How many spoonfuls of sugar? A Bert s-eye view of prescribing to manage blood sugar

Transcription

1 How many spoonfuls of sugar? A Bert s-eye view of prescribing to manage blood sugar

2 What would Mary Poppins think? Please discuss

3 Some Sums Annual cost of diabetes (1 &2) in England = c. 24 billion Around 60% of this indirect loss of work, caring, etc. Around 40% direct healthcare cost to NHS = c. 10 billion [>90% type 2] = c. 10% TOTAL NHS budget Cost of prescriptions to manage blood sugar almost 10% of this

4 Multi-factorial management of Type 2 diabetes Education Smoking Lifestyle Diet & Activity Control blood pressure Everything else Control blood sugar Metformin Statins Individualised care of patients: based on evidence for each intervention

5 Management for type 2 diabetes: AIMS NICE Clinical Guideline 87; May 2009 Adopt a healthy lifestyle (stop smoking, exercise, weight management, etc.) Manage symptoms associated with having high blood glucose levels if patients have them Reduce risk of major life-threatening or disabling complications (heart attacks and stroke) Manage diabetic kidney damage, eye damage and nerve damage (foot disease, neuropathic pain, erectile-dysfunction, etc.) BUT targets for all the different aspects of this condition (BP, lipids, blood glucose etc.) can be demanding to reach Agree the priorities for care and targets for each aspect of management on an individualised patient basis as aggressive therapy of each aspect may not be appropriate for all.

6 Control blood sugar

7 North East CCGs total: Top 5 BNF sections in terms of current spend - April 2014 to December 2014 Actual Cost Rank BNF Section Current Previous Growth % 1 Corticosteroids (Respiratory) 34,813,707 33,098, Drugs Used In Diabetes 33,871,479 32,344, Analgesics 30,935,477 29,326, Antiepileptics 24,007,843 21,818, Bronchodilators 19,586,543 18,727, NHS North of England: Top 5 BNF sections in terms of current spend - April 2014 to December 2014 Actual Cost Rank BNF Section Current Previous Growth % 1 Drugs Used In Diabetes 176,759, ,287, Corticosteroids (Respiratory) 167,543, ,280, Analgesics 138,582, ,690, Antiepileptics 114,962, ,141, Bronchodilators 84,888,256 80,847, England: Top 5 BNF sections in terms of current spend - April 2014 to December 2014 Actual Cost Rank BNF Section Current Previous Growth % 1 Drugs Used In Diabetes 600,948, ,124, Corticosteroids (Respiratory) 490,872, ,079, Analgesics 377,086, ,921, Antiepileptics 339,559, ,530, Oral Nutrition 251,838, ,812,

8 HUGELY VARIABLE

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10 Actual Cost per diabetic patient North East & Cumbria CCGs: Weighted prescribing cost of BNF 6.1: Drugs used in Diabetes - January 2012 to December Costs 38% more per patient to lower blood sugar levels in top spending CCG than in lowest spending CCG 1.2 million per annum EXTRA Cumbria Darlington Durham Dales, Easington & Sedgefield Gateshead Hartlepool & Stockton Newcastle North and East Newcastle West North Durham North Tyneside Northumberland South Tees South Tyneside Sunderland Teaching North East & Cumbria England North East & Cumbria Q4 1213Q1 1213Q2 1213Q3 1213Q4 1314Q1 1314Q2 1314Q3 1314Q4 1415Q1 1415Q2 1415Q3 Copyright RDTC 2015

11 Why such HUGE differences? Insulins analogue v human Newer drugs DPP4 inhibitors, GLP1 agonists, SGLT2 inhibitors Blood glucose testing strips

12 Insulin analogues

13 Insulins

14 Percentage (DDDs) Percentage (DDDs) Percentage (actual cost) Percentage (items) Spread? 110 North East & Cumbria CCGs: Analogue insulins as a % of all insulins - Actual cost - January 2012 to December 2014 North East & Cumbria CCGs: Insulins Detemir, Glargine and Degludec as a Percentage of All Long Acting and Intermediate Insulins (excluding biphasic insulins) - January 2012 to December Q4 1213Q1 1213Q2 1213Q3 1213Q4 1314Q1 1314Q2 1314Q3 1314Q4 1415Q1 1415Q2 1415Q3 Copyright RDTC 1112Q4 1213Q1 1213Q2 1213Q3 1213Q4 1314Q1 1314Q2 1314Q3 1314Q4 1415Q1 1415Q2 1415Q3 Copyright RDTC North East & Cumbria CCGs: Biphasic analogues as a % of all biphasic insulins - DDDs - January 2012 to December North East & Cumbria CCGs: Rapid acting analogues as a % of all short & rapid-acting insulins - DDDs - January 2012 to December Q4 1213Q1 1213Q2 1213Q3 1213Q4 1314Q1 1314Q2 1314Q3 1314Q4 1415Q1 1415Q2 1415Q3 Copyright RDTC Q4 1213Q1 1213Q2 1213Q3 1213Q4 1314Q1 1314Q2 1314Q3 1314Q4 1415Q1 1415Q2 1415Q3 Copyright RDTC 2015

15 Newer drugs Durham Dales, Easington & Sedgefield England Sunderland Teaching North Durham Darlington South Tees South Tyneside Hartlepool & Stockton North East & Cumbria Gateshead Cumbria Newcastle North and East Newcastle West North Tyneside Northumberland Actual Cost per diabetic patients Sitagliptin Liraglutide Exenatide Linagliptin Saxagliptin Dapagliflozin Lixisenatide Metformin Hydrochloride/Sitagliptin Vildagliptin Metformin Hydrochloride/Vildagliptin Others Copyright RDTC

16 Test Strips North East CCGs: Weighted prescribing cost of SMBG test strips - April 2014 to December 2014 Cumbria North Durham Newcastle North and East South Tees Newcastle West Sunderland Teaching North East & Cumbria North Tyneside Hartlepool & Stockton England South Tyneside Northumberland Durham Dales, Easington & Sedgefield Gateshead Darlington Actual Cost per diabetic patients Aviva (Reagent)_Strips Contour (Reagent)_Strips Contour Next (Reagent)_Strips Mobile (Reagent)_Strips OneTouch Ultra (Reagent)_Strips FreeStyle Lite (Reagent)_Strips GlucoRx Nexus (Reagent)_Strips Element (Reagent)_Strips FreeStyle Optium (Reagent)_Strips Compact (Reagent)_Strips Others Copyright RDTC

17 Photo finish?

18 % target met Spend per patient with diabetes vs HbA1c QOF (59mmol/mol_7%) North East and Cumbria CCGs: Prescribing cost per patient v Percentage with IFCC-HbA1c 59 mmol/mol or less in the last 12 months (DM 7) 78 Higher Target Achievement / Lower Cost Northumberland Newcastle North and East Darlington North Tyneside North East & Cumbria Newcastle West Cumbria Hartlepool & Stockton Gateshead South Tyneside Durham Dales, Easington & Sedgefield England North Durham South Tees Sunderland Teaching Lower Target Achievement / Higher Cost Actual Cost / diabetic patient Copyright RDTC

19 % target NOT met North East and Cumbria CCGs: Prescribing cost per patient v % with HbA1c above 75mmol/mol (9%) in the last 12 months [DM009 inverse] 14 More "treatment failures" / Higher Cost Gateshead 13 England 12 South Tyneside Sunderland Teaching North Tyneside Newcastle West Darlington Newcastle North and East North East & Cumbria Cumbria Hartlepool & Stockton South Tees North Durham Durham Dales, Easington & Sedgefield 9 Northumberland Fewer "treatment failures" / Lower Cost Actual Cost / diabetic patient Copyright RDTC 2015

20 Bed day excess vs expenditure on blood sugar 25% 20% 15% 10% 5% 0%

21 Multi-factorial management of Type 2 diabetes Education Smoking Lifestyle Diet & Activity Control blood pressure Everything else Control blood sugar Metformin Statins Individualised care of patients: based on evidence for each intervention

22 Control blood sugar

23 Relationship of reductions in cholesterol, blood pressure and HbA1c with improvements in CHD and CV outcomes Yudkin JS, et al. Diabetologia 2010;53: , MeReC Bulletin Vol. 21, No. 5, June 2011 Blood pressure lowering (reduction of 10/5mmHg) Cholesterol lowering (reduction of 1mmol/L) Intensive Blood glucose lowering (HbA1c reduction of 0.9%) (10mmol/mol) CV event Stroke CHD Number of events prevented per 1000 patients over 5 years

24 The Goldilocks effect Blood glucose lowering: not too little, not too much Currie CJ, et al. Lancet 2010;375:481 9, MeReC Rapid Review No Observational study: HbA1c of about 7.5% associated with lowest risk of all-cause mortality (increase above or decrease below this associated with greater risk) Adjusted hazard ratios for all-cause mortality by HbA1c deciles in people given metformin plus sulphonylurea (A) and insulin-based therapy (B) Metformin plus sulphonylurea Insulin-based therapy Vertical error bars show 95%CIs, horizontal bars show HbA1c range. Red circle = reference decile. *Truncated at lower quartile. Truncated at upper quartile

25 Law of diminishing returns: The absolute benefit decreases with each intervention, yet harms accumulate HARM BENEFIT Number of interventions

26 Reflection? At organisational level Do we know how we compare with others? Do we need to do something different? Insulins Newer drugs Blood glucose testing strips At individual prescriber level Do we need to pursue blood glucose target further? Can we get a better outcome another way? Am I making life more difficult polypharmacy Can I prescribe a less expensive drug and get the same effect?

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