Forecasting and Monitoring Budgetary impact and medicines uptake

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1 Forecasting and Monitoring Budgetary impact and medicines uptake Kate Jenkins and Paul Deslandes Welsh Analytical Prescribing Support Unit All Wales Therapeutics and Toxicology Centre

2 WAPSU Remit Medicines management projects Wales Patient Access Schemes Financial forecasting for new medicines Prescribing monitoring and analysis

3 Introduction Estimating budget impact of medicines in the AWMSG work program Budget impact of medicine uptake post ratification Monitoring usage (in Wales) of medicines appraised by AWMSG and NICE Correlating predicted vs observed expenditure

4 Budget impact

5 In an ideal world (At least) two years before positive appraisal recommendation: Implementation date Estimated number of patients Estimated cost Estimated place in treatment Service delivery costs (resource use)

6 Background Financial forecasting added to the WAPSU work-plan by Welsh Government in 2013 Forecasting focus group meeting held in Abergavenny in July 2013 Forecasting group established autumn 2013 and includes: Pharmacist, and finance representatives Members from each health board, NWIS and Welsh Government Forecasting group met for the first time in December 2013 with subsequent meetings on a quarterly basis

7 Role of WAPSU and forecasting group Collate data from budget impact section of AWMSG ASAR documents Produce a rolling quarterly report Report reviewed by the group at each meeting Individual members feedback to relevant colleagues at their health board An interactive budget impact calculator is in development (in pilot phase)

8 Budget impact software Initially focussed on AWMSG appraisals, to provide: Estimate of direct drug cost using list price Estimate of net change in direct drug cost vs comparator Default values for the above using estimates from the ASAR Ability to input predicted local level usage (to account for variation in disease prevalence, prescriber interest etc) Ability to input local drug unit cost (to account for PAS and other local price variation)

9 What do we need? Budget impact information presented in a consistent way Consider: Patients eligible: prevalence, incidence, applicable population Patients treated: estimated uptake, discontinuers, cumulative numbers CIC information

10 Remit to produce an annual report analysing the use of medicines which have undergone appraisal by either NICE or AWMSG.

11 Limitations with the data

12 April 2003 March 2015 NICE TAs currently active 150 AWMSG Number appraisals medicines 0 Negative recommendation Positive recommendation Statement of Advice

13 Top 20 - Recommended

14 Inositol nicotinate Bosutinib Aflibercept concentrate for infusion Amantadine hydrochloride Paricalcitol Eribulin Ruxolitinib Fulvestrant Sorafenib Bevacizumab Ofatumumab Micafungin Fampridine Insulin degludec Olanzapine depot injection Bromfenac Pentoxyfylline Cilostazol Racecadotril granules for suspension Aliskiren Cabazitaxel Dasatinib M

15 Use of the newer oral anticoagulants is increasing 700, , ,000 Spend ( ) 400, , , ,000 0 Apixaban Dabigatran Rivaroxaban Warfarin

16 Oral anticoagulants Total NHS Wales spend on NOACs for the financial year was 3.6 million: a 158% increase in spend over the previous year. Rivaroxaban made up the majority (53%), perhaps because of its broader range of indications, dabigatran etexilate makes up 27% and apixaban 19% of total spend NOACs make up 5.2% of anticoagulant items prescribed in primary care Variation across Wales 1.78 to 6.93 items/1,000 PUs (average 4.2 items/1,000 PUs) NOACs make up 10.5% of anticoagulant items in primary care in England, average 6.06 items/1,000 PUs

17 Long-acting muscarinic antagonists Tiotropium was the first inhaled LAMA to be available in the UK In the last three years, three new inhaled LAMAs have been launched and received a positive recommendation from AWMSG. Spend on tiotropium by NHS Wales for was 15.9 million Spend on the three newer LAMAs for the same period was 538,000 (3% of all LAMA spend) Also need to consider the new LAMA/LABA combination inhalers Spend ( ) 120, ,000 80,000 60,000 40,000 20,000 0 Aclidinium bromide Glycopyrronium Umeclidinium

Actual versus estimated Medicine Ratification date Company estimate patients Company estimate cost Observed cost % of estimated cost Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Year 1 Year 1

18 Actual versus estimated Medicine Ratification date Company estimate patients Company estimate cost Observed cost % of estimated cost Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Year 1 Year 1 Glycopyrronium bromide 22/5/ ,270 30, , ,917 99, % Aclidinium bromide 31/7/ ,220 3, , ,904 1,203, ,844 56% Umeclidinium 9/1/15 1,289 2,611 3, , ,685 1,329,280

19 Analogue insulin Three analogue insulins currently available in the UK Approximately 97% of insulin spend is in primary care Analogue insulin accounts for 91% of long- and intermediate- acting insulin items issued in primary care ( 8.5 million for the financial year ) Although majority of use is in primary care, influenced heavily by specialists in secondary care Spend ( ) 1,800,000 1,600,000 1,400,000 1,200,000 1,000, , , , ,000 0 Area of potential interest in light of: new NICE guideline licensing of biosimilar insulins Insulin degludec Insulin glargine Insulin detemir Isophane insulin

20 Thank you Diolch yn Fawr

MONITORING OF MEDICINES APPRAISED BY NICE AND AWMSG SUMMARY

MONITORING OF MEDICINES APPRAISED BY NICE AND AWMSG SUMMARY April 2014 This report has been prepared by the Welsh Analytical Prescribing Support Unit (WAPSU), part of the All Wales Therapeutics and Toxicology