Forecasting and Monitoring Budgetary impact and medicines uptake Kate Jenkins and Paul Deslandes Welsh Analytical Prescribing Support Unit All Wales Therapeutics and Toxicology Centre
WAPSU Remit Medicines management projects Wales Patient Access Schemes Financial forecasting for new medicines Prescribing monitoring and analysis
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
Budget impact
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)
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
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)
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)
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
Remit to produce an annual report analysing the use of medicines which have undergone appraisal by either NICE or AWMSG.
Limitations with the data
April 2003 March 2015 NICE 250 336 TAs 200 254 currently active 150 AWMSG Number 100 239 appraisals 50 185 medicines 0 Negative recommendation Positive recommendation Statement of Advice
Top 20 - Recommended
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 14.74 1M
Use of the newer oral anticoagulants is increasing 700,000 600,000 500,000 Spend ( ) 400,000 300,000 200,000 100,000 0 Apixaban Dabigatran Rivaroxaban Warfarin
Oral anticoagulants Total NHS Wales spend on NOACs for the financial year 2014 2015 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
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 2014-2015 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 ( ) 120,000 100,000 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 Glycopyrronium bromide 22/5/13 90 581 1,270 30,112 194,391 424,917 99,053 329% Aclidinium bromide 31/7/13 942 2,220 3,506 323,294 761,904 1,203,259 180,844 56% Umeclidinium 9/1/15 1,289 2,611 3,968 431,815 874,685 1,329,280
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 2014 2015) 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 1,000,000 800,000 600,000 400,000 200,000 0 Area of potential interest in light of: new NICE guideline licensing of biosimilar insulins Insulin degludec Insulin glargine Insulin detemir Isophane insulin
Thank you Diolch yn Fawr