disease & Immunosuppression 633, ,205 30, % -5.08% 9.84% Immunological Products & Vaccines 426, ,329 24, % -3.62% 9.45% Gastro-Intestinal System 1,625,338 1,644,395 19, % -0.61% 1.79% Incontinence Appliances 172, ,265 13, % 2.40% 5.39% Other Drugs And Preparations 92, ,148 12, % 1.26% 12.34% Anaesthesia 39,494 48,418 8, % 18.00% 4.59% Ear, Nose And Oropharynx 245, ,492 5, % -1.40% 3.83% Musculoskeletal & Joint Diseases 606, ,250 1, % 0.28% -0.06% Infections 874, ,307-25, % -1.02% -1.88% Nutrition And Blood 2,389,212 2,180, , % 5.59% % Dressings 618, , , % -0.52% % Grand Total 31,412,038 32,792,484 1,380, % 3.81% 0.58% At BNF chapter level the CCG has experienced the highest growth in Endocrine System, Cardiovascular System, Central Nervous System and Stoma Appliances. The below demonstrates the savings achieved by switching to a seondary care model for supply of tube feeds and seconding a dietician to review sip feeds which have led to the low growth in the Nutrition and Blood chapter. Page 2 of 16

3 Enteral Nutrition prescribng costs and variance % % % 80.00% 60.00% 40.00% 20.00% 0.00% 120, , , , , , Ratio Act Cost Total Act Cost Linear (Ratio Act Cost ) Linear (Total Act Cost ) Top 20 Chemicals by Actual Growth in Cost with National Variance sorted total actual growth cost descending; May April 2016 V May April 2015 Chemical Substance (Name) Total cost last year Total cost this year Actual growth cost % growth cost England % growth cost Diff to national growth cost Pregabalin 942,103 1,217, , % 13.15% 16.09% Apixaban 81, , , % % 5.42% Rivaroxaban 182, , , % % % Dapagliflozin 68, ,516 98, % % 40.55% Atorvastatin 206, ,761 58, % 18.75% 9.73% Pioglitazone Hydrochloride 9,041 66,666 57, % % 2.58% Carbimazole 74, ,309 56, % 58.47% 17.66% Lercanidipine Hydrochloride 31,223 87,667 56, % % % Hydrocortisone 192, ,452 55, % 29.89% -1.26% Liraglutide 140, ,739 50, % 11.51% 24.54% Beclometasone Dipropionate 303, ,890 45, % 19.88% -5.07% Umeclidinium - Brom/Vilanterol 4,871 49,222 44, % % % Leuprorelin Acetate 152, ,931 44, % 12.00% 16.95% Glucose Blood Testing Reagents 726, ,585 43, % 3.27% 2.69% Mirabegron 32,513 74,498 41, % 82.05% 47.09% Ferrous Sulfate 28,644 67,791 39, % % 8.27% Phenindione 8,356 47,073 38, % % % - Umeclidinium Brom 3,588 41,244 37, % % % Solifenacin 243, ,043 37, % 1.06% 14.19% Trazodone Hydrochloride 63,101 98,055 34, % 64.94% -9.55% Drugs where growth has been caused by the increased cost of the generic medicine in the Drug Tariff carbimazole, pioglitazone, lercanidipine, hydrocortisone, ferrous sulfate, phenindione, trazodone. Options to address these cost Page 3 of 16

4 increases are limited, but some patients have been switched from phenindione and there is an active switch programme for ferrous sulfate. The most significant growth is in pregablin (used maily for neuropathic pain). The CCG has audited pregablin use and found around 50% of intitiation by both primary and secondary care is outside of local guidance. This has been reflected back to secondary care clinicians and the secondary care pain clinic lead has provided a workshop for GPs around analgesic prescribing. The chart below suggests costs have are beginning to reduce. Pregabalin cost and variance % 140, % 120, % 100, % 80, % 60, % 40, % 20, % Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar Ratio Act Cost Total Act Cost Linear (Ratio Act Cost ) Linear (Total Act Cost ) Mirabegron and solifenacin are used to treat over active bladder, and the CCG pharmcists are currently auditing their use against the local guidance to ensure these costs can be justified, prescribing will be challenged if their use does not prove justified. The groups of drugs listed below are used to prevent complications of diseases and need to be considered in the context of disease prevalence and patient outcomes and considered in more detail later: Apixaban and rivaroxiban (new oral anticoagulant drugs) are recommended by NICE for the prevention of stroke and represents a cost effective intervention according to NICE. Dapaglifozin, pioglitazone, liraglutide and blood glucose test strips are all used in the treatment of diabetes and again supported by NICE guidance. Beclomethasone and umeclidinium with or without vilanterol are used to treat respiratory disease. Prescribing Cost Variance at chapter level May April 2016 sorted variance desending BNF Name Variance Act Cost Ratio Act Cost Total Act Cost Endocrine System 575, % 5,527, Central Nervous System 373, % 7,065, Obstetrics,Gynae+Urinary Tract Disorders 77, % 1,319, Page 4 of 16

5 Cardiovascular System 64, % 3,969, Infections 40, % 849, Stoma Appliances 33, % 981, Appliances 27, % 1,122, Immunological Products & Vaccines 25, % 451, Respiratory System 4, % 4,054, Incontinence Appliances 1, % 186, Malignant Disease & Immunosuppression Preparations used in Diagnosis Other Drugs And Preparations Ear, Nose And Oropharynx Musculoskeletal & Joint Diseases % 663, % , % 105, , % 251, , % 608, Anaesthesia - 42, % 48, Nutrition And Blood - 60, % 2,180, Eye - 71, % 470, Gastro-Intestinal System - 84, % 1,644, Skin - 98, % 976, Dressings - 347, % 317, , ,792, The Endocrine system and CNS show high variance to the England average in addition to high growth. Prescribing Cost Variance at chemical substance level May April 2016 sorted variance desending BNF Name Variance Act Cost Ratio Act Cost Total Act Cost Fluticasone Propionate (Inh) 236, % 1,532, Pregabalin 179, % 1,217, Glucose Blood Testing Reagents Duloxetine Hydrochloride 126, % 769, , % 259, Page 5 of 16

6 Apixaban 105, % 289, Budesonide 101, % 782, Dapagliflozin 83, % 167, Co-Codamol (Codeine Phos/Paracetamol) 68, % 409, Leuprorelin Acetate 68, % 196, Atorvastatin 67, % 264, Other Food For Special Diet Preps 65, % 409, Nicotine 64, % 118, Trandolapril 60, % 67, Omeprazole 60, % 283, Buprenorphine 59, % 289, Lisinopril 58, % 106, Dalteparin Sodium 55, % 112, Metformin Hydrochloride 53, % 469, Insulin Lispro 50, % 119, Tramadol Hydrochloride 44, % 212, Fluticasone (used for asthma and COPD) is the highest spend drug in the CCG, but is not fast growing. Pregabalin has a large variance and high growth, as to a lesser extent does Blood Glucose test Strips. Duloxetine has recently become available as a generic and costs are therefore expected to drop rapidly. Co-codamol, like pregabalin is used to treat pain and there is no benchmarking or prevalence data to help decide if these levels of prescribing locally can be justified. There is ongoing targeted work to reduce pregabalin spend. Leuprorelin is used to treat prostate cancer, there are cheaper preparations, but switching to the cheapest will give limited savings. Prescribing Costs in context It is potentially harmful to consider reducing prescribing costs without giving due consideration to the population context in which drugs are prescribed, including disease prevalence and patient outcomes. The pathways below are taken from the NHS Right Care Commissioning for Value pack for Swindon CCG. Page 6 of 16

7 Diabetes Endocrine system prescribing is responsible for both the highest growth and variance, and the bulk of this cost is accounted for by drugs used for diabetes. Taken in isolation the CCG diabetes prescribing costs shown below appear significantly higher than the England average. Cost and variance in Drugs for diabetes spend % 450, % 400, % % % 350, , % 250, % 200, % % % 150, , % 50, % 0.00 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Ratio Act Cost Total Act Cost Linear (Ratio Act Cost ) Linear (Total Act Cost ) However, when compared to the 10 most similar CCGs prescribing costs shown in the pathway below, the CCG prescribing costs appear modest compared to the prevalence of both diabetes and obesity. Although the CCG performs below the group averages for cholesterol and blood glucose control, blood pressure control is better and the risk of MI and heart failure is lower. The risk of stroke in people with diabetes is however higher. Note the wide confidence intervals for the patient outcomes. Page 7 of 16

8 The CCG spend on diabetes drugs is high and likely to continue to increase. To address cost concerns without compromising patient outcomes, the CCG is promoting the NICE shared decision aid for diabetes which begins to address the perception gap of both patients and clinicians who tend to overestimate the benefits of drugs and underestimate the impact of their side effects. This approach may slow growth if patients decide the benefit from the diabetes drugs is out weighted by the side effects and will ensure patients are on the most appropriate therapy. Increased adherence to diet and exercise advice would also lower prescribing costs. The CCG has also worked with Diabetes UK to agree a choice of cost effective blood glucose meter and testing guidance and will role this out in 2016/17. It is also working with the diabetes consultants to look at where savings can be made through cost effective choice of insulins and other drugs. Page 8 of 16

9 Heart Disease Heart Disease also has wide confidence interval for outcomes, but if the CCG outcomes shown are a true representation then the relatively high CCG prescribing costs may need to increase to improve outcomes for patients. The CCG has a high spend on atorvastatin the statin of choice recommended by NICE and primary care clinicians are encouraged to use the NICE shared decision aid when considering initiating a statin for primary prevention. The CCG is a lower cost prescriber and continues to review the premium priced rosuvastatin and ezetimibe. Page 9 of 16

10 Stroke Outcomes appear poor based on prevalence, with high elective spend, but the year on year stroke rate is reducing. The increase in cardiovascular spend is driven by adoption of the new oral anticoagulant drugs as recommended by NICE. They appear equivalent to warfarin in clinical trials for reducing stroke, but have the advantage of causing less bleeds and do not require the measurement of INR, although they are significantly more expensive than warfarin Most anticoagulation in Swindon is initiated in secondary care and the spend data below suggests costs may be levelling off. Over last 2 years, 9 practices in the CCG have undertaken an audit to identify and treat high stroke risk AF patients with a view to appropriate anticoagulation. Page 10 of 16

11 NOACS - spend and variance % % % % 95.00% 90.00% 85.00% 80, , , , , , , , Ratio Act Cost Total Act Cost Linear (Ratio Act Cost ) Linear (Total Act Cost ) COPD COPD mortality appears high, but drug interventions have not been shown to extend life. Prescribing costs seem well controlled compared to prevalence. Asthma Page 11 of 16

12 Prescribing costs may be slightly above what is expected based prevalence but may possibly be justified by good outcomes, but again this statement need to be qualified by the wide confidence intervals. There have been a large number of new inhalers bought to market over the last few years, most of which have cost benefits over existing inhalers, but those containing new molecules have weaker evidence than the established therapies. The CCG has a switch programme in place swapping Seretide Evohalers to Sirdupla Inhalers and Symbicort Turbohalers to DuoResp inhalers which is producing significant savings. When this is complete we will consider if further savings can be safely made by recommending the use of the newer inhalers. There is also a program to step down COPD patients when inappropriately prescribed triple therapy outside of NICE guidance. The chart below suggests respiratory work to date appears to be maintaining a constant prescribing cost but has reduced the variance to below the England average. Page 12 of 16

13 Respiratory Chapter - Cost and variance % 400, % % 350, % 300, % 250, % 99.00% 200, % 150, % 100, % 95.00% 50, % 0.00 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Ratio Act Cost Total Act Cost Linear (Ratio Act Cost ) Linear (Total Act Cost ) Medicines Optimisation Plan 2016/17 A savings target of 3,000,000 has been allocated to the prescribing budget, and the plan to achieve this saving has 3 components: 1. Category M cost reductions in June 2016 have been modelled and will save an estimated 500,000 in year 2. MOP work. The medicines optimisation pharmacists and dietician will work with practices to implement their practice plans, this combined with the Optimise Rx savings have a target monthly saving of 100K saving 1,200,000 per annum. 3. Implement the Prescription Ordering Direct scheme in 22 practices by October will save 1,300,000. Actions to reduce cost 1. Therapeutic substitution Top 20 Savings Switches for NHS Swindon CCG [May April 2016] Switch From Switch To Saving p/m Annual savings Rosuvastatin (Crestor) 5 mg tab Pack of 28 Atorvastatin 10 mg tab Pack of 28 6,872 82,464 Page 13 of 16

14 Ferrous Sulphate Tadalafil (Cialis) Rosuvastatin (Crestor) Salmeterol/ Fluticasone MDI (Seretide Evohaler) Budesonide/ Formoterol (Symbicort Turbohaler) Budesonide/ Formoterol (Symbicort Turbohaler) Rosuvastatin (Crestor) Salmeterol/ Fluticasone MDI (Seretide Evohaler) Metformin SR Tadalafil (Cialis) Mycophenolate (Cellcept) Levetiracetam (Keppra) Gliclazide (Zicron) Desogestrel (Cerazette) Dicycloverine Cyanocobalamin (Cytacon) Tolterodine Mesalazine SR Tablet (Asacol MR) Dutasteride / Tamsulosin Capsules (Combodart) 200 mg tab Pack of mg tab Pack of 4 10 mg tab Pack of /25mcg (120 dose unit) Pack of / 6mcg (120 dose unit) Pack of / 12mcg (60 dose unit) Pack of 1 20 mg tab Pack of /25mcg (120 dose unit) Pack of mg SR Tab Pack of mg tab Pack of mg tab Pack of mg tab Pack of mg tab Pack of mcg tab Pack of mg tab Pack of 100 Ferrous Fumarate (Fersamal) Sildenafil Atorvastatin Salmeterol/ Fluticasone MDI (Sirdupla) Budesonide /Formoterol (Duoresp Spiromax) Budesonide /Formoterol (Duoresp Spiromax) Atorvastatin Salmeterol/ Fluticasone MDI (Sirdupla) Metformin (Sukkarto) Sildenafil Mycophenolate Levetiracetam Gliclazide Desogestrel Hyoscine Tablets (Buscopan) 50 mcg tab Pack of 50 No Prescribing 4 mg XL cap Pack of 28 Tolterodine Mesalazine SR 400 mg tab Tablet Pack of 90 (Octasa) 0.5 / 400 mcg cap Pack of 30 Finasteride 210 mg tab Pack of 100 6,492 77, mg tab Pack of 4 5,667 68, mg tab Pack of 28 5,334 64, /25mcg (120 dose unit) Pack of 1 5,084 61, mcgs/4.5mcgs dry powder inhaler 120 dose Pack of 1 4,582 54, mcgs/9 mcgs dry powder inhaler 60 dose Pack of 1 4,556 54, mg tab Pack of 28 3,333 39, /25mcg (120 dose unit) Pack of 1 3,317 39, mg tablets SR Pack of 56 2,809 33, mg tab Pack of 4 2,711 32, mg tab Pack of 50 2,656 31, mg tab Pack of 60 2,520 30, mg tab Pack of 28 2,476 29, mcg tab Pack of 84 2,227 26, mg tab Pack of 56 2,036 24,432 1 N/A N/A Pack of 1 1,920 23,040 2 mg tab Pack of 56 1,800 21, mg tab Pack of 90 1,750 21,000 5 mg tab Pack of 28 1,722 20, ,368 Page 14 of 16

15 The top 20 prescribing switches are shown above. All switches are to clinically equivalent drugs that will not affect patient outcomes. The majority of switches are to medications that are taken the same number of times a day or to devices that are exactly the same to use so the majority of patients should not experience any additional medicine compliance problems as a result of the switches. The annual prescribing report distributed to practices details their individual top 20 switch savings and practices supported their Medicines Optimisation Pharmacists are working to achieve these savings, and these practice switches are contributing to the 100K saving the CCG has generated every month for more than the last 12 months. Patient letters explain that these switches are made to save the NHS money and are given the option to contact their practice if they do not want to switch. If a medication does not suit a patient they are able to switch back. 2. Prescribing Incentive Scheme a. Encourages practices to use the NICE diabetes shared decision aid, informing and engaging patients in their treatment decisions. b. Sets targets for the total volume of antibiotics and the use of broad spectrum antibiotics to reduce side effects and resistance, but does not generate savings. c. Review of pregabalin against NICE guidance to ensure appropriate use. The intent is for a pharmacist to review every patient on pregabalin before the end of the financial year. d. Tackle inappropriate polypharmacy in the over 75s to reduces medication burden, side effects and improving patient outcomes. e. Encourage use of Eclipse to monitor patient safety alerts and prescribing audits. Practice are encouraged to regularly review their Radar alerts, identifying patients at potential risk of harm from their medicines and perform an audit each month intending to both improve patient care and reduce costs. The audit for Q1 is a review of high dose steroid use in asthma, stepping down doses avoids patients being exposed to excessive does of steroids with the associated side effects and also reduces costs. 3. OptimiseRx For 16/17 the CCG has switched for point of decision software from ScriptSwitch to OptimiseRx. This software is endorsed by NICE for the ability to inform prescribers of NICE guidance at the point of prescribing, but it also contains cost effectiveness messages and in the first 3 months of 16/17 is achieving over twice the level of savings achieved through ScriptSwitch. 4. Medicines and Care homes Working alongside GPs who care for care and nursing home residents to review frail elderly patients with the aim to reduce inappropriate polypharmacy and with homes to reduce medicines waste. The intent is to review all residents in care and nursing homes on a 2 year cycle. 5. Prescription Ordering Direct NHS Prescription Ordering Direct (POD) is based on the call centre model piloted in Coventry and Rugby (C&R) where patients from more than one GP practice will telephone to request a repeat prescription to a central location. In C&R the NHS POD provides an additional method for patients to order their repeat prescriptions enabling increased patient empowerment and the ability to take control of their own repeat medication requirements. Practices are asked not to accept repeats from community pharmacists. The aim of the service is to ensure patients only order the medication they require empowering patients to manage their medication and therefore reduce waste. Patients are asked about what medication is needed at that time. Can I have everything is challenged to ensure all medicines are required. Page 15 of 16

16 Patients requiring PRN medication are asked about current stocks in their cupboards at home. Patients requesting multi dose packs every month are asked about their current dosage and informed about how long the pack should last (eg inhalers that contain 200 doses with a 1 puff QDS dose are informed that their inhaler should last 50 days) Savings from the C&R scheme are detailed below. Patients who were surveyed for the pilot like the opportunity to speak to in person to someone about their medicines and practice feedback has been positive. Quantifying potential savings Coventry and Rugby savings extrapolated from 5 practices Applying to Swindon CCG CCG spend 2015/16 (less public health and NHSE prescribing) 31,842,063 Predicted outturn (4.8% growth) 33,370,482 Predicted POD outturn (less 7%) 29,613,118 Gross Saving 3,757,364 Estimated cost (based on R&C for 200,000 pop) 600,000 Net saving approx. 3 million OR Approx. 120k per practice per year (Caution - Data based on a small sample of practices in a single CCG, but seems likely to be applicable) Conclusion It is possible to maintain or improve patient outcomes at the same time as achieving significant savings in the prescribing budget. Page 16 of 16