Medicines Optimisation Annual Report 2015-2016 Dr Emma Harris and Neil Hardy on behalf of the Medicines Management Team June 2016 1
Clinical Objectives Improve the effective use of medicines Maximise health gain Minimise harm associated with medicines Empower patients Set out a clear strategy Ensure effective communication Engage with clinicians 2
Work Programme and Key Outcomes Primary Care Prescribing 2015/16 Medicines Optimisation Incentive Scheme Cost Saving Interventions Quality and Safety Interventions Deprescribing in Polypharmacy Stroke Prevention in Atrial Fibrillation Respiratory Inhaler Technique Counselling GP Engagement and Feedback 3
Primary Care Prescribing 2015/16 Total spend was 85.1M, an increase of 5.1% on 14/15 spend The England mean increase was 4.0% Total number of prescription items dispensed was 9.3M, an increase of 0.4%. The England mean increase was 1.6% Average cost per prescription item was 9.17 The cost per ASTRO PU was 38.86 which is 7% lower than the England mean. Practices varied from 46.77 (21% higher than the CCG mean) to 29.38 (24% below the CCG mean) 4
Primary Care Prescribing 2015/16 5
Cost-Saving Interventions 2015/16 Doxazosin 130K Blood glucose test strips 395K Rosuvastatin 61K Quetiapine 142K Consilient OCs 114K TOTAL 1.9M Sildenafil 363K Ezetimibe 181K Seretide/ Sirdupla 251K 6
Quality & Safety Interventions 2015/16 Deprescribing in Polypharmacy Stroke prevention in AF Respiratory work 7
Deprescribing in Polypharmacy By 2018 3 million people in the UK will be living with long-term conditions managed with polypharmacy 60% Rx are for persons 60 years + 75 years + are taking at least 6 medicines 1/3 people A person taking 10 or more medicines is 300% more likely to be admitted to hospital
Deprescribing in Polypharmacy 14/16 Polypharmacy cardiovascular Aspirin &/or dipyridamole Statins or ezetimibe Diuretics & CCBs Digoxin 63 Quinine 526 Amiodarone Polypharmacy analgesia Polypharmacy endocrine 74 Opioids 42 Bisphosphonates 205 174 NSAIDs 24 Alphablockers 14 Polypharmacy other ACE-I/ARB combinations Triple whammy (ACE-I/ARB; diuretic; NSAID) 19 PPIs 53 Antimuscarinics 277 Inhalers 9 SSRIs & NSAIDs Pregabalin or gabapentin 86 229 27 Antipsychotics 15 Other 396 Metformin 4 Specials 275 1 Grand Total: 2,513
West Hampshire CCG 546,000 population 106,000 over 65s 16,000 over 85s 119,000 under 20 Ageing population 51 practices 2,000 undiagnosed AF 12,000 people with AF 10,500 AF high risk stroke 3,700 no OAC 6,800 on OAC
Stroke Prevention in Atrial Fibrillation Identify undiagnosed AF using WatchBP tool Identify and treat people not treated with OAC Identify people on warfarin sub-optimally-controlled
Stroke Prevention in Atrial Fibrillation WatchBP GRASP AF Before No OAC On OAC 19 new cases AF diagnosed No OAC After On OAC 1629 more OAC 36 expected strokes avoided
Stroke Prevention in Atrial Fibrillation WPSAT % patients taking warfarin well-controlled 3000 people poorly-controlled on warfarin reviewed 100 50 59 67 62 actual strokes 0 Before After saved
Respiratory Inhaler Technique 8.4 million inhaled medications Prescribing Budget 10.5% prescribing budget Many new products have recently been launched to the market: Crucial that they are used appropriately and to maximum effect 6 accredited training sessions on inhaler technique 114 people attended 51 practices GPs, practice nurses and dispensary staff
Respiratory Inhaler Technique I ve been able to breathe properly for the first time in 30 years Good review of devices and tips to teach patients Very relevant, practical knowledge to improve patient education
GP Engagement As part of the incentive scheme all practices participated in a practice-based meeting to agree their action plan, a locality peer review meeting and a practice based mid-year review meeting All practices have a nominated GP prescribing lead who meets regularly with the attached medicines management team pharmacist and technician There are four locality medicines optimisation groups in place. During 2015/16 there were 21 meetings with an average of 12 GPs attending each meeting 16
GP Engagement The medicines management team continues to provide a medicines update course to practice staff. A monthly bulletin News Headlines goes to all practices and community pharmacists All resources are available on the CCG public website: http://www.westhampshireccg.nhs.uk/medicines 17
GP Feedback The work done in the background to enable us to prescribe more effectively and safely is wonderful. A real triumph of team working. Dr Samuel Gee The Fryern Surgery I really enjoy working in partnership with the Medicines Management team. They clearly are trying to help with change that not only improves cost effectiveness but also improves patient safety and outcomes. When implementing the changes within our practice they are hardworking and thorough and the team are very quick in responding to any queries that we have as a practice. Dr James Beer The Red & Green Practice The team are an integral part of general practice and without you our job would be, if not impossible, much more difficult! Dr Mike Zardis Testvale Surgery I personally, and my practice have always found the Medicines Management Team helpful and valued members of the practice team. But there is more work that can be done, to improve patient care, that needs more pharmacists. Dr Simon Le Besque, West End 18
It is a pleasure and a privilege having Emma work in conjunction with us here at Blackthorn surgery. She is approachable, efficient and above all friendly. I am sure it is improved our prescribing and safety as well its cost. I look forward to continued working with her in the future. Dr Mark Tomson Blackthorn We have little time coping with the daily needs of patients to be proactive and it s great to have the support which must save a significant amount of money and provide better quality of prescribing for patients. Dr John Bush Hedge End Medical Centre I feel the Medicine s Optimisation Team has been absolutely crucial in supporting Forest Gate Surgery in all aspects of our medicine s management work. We have benefited from your continuous expertise and input which has enabled us to improve our delivery of care to our patients. With your help we can ensure we are prescribing safely and cost effectively and in line with both local and national guidance. The team is helpful and approachable on a wide variety of queries and your assistance with audits and the implementation of changes to a patient s medication is invaluable. Thank you all very much, we couldn t do it without you! Dr Ely Hunt Forest Gate Surgery 19
Trend charts of Interventions Cost-saving interventions (cost is a quality issue) Blood Glucose Test Strips Ezetimibe Quetiapine MR Quality and Safety interventions Deprescribing in Polypharmacy Aspirin and dipyridamole Digoxin 250mcg Quinine Stroke Prevention in Atrial Fibrillation 20
100.0 90.0 80.0 Low Acquisition Cost Blood Glucose Test Strips vs. Total Blood Glucose Test Strip Items 70.0 Percentage 60.0 50.0 40.0 30.0 20.0 10.0 West Hampshire CCG England 0.0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 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 Month 21
6.0 5.0 Ezetimibe (including combination with Simvastatin) - % Items vs. Total Lipid Lowering Items Percentage Items 4.0 3.0 2.0 West Hampshire CCG England 1.0 0.0 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Month 22
23 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 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 Percentage Month Cost-savings % Quetiapine Prescribed as M/R West Hampshire CCG England
10.0 9.0 Deprescribing Polypharmacy Dipyridamole (including combination with Aspirin) Items vs. Total Antiplatelet Items 8.0 7.0 6.0 5.0 4.0 3.0 2.0 West Hampshire CCG England 1.0 0.0 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 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 24
450 400 Deprescribing Polypharmacy Digoxin 250microgram Items 350 300 Items 250 200 150 100 50 0 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Month Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 25
7.0 6.0 Deprescribing Polypharmacy Quinine Items per 1000 Patients Items per 1000 Patients 5.0 4.0 3.0 2.0 1.0 West Hampshire CCG England 0.0 Month 26
100.0 80.0 60.0 Percentage 40.0 20.0 Stroke Prevention in AF % Newer Oral Anticoagulant Items vs Total Anticoagulant Items West Hampshire CCG England 0.0 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 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-16-20.0 Month 27
28 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 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 Items Month Stroke Prevention in AF Oral Anticoagulant Items Total Oral Anticoagulants NOACs Warfarin
Work Programme and Key Outcomes Other Priorities Oral Nutrition Antimicrobial Stewardship Basingstoke, Southampton and Winchester District Prescribing Committee High Cost Secondary Care Medicines Medicines Safety 29
Oral Nutrition Dietitian support from HHFT Guidelines and resources on website Food first strategy, formulary adherence, gluten free prescribing Working closely with the Nurse Facilitators to implement changes in care homes Sip feed nursing home request form Hampshire wide guidelines for infant formula 30
Antimicrobials Antimicrobial stewardship remains an international priority 26,000 fewer prescriptions for antibiotics written compared to 2014/15 (a 7.5% reduction) West Hampshire GPs prescribe 10% fewer prescriptions than the England average Practice prescribing rates vary from 26% above the CCG mean to 34% below Intervention in 16/17 incentive scheme for practices above England mean 31
Basingstoke, Southampton and Winchester District Prescribing Committee Hosted by West Hampshire CCG Good WHCCG GP representation: Drs Emma Harris, Madelyn Dakeyne and Mike Zardis Dr Mark Aley Chairs the Medicines Evaluation Committee Evaluates new medicines and considers shared care Shared care guidelines written in GP friendly format 32
High Cost Secondary Care Medicines Hosted service across SHIP7 Successful introduction of biosimilar infliximab (particularly at UHSFT) Support to IFR process Monthly monitoring of PbR excluded medicines charges Liaison with specialised commissioning 33
Medicines Safety Medicines Safety Officer in place Hampshire Medicines Safety Group supported by West Hampshire CCG Medicines incidents reported through NRLS are reviewed and learning shared with all practices Amiodarone intervention in 16/17 incentive scheme is a direct result of an incident in West Hampshire Work programme included the recording of hospital prescribed medicines on GP clinical systems 34
Publications and Awards Improving early diagnosis and treatment of people with AF case study published in Delivering a healthier future NHS Clinical Commissioners AF work shortlisted for HSJ Value in Healthcare Awards AF work presented to the Wessex Quality Improvement conference Dr Keith Ridge (Chief Pharmacist at DH/NHSE) included our work on polypharmacy and AF in his presentation to the H&C Commissioning Show 35