Primary Care Prescribing Analysis – Medicines Used in Diabetes

September 2015

This report has been prepared by the Welsh Analytical Prescribing Support Unit (WAPSU) with the support of a multiprofessional collaborative group, which includes members of the All Wales Prescribing Advisory Group (AWPAG) and the All Wales Therapeutics and Toxicology Centre (AWTTC), and has subsequently been endorsed by the All Wales Medicines Strategy Group (AWMSG).

Please direct any queries to AWTTC:

All Wales Therapeutics and Toxicology Centre University Hospital Llandough Penlan Road Llandough Vale of Glamorgan CF64 2XX

awttc@wales.nhs.uk 029 2071 6900

This document should be cited as: All Wales Medicines Strategy Group. Primary Care Prescribing Analysis – Medicines Used in Diabetes. September 2015.

Primary Care Prescribing Analysis – Drugs Used in Diabetes

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EXECUTIVE SUMMARY

• Medicines used in diabetes account for approximately 10% of primary care

prescribing.

• Services for diabetes account for 10% of all NHS expenditure in the UK, and the incidence of diabetes is increasing in Wales1.

• Prescribing of medicines used in diabetes in 2014–2015 accounted for £57.2 million (9.8% of total medicines expenditure in NHS Wales) and 3,273,664 items (4.2%) in primary care, and £2.6 million (1.5%) in secondary care. Prescribing via the WP10HP route amounted to £78,668 (6,319 items).

• The prescribing of insulins accounted for £20.7 million and 442,107 items in

2014–2015, while antidiabetic drugs accounted for £25.2 million and 2.4 million items. Monitoring and screening agents accounted for £11 million and 452,565 items in the same period.

• Items of long-acting insulin analogues as a percentage of total long- and

intermediate-acting insulin (excluding biphasics) are monitored as part of the Clinical Effectiveness Prescribing Programme (CEPP) Local Comparators for 2015–2016. Long-acting insulin analogues accounted for £8.5 million and 157,297 items in primary care in 2014.

• There is variation between the health boards in a number of areas including

blood glucose monitoring agents, long-acting insulin analogues as a percentage of total long- and intermediate-acting insulin, and sulphonylureas and metformin items as a percentage of all diabetic treatment agents.

• There has been a 14% increase in the cost of prescribing of ‘other antidiabetic

drugs’ such as GLP-1s, DPP-4 inhibitors and thiazolidinediones within NHS Wales in 2014–2015 compared to 2013–2014, with variation between health boards. There may be opportunities for cost savings to be made through prescribing in line with national guidance, such as the first- and second-line use of metformin and sulphonylureas.

• Outcome measures are explored in the document, and outcomes data are

analysed alongside prescribing data for diabetes medicines. Diabetes-related admissions and prescribing vary across the health boards, but the relationship between the two is complex and more work is needed to understand how prescribing can influence measurable outcomes.

• GP cluster data are presented in this document, in which GP clusters are

grouped together based on diabetes prevalence and deprivation scores to produce comparators for the purpose of benchmarking.

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CONTENTS 1.0 INTRODUCTION .................................................................................................... 4

1.1 Diabetes overview .............................................................................................. 4

1.2 Diabetes complications ....................................................................................... 4

2.0 BACKGROUND ...................................................................................................... 5

3.0 CURRENT DIABETES GUIDANCE ........................................................................ 6

3.1 Welsh Government Report – Together for Health – A Diabetes Delivery Plan .... 6

3.2 National Institute of Health and Care Excellence (NICE) guidance ..................... 6

3.3 Clinical Effectiveness Prescribing Programme (CEPP) Local Comparators ........ 6

3.4 Driver and Vehicle Licensing Agency (DVLA) guidance ...................................... 6

4.0 DIABETES PREVALENCE ..................................................................................... 7

4.1 Diabetes prescribing data ................................................................................... 8

4.1.1 Total diabetes prescribing data ..................................................................... 8

4.2 Insulins ..............................................................................................................12

4.3 Antidiabetic drugs ..............................................................................................14

4.4 Diagnostic and monitoring devices for diabetes .................................................16

5.0 OUTCOMES DATA ...............................................................................................17

REFERENCES ............................................................................................................21

APPENDIX 1. GP CLUSTER COMPARATORS ..........................................................23

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TABLE OF FIGURES Figure 1. Number of patients on QOF diabetes register in Wales 2008–2009 to 2013–2014 ...... 7 Figure 2. Prescribing for the three major sub-sections within Drugs used in diabetes (BNF 6.1) – Total items in Wales ...................................................................................................................... 8 Figure 3. Prescribing for the three major sub-sections within Drugs used in diabetes (BNF 6.1) – Total cost in Wales ........................................................................................................................ 9 Figure 4. Prescribing for all diabetes medicines – Items per 1,000 PUs in Wales, England and NE England ................................................................................................................................... 9 Figure 5. Prescribing for all diabetes medicines – Cost per 1,000 PUs in Wales, England and NE England ................................................................................................................................... 9 Figure 6. Prescribing for all diabetic medicines by category – Total items in Wales .................. 10 Figure 7. Prescribing for all diabetic medicines by category – Total cost in Wales .................... 10 Figure 8. Average cost per item for different diabetic medicine categories in Wales ................. 10 Figure 9. Diabetes prescribing cost breakdown April 2014–March 2015 ................................... 11 Figure 10. Diabetes prescribing items breakdown April 2014–March 2015 ............................... 11 Figure 11. Prescribing for DPP-4 inhibitors – Total items in Wales ............................................ 11 Figure 12. Prescribing for GLP-1s – Total items in Wales .......................................................... 12 Figure 13. Prescribing of selected non-biphasic intermediate- and long-acting insulins – Total items in Wales ............................................................................................................................. 12 Figure 14. Prescribing of selected non-biphasic intermediate- and long-acting insulins – Total cost in Wales ............................................................................................................................... 13 Figure 15. Local Comparator: Items of long-acting insulin analogues as a percentage of total long- and intermediate-acting insulin (excluding biphasics) in Wales ......................................... 13 Figure 16. Prescribing of long-acting insulin analogues as a percentage of total long- and intermediate-acting insulin (excluding biphasics) – Welsh health boards compared to English CCGs – Quarter ending March 2015 .......................................................................................... 13 Figure 17. Prescribing of antidiabetic medicines – Total items in Wales .................................... 14 Figure 18. Prescribing of antidiabetic medicines – Total cost in Wales ...................................... 14 Figure 19. Local Comparator: Sulphonylureas and metformin items as a percentage of all diabetic treatment agents (excluding insulin) June 2012–March 2015 ....................................... 14 Figure 20. Breakdown of ‘Other antidiabetic drugs’ – Items per 1,000 PUs April 2014–March 2015............................................................................................................................................. 15 Figure 21. Breakdown of ‘Other antidiabetic drugs’ – Cost per 1,000 PUs April 2014–March 2015............................................................................................................................................. 15 Figure 22. Prescribing of glucose blood testing reagents– Cost per 1,000 PUs weighted by diabetes prevalence April 2013–March 2015 .............................................................................. 16 Figure 23. Prescribing of glucose blood testing reagents – Items per 1,000 PUs weighted by diabetes prevalence April 2013–March 2015 .............................................................................. 16 Figure 24. Admissions for diabetes-related HRGs per 100,000 diabetic population 2013–2014 18 Figure 25. Diabetes-related HRG admissions per 100,000 population against the cost of prescribing in diabetes 2013–2014 ............................................................................................. 19 Figure 26. Diabetes-related HRG admissions per 100,000 population against the prescribing of long-acting insulin analogues as a percentage of total long- and intermediate-acting insulins (excluding biphasics) 2013–2014 ................................................................................................ 19 Figure 27. Percentage of patients achieving HbA1c target compared with the cost of diabetes prescribing per 1,000 PUs 2014–2015........................................................................................ 20

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1.0 INTRODUCTION 1.1 Diabetes overview Diabetes has a significant impact on the population of Wales, affecting 5.6% of the adult population2. This percentage increases with age, and in the older age group (over 65 years) a higher proportion of men than women are reported as being treated for diabetes. The prevalence of type 2 diabetes mellitus is increasing in the UK and worldwide3, and projections estimate that UK prevalence will increase by 50% over the next decade. Although diabetes can result in ill health, disability and even premature death, these can often be prevented by effective self-management, education and high-quality care. The diabetic therapeutic area is complex and encompasses a wide range of specific indications and treatment areas. Prescribing data presented in this report relate to the use of medicines across the diabetic therapeutic area and the term ‘diabetes medicines’ refers to medicines that are listed in the British National Formulary (BNF) under Section 6.1 Drugs used in diabetes. However, we can assume that the main indications for treatment, representing the majority of prescribing, will be type 1 and type 2 diabetes mellitus. Therefore, although the treatment of diabetes may cover a wider range of medicines, e.g. medicines used in diabetic neuropathy, nephropathy and retinopathy, as well as medicines used for foot care, for the purposes of this report, diabetic medicines refers to medicines used directly in diabetes. 1.2 Diabetes complications Diabetes is associated with raised blood pressure, a disturbance of blood lipid levels and a tendency to develop cardiovascular disease and stroke. The increased cardiovascular risks associated with type 2 diabetes include coronary artery disease, peripheral artery disease and carotid artery disease. Specific complications of diabetes include eye damage, kidney damage and nerve damage. The wide ranging complications of diabetes mean that the condition draws on many areas of healthcare management and that the pharmacological treatment is often complex. Management of type 2 diabetes often involves a large element of self-care and therefore treatment will be tailored for the individual4. While the prescribing for these complications is beyond the scope of this report, safe, effective and cost-effective prevention and treatment of diabetes will influence the impact of these complications.

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2.0 BACKGROUND The Primary Care Prescribing Analysis – Medicines Used in Diabetes is the latest in a series of prescribing analysis reports produced by WAPSU:

• Respiratory Prescribing Analysis with Cluster Level Comparators (Feb 2015) • GP Cluster Level Comparators (October 2014) • BNF Chapter Analysis of the Eye, Respiratory and Cardiovascular Therapeutic

Areas (March 2014) • BNF Chapter Analysis (September 2013)

Diabetes medicines have been chosen as the next area for analysis as they account for a large proportion, approximately 10%, of prescribing expenditure and services in the UK5, and diabetes incidence is increasing in Wales6. The Diabetes Delivery Plan describes the current rate of increase in spend on diabetes as unsustainable and recommends that action needs to be taken to address this6. This report aims to provide prescribing leads with analysis of the diabetes therapeutic area, and in particular focuses on:

• Primary care prescribing analysis of the BNF diabetes chapter; • Prescribing trends, cost and items per patient; • Wales, England and North East (NE) England comparative prescribing trends; • Influence of measurable variables on prescribing e.g. demographics; • Outcomes data; • GP cluster level comparators.

Diabetes prescribing GP cluster data for Wales are presented in eight groups of the most similar GP clusters based on diabetes prevalence and deprivation. This method for presenting data should enable GP cluster groups and health boards to make meaningful comparisons of their prescribing rates with areas of a similar disease prevalence and deprivation profile.

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3.0 CURRENT DIABETES GUIDANCE 3.1 Welsh Government Report – Together for Health – A Diabetes Delivery Plan It is important that ongoing work in NHS Wales addresses the number of people affected by diabetes and the complications arising from the condition by promoting healthy lifestyles and ensuring that those affected by any kind of diabetes are well informed about their condition and have timely access to services1. The Welsh Government report, Together for Health – A Diabetes Delivery Plan, describes aims to have effective plans in place in Wales to prevent diabetes and reduce the risk of long-term diabetic complications6. The report sets out new Welsh Government commitments to the public and supports the continuing delivery of service standards established in the Diabetes National Service Framework, published in 20037. The report describes the outcome indicators below to measure success:

• Incidence of type 2 diabetes mellitus per 100,000 population • Circulatory disease mortality rate for < 75 year olds/100,000 population • Age group specific diabetes mortality rate for < 75 year olds/100,000 population • Variations in incidence of complications of diabetes by geography and

deprivation6 3.2 National Institute of Health and Care Excellence (NICE) guidance There are a number of specific NICE Clinical Guidelines (CGs) and NICE Technology Appraisals (TAs) relating to the use of diabetes medicines and patient treatment. See the Diabetes topic page on the NICE website for more information. Current diabetes guidance recommends a patient-centred care approach and the management of diabetes typically involves a considerable element of self-care. The advice, therefore, should be aligned with the perceived needs and preferences of people with diabetes and their carers. People with diabetes should be able to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Communication between healthcare professionals and patients is essential and should be supported by evidence-based written information tailored to the patient’s needs. New NICE guidance on type 2 diabetes is due in October 2015. 3.3 Clinical Effectiveness Prescribing Programme (CEPP) Local Comparators Diabetes treatment is included in the CEPP Local Comparators for Wales 2015–20168 to promote the appropriate use of the newer diabetic treatment agents and long-acting insulin analogues in type 2 diabetes mellitus in line with NICE CG87, TA203 and TA2484,9,10. The Local Comparators are measures produced to allow health boards to benchmark across a range of prescribing indicators. They are not reported nationally but are available for both local and national comparative measurement as necessary in accordance with local prioritisation. Caution should be exercised in the interpretation of Local Comparator data, as some comparators may be more relevant to benchmark for one health board than another. The list of comparators is circulated directly to Chief Pharmacists and Medicines and Therapeutics Committees. The diabetes-related Local Comparators include:

• Sulphonylureas and metformin items as a percentage of all diabetic treatment agents (excluding insulin).

• Glucagon-like peptide-1 agonists – exenatide, liraglutide and lixisenatide – as a percentage of diabetic treatment agents (excluding insulin).

• Items of long-acting insulin analogues as a percentage of total long- and intermediate-acting insulin (excluding biphasics).

• Cost of diabetic self-monitoring agents per 1,000 PUs (weighted by diabetes prevalence).

3.4 Driver and Vehicle Licensing Agency (DVLA) guidance The DVLA gives advice on driving requirements relating to blood glucose control.

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4.0 DIABETES PREVALENCE Table 1 shows diabetes percentage prevalence for Wales and the Welsh health boards from 2008–2009 to 2013–2014. Diabetes prevalence data are from the Quality and Outcomes Framework (QOF), Wales. The data are taken from the GP register and include patients aged 17 and over and does not distinguish between type 1 and type 2 diabetes2. Table 1. Diabetes prevalence

Year QOF figures for diabetes prevalence (%)

ABMU Aneurin Bevan Betsi Cadwaladr

Cardiff and Vale

Cwm Taf

Hywel Dda Powys All

Wales 2008/09 5.1 5.1 4.4 3.8 4.7 4.8 4.6 4.6 2009/10 5.3 5.4 4.6 4.0 4.9 5.1 4.8 4.9 2010/11 5.5 5.6 4.8 4.1 5.1 5.3 5.0 5.1 2011/12 5.6 5.9 5.0 4.3 5.3 5.4 5.3 5.3 2012/13 5.8 6.1 5.2 4.4 5.5 5.6 5.5 5.4 2013/14 6.0 6.2 5.4 4.5 5.7 5.8 5.7 5.6

Figure 1. Number of patients on QOF diabetes register in Wales 2008–2009 to 2013–2014

Table 2 shows a selection of health-related indicators relevant to the diabetes therapeutic area for Wales, England and NE England and for the Welsh health boards. Table 2. Prevalence of health-related indicators (percentage of population)

ABMU Aneurin Bevan BCU Cardiff

& Vale Cwm Taf

Hywel Dda Powys Wales England NE

England

Obesity2 9.9 11.8 10.2 7.9 12.0 10.1 10.8 10.3 7.7 10.2

Hypertension2 15.2 16.2 16.2 12.5 16.8 16.3 17.3 15.5 13.7 15.6

Heart failure2 1.0 0.9 1.0 0.7 0.8 1.0 1.1 0.9 0.7 0.9

Coronary heart disease2 4.0 3.9 4.1 2.9 4.0 4.2 4.1 3.9 3.3 4.5

Adults smoking daily or occasionally11,12

23 24 23 22 27 23 23 24 20 21

% in most deprived 5th13 26.7 24.1 12.7 23.5 35.5 8.1 1.7 20 20.3 32.4

It should be noted that the data in Table 2 are taken from a variety of sources and that data collection methods may vary between England and Wales. Smoking prevalence figures, for example, vary from source to source and year to year depending on how prevalence is measured e.g. Welsh smoking prevalence rates vary from 25% in the

0

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2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

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2010 ONS general lifestyle survey to 20% in the Welsh Government Welsh health survey. Some of the data are taken from surveys, which rely on people being honest about their habits, while QOF data are recorded by the GP. Likewise, the Welsh and English Indices of Multiple Deprivation are calculated slightly differently and this should be taken into account when making comparisons. 4.1 Diabetes prescribing data The data presented in this report include:

• Overall prescribing for Wales • Prescribing trends for health boards, Wales, England and NE England • Comparisons of health boards with CCGs

Most recent data represent the year or quarter to March 2015, and trend data date back to the quarter ending June 2009. The figures were provided by NHS Wales Shared Services Partnership (NWSSP) and were accessed via the Comparative Analysis System for Prescribing Audit (CASPA) database. The figures in the document represent items prescribed and cost, and relate to prescriptions that were dispensed and forwarded for reimbursement. Information on prescriptions that were not dispensed is not available, therefore the term “prescribed” is used here to represent items which were both prescribed and dispensed. 4.1.1 Total diabetes prescribing data Table 3. Prescribing for all medicines included in Drugs used in diabetes (BNF 6.1) in Wales

Items Cost

Total items Change on previous

year

% change on previous

year Total cost (£)

Change on previous

year

% change on previous

year 2010/11 2,666,389.00 181,985 7.33 45,459,650.16 4,768,031 11.72

2011/12 2,826,009.00 159,620 5.99 48,763,885.73 3,304,236 7.27

2012/13 2,955,880.00 129,871 4.60 49,564,275.31 800,390 1.64 2013/14 3,119,112.00 163,232 5.52 52,666,259.72 3,101,984 6.26

2014/15 3,273,664.00 154,552 4.96 57,235,757.82 4,569,498 8.68 Figure 2. Prescribing for the three major sub-sections within Drugs used in diabetes (BNF 6.1) – Total items in Wales

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Insulins Antidiabetic drugs Blood glucose testing

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Figure 3. Prescribing for the three major sub-sections within Drugs used in diabetes (BNF 6.1) – Total cost in Wales

Figure 4. Prescribing for all diabetes medicines – Items per 1,000 PUs in Wales, England

and NE England

Figure 5. Prescribing for all diabetes medicines – Cost per 1,000 PUs in Wales, England and NE England

0

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Figure 6. Prescribing for all diabetic medicines by category – Total items in Wales

Figure 7. Prescribing for all diabetic medicines by category – Total cost in Wales

Figure 8. Average cost per item for different diabetic medicine categories in Wales

0 50,000

100,000 150,000 200,000 250,000 300,000 350,000 400,000

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Human analogue insulins Other insulins Metformin

Sulfonylureas Other antidiabetic drugs Blood glucose testing

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Sulfonylureas Other antidiabetic drugs Blood glucose testing

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Figure 9. Diabetes prescribing cost breakdown April 2014–March 2015

Figure 10. Diabetes prescribing items breakdown April 2014–March 2015

Figure 11. Prescribing for DPP-4 inhibitors – Total items in Wales

£0.00 £2,000.00 £4,000.00 £6,000.00 £8,000.00

£10,000.00 £12,000.00 £14,000.00 £16,000.00

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Vildagliptin Sitagliptin Saxagliptin Linagliptin Alogliptin

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Figure 12. Prescribing for GLP-1s – Total items in Wales

4.2 Insulins This section examines the prescribing of injectable insulin products. Insulin is inactivated by gastro-intestinal enzymes and therefore cannot be orally administered14. The use of human sequence insulins, produced bio-synthetically by recombinant DNA technology and commonly known as human analogue insulins, has replaced some use of more established and less expensive insulins. The BNF describes and categorises these human analogue insulins as:

• Short-acting insulin − Insulin aspart − Insulin glulisine − Insulin lispro

• Intermediate- and long-acting insulin − Insulin degludec − Insulin detemir − Insulin glargine − Biphasic insulin aspart − Biphasic insulin lispro

Figures 13 and 14 show the prescribing of selected non-biphasic intermediate and long acting insulins. AWMSG advice states that insulin degludec is not recommended for use within NHS Wales for the treatment of diabetes mellitus in adults. This advice was ratified by the Minister for Health and Social Services in July 201415. Figure 13. Prescribing of selected non-biphasic intermediate- and long-acting insulins –

Total items in Wales

0

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Liaglutide Exenitide Lixisenatide

0 5000

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Insulin detemir Insulin glargine Isophane insulin Insulin degludec

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Figure 14. Prescribing of selected non-biphasic intermediate- and long-acting insulins – Total cost in Wales

Figure 15. Local Comparator: Items of long-acting insulin analogues as a percentage of

total long- and intermediate-acting insulin (excluding biphasics) in Wales

Figure 16. Prescribing of long-acting insulin analogues as a percentage of total long- and

intermediate-acting insulin (excluding biphasics) – Welsh health boards compared to English CCGs – Quarter ending March 2015

0 200,000 400,000 600,000 800,000

1,000,000 1,200,000 1,400,000 1,600,000 1,800,000

Tota

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t (£)

Insulin detemir Insulin glargine Isophane insulin Insulin degludec

78.00

83.00

88.00

93.00

98.00

Perc

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ABMU Aneurin Bevan BCU Cardiff and Vale

Cwm Taf Hywel Dda Powys

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4.3 Antidiabetic drugs NICE CG87 on blood glucose lowering therapy for type 2 diabetes recommends that metformin should be used first-line and a sulphonylurea second-line unless contra-indicated16. Figures 17 and 18 show prescribing of metformin and sulphonylureas alongside other anti-diabetic drugs, and Figure 19 shows the proportion of metformin and sulphonylurea prescribing that is in line with the CEPP Local Comparator 2015–2016.

Figure 17. Prescribing of antidiabetic medicines – Total items in Wales

Figure 18. Prescribing of antidiabetic medicines – Total cost in Wales

Figure 19. Local Comparator: Sulphonylureas and metformin items as a percentage of all diabetic treatment agents (excluding insulin) June 2012–March 2015

0

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0 500000

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Metformin Sulphonylureas Other antidiabetic drugs

68 70 72 74 76 78 80 82 84 86 88

% o

f ite

ms

Aneurin Bevan Cardiff and Vale Hywel Dda Betsi Cadwaladr

ABMU Powys Cwm Taf

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There has been a 14% increase in the cost of prescribing of ‘other antidiabetic drugs’ such as GLP-1s, DPP-4 inhibitors and thiazolidinediones within NHS Wales in 2014–2015 compared to 2013–2014, with variation between health boards. There may be opportunities for cost savings to be made through prescribing in line with national guidance, such as the first- and second-line use of metformin and sulphonylureas.

Figure 20. Breakdown of ‘Other antidiabetic drugs’* – Items per 1,000 PUs April 2014–March 2015

Figure 21. Breakdown of ‘Other antidiabetic drugs’* – Cost per 1,000 PUs April 2014–March 2015

* ‘Other antidiabetic drugs’ are grouped together as per the BNF and include thiazolidinediones, DPP-4 inhibitors and GLP-1s.

0.00

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4.4 Diagnostic and monitoring devices for diabetes Diagnostic monitoring for diabetes comprises a significant cost in NHS Wales primary care prescribing, accounting for almost £11 million and 452,565 items in 2014–2015. This included glucose blood testing reagents, ketone blood testing reagents and urine testing reagents. The majority of the cost was for glucose blood testing reagents accounting for £10.8 million and 440,118 items. Figure 22. Prescribing of glucose blood testing reagents – Cost per 1,000 PUs weighted

by diabetes prevalence April 2013–March 2015

Figure 23. Prescribing of glucose blood testing reagents – Items per 1,000 PUs weighted

by diabetes prevalence April 2013–March 2015

0

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ABMU Hywel Dda

Aneurin Bevan

Wales Cardiff And Vale

Powys Cwm Taf Betsi Cadwaladr

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5.0 OUTCOMES DATA Outcomes data have been analysed here using healthcare resource groups (HRGs). These are groups of patient-anonymised data, which refer to secondary care procedures and admissions. They comprise standard groupings of clinically similar treatments, which use common levels of healthcare resource17. HRGs help organisations to understand their activity in terms of the types of patients they care for and the treatments they undertake. The data are also linked back to GP practices. They cover a wide range of diabetes outcomes from admissions with a primary diagnosis of diabetes mellitus to lower limb complication admissions and amputation procedures. They enable the comparison of activity within and between different organisations and provide an opportunity to benchmark treatments and services to support trend analysis over time. Table 4. Selected diabetes-related HRG codes HRG code Description KB01C Diabetes with Hypoglycaemic Disorders, with CC Score 8+ KB01D Diabetes with Hypoglycaemic Disorders, with CC Score 5-7 KB01E Diabetes with Hypoglycaemic Disorders, with CC Score 3-4 KB01F Diabetes with Hypoglycaemic Disorders, with CC Score 0-2 KB02G Diabetes with Hyperglycaemic Disorders, with CC Score 8+ KB02H Diabetes with Hyperglycaemic Disorders, with CC Score 5-7 KB02J Diabetes with Hyperglycaemic Disorders, with CC Score 2-4 KB02K Diabetes with Hyperglycaemic Disorders, with CC Score 0-1 KB03C Diabetes with Lower Limb Complications, with CC Score 9+ KB03D Diabetes with Lower Limb Complications, with CC Score 5-8 KB03E Diabetes with Lower Limb Complications, with CC Score 0-4

YQ23A Multiple Amputation Stump or Partial Foot Amputation Procedures, for Diabetes or Arterial Disease, with CC Score 8+

YQ23B Multiple Amputation Stump or Partial Foot Amputation Procedures, for Diabetes or Arterial Disease, with CC Score 0-7

YQ24A Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial Disease, with Other Open Blood Vessel Procedure, with CC Score 8+

YQ24B Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial Disease, with Other Open Blood Vessel Procedure, with CC Score 0-7

YQ25A Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial Disease, with Imaging Intervention, with CC Score 8+

YQ25B Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial Disease, with Imaging Intervention, with CC Score 0-7

YQ26A Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial Disease, with CC Score 8+

YQ26B Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial Disease, with CC Score 5-7

YQ26C Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial Disease, with CC Score 0-4

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Figure 24 shows admissions per 100,000 health board population for the diabetes-related HRGs detailed in Table 4 for April 2013–March 2014. Figure 24. Admissions for diabetes-related HRGs per 100,000 diabetic population 2013–

2014

There are limitations to the outcomes data available through the HRGs. For example, although diabetes may be the underlying reason for the admission to hospital, and the complexity of the condition may affect length of stay, the primary reason for admission may be coded as something different and unrelated. A National Diabetes Inpatient Audit in 201318 reported the percentage of beds occupied by people with diabetes as 15.8%, although only 8.1% of these patients were recorded as having been admitted due to diabetes or a diabetes-related complication. This may indicate that the HRG admission figures which are directly related to diabetes would only cover a small proportion of admissions for which diabetes was a contributing factor. The correlation between admissions directly related to diabetes and prescribing of diabetes medicines, as represented in Figures 25 and 26, is not significant (p>0.05). Further relationships between diabetes-related admissions and prescribing related to diabetes were examined, for example the relationship between admissions due to hypoglycaemic or hyperglycaemic disorders and various prescribing measures, but showed no significant correlations. This highlights that the link between prescribing and admissions may be complex.

0 2 4 6 8

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Figures 25 and 26 show diabetes-related HRGs per 100,000 population against the cost of prescribing in diabetes per 1,000 PUs. The outcomes data and the prescribing data have been adjusted to account for variation in disease prevalence between the health boards. There is variation between the health boards in the relationship between diabetes-related HRGs and the cost of medicines prescribed for diabetes, and this further highlights that the association between prescribing and outcomes is complex.

Figure 25. Diabetes-related HRG admissions per 100,000 population against the cost of prescribing in diabetes 2013–2014

Figure 26. Diabetes-related HRG admissions per 100,000 population against the prescribing of long-acting insulin analogues as a percentage of total long- and

intermediate-acting insulins (excluding biphasics) 2013–2014

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Figure 27. Percentage of patients achieving HbA1c target compared with the cost of diabetes prescribing per 1,000 PUs 2014–2015

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REFERENCES 1 Welsh Government. Together for Health Diabetes Delivery Plan. Annual Report

2014. 2014. Available at: http://gov.wales/docs/dhss/publications/150116reporten.pdf. Accessed Feb 2015.

2 Welsh Government. General medical services contract: Quality and outcomes framework 2012-2013. 2014. Available at: http://gov.wales/statistics-and-research/general-medical-services-contract/?lang=en. Accessed Feb 2015.

3 Gillett M, Royle P, Snaith A et al. Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation: a systematic review and economic evaluation. Health Technology Assessment 2012; 16 (33). Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0048463/pdf/summ1633.pdf. Accessed: Feb 2015.

4 National Institute for Health and Care Excellence. Clinical Guideline 87. Type 2 diabetes: The management of type 2 diabetes (CG87). 2014. Available at: http://www.nice.org.uk/guidance/cg87. Accessed Jul 2015.

5 NHS Wales Shared Services Partnership. Comparative Analysis System for Prescribing Audit. 2015. Accessed Aug 2015.

6 Welsh Government. Together for Health - A Diabetes Delivery Plan. 2013. Available at: http://gov.wales/docs/dhss/publications/130923diabetesen.pdf. Accessed Feb 2015.

7 Welsh Assembly Government. National Service Framework for Diabetes in Wales. 2003. Available at: http://www.wales.nhs.uk/documents/diabetesnsf_eng.pdf. Accessed Feb 2015.

8 Welsh Analytical Prescribing Support Unit. Clinical Effectiveness Prescribing Programme Local Comparators 2015-2016. 2015. Accessed Feb 2015.

9 National Institute for Health and Care Excellence. Technology Appraisal 203. Liraglutide for the treatment of type 2 diabetes mellitus (TA203). 2010. Available at: http://www.nice.org.uk/guidance/ta203. Accessed Feb 2015.

10 National Institute for Health and Care Excellence. Technology Appraisal 248. Exenatide prolonged-release suspension for injection in combination with oral antidiabetic therapy for the treatment of type 2 diabetes (TA248). 2012. Available at: http://www.nice.org.uk/guidance/TA248. Accessed Feb 2015.

11 Welsh Government. Welsh Health Survey 2014: Health-related lifestyle results. 2015. Available at: http://gov.wales/docs/statistics/2015/150603-welsh-health-survey-2014-health-related-lifestyle-en.pdf. Accessed Aug 2015.

12 Office for National Statistics. General Lifestyle Survey Overview. 2012. Available at: http://harridanic.com/w/images/1/16/Glfreport2010_tcm77-259420.pdf. Accessed Aug 2015.

13 Public Health Wales Observatory. GP Cluster Profiles 2013. 2014. Available at: http://www.wales.nhs.uk/sitesplus/922/page/67714. Accessed Feb 2015.

14 BMA, Royal Pharmaceutical Society. British National Formulary. 2015. 15 All Wales Medicines Strategy Group. insulin degludec (Tresiba®). 2015. Available

at: http://www.awmsg.org/awmsgonline/app/appraisalinfo/840. Accessed Jul 2015.

16 National Institute for Health and Care Excellence. Blood glucose lowering therapy for type 2 diabetes. 2015. Available at: http://pathways.nice.org.uk/pathways/diabetes#path=view%3A/pathways/diabetes/blood-glucose-lowering-therapy-for-type-2-diabetes.xml&content=view-index. Accessed Jul 2015.

17 Health and Social Care Information Centre. Introduction to Healthcare Resource Groups. 2015. Available at: http://www.hscic.gov.uk/hrg. Accessed Feb 2015.

18 Health and Social Care Information Centre. National Diabetes Inpatient Audit. 2013. Available at: http://www.hscic.gov.uk/catalogue/PUB13662/nati-diab-inp-audi-13-nat-rep.pdf. Accessed Jul 2015.

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19 Commission on Human Medicines, Medicines and Healthcare Products Regulatory Agency. Current Problems in Pharmacovigilance. 2006. Available at: https://assets.digital.cabinet-office.gov.uk/media/547307e5e5274a1301000030/con2023860.pdf. Accessed Feb 2015.

20 Public Health Wales Observatory. Wales and its Local Health Boards: Demography Profile. 2015. Available at: http://www.wales.nhs.uk/sitesplus/922/page/49931. Accessed Feb 2015.

21 National Public Health Service for Wales. Deprivation and Health. 2004. Available at: http://www2.nphs.wales.nhs.uk:8080/HIATDocs.nsf/public/2EAEBE01733430F8802576EA004BC063/$file/Deprivationreport10Dec04.pdf. Accessed Feb 2015.

22 Office for National Statistics. UK indices of multiple deprivation - a way to make comparisons across constituent countries easier. 2012. Available at: http://www.ons.gov.uk/ons/rel/hsq/health-statistics-quarterly/no--53--spring-2012/uk-indices-of-multiple-deprivation.html. Accessed Feb 2015.

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APPENDIX 1. GP CLUSTER COMPARATORS To make realistic comparisons of prescribing between Wales and England, between the health boards and between the 64 established GP clusters in Wales, consideration of confounding factors is essential. WAPSU has developed cluster comparators based on disease prevalence and socio-economic variables, in order to appropriately benchmark prescribing data and influence prescribing behaviour accordingly.

The intention is to utilise this method of presenting prescribing data for a range of therapeutic areas, such as cardiovascular and mental health. The method could also potentially be applied to CCGs in England in order to make comparisons between Welsh health boards and English CCGs.

In this paper, diabetic product prescribing for GP clusters is analysed and therefore relevant variables for comparators are diabetes prevalence and deprivation. Other variables that could influence variation in diabetes therapeutic area prescribing were also considered, such as cardiovascular disease, obesity, smoking status and ethnicity. However, there could be an element of double counting as many of the variables also closely correlate with each other. Diabetes prevalence and deprivation were chosen to produce GP cluster comparators as this data is readily available at cluster level.

Other considerations – It may be appropriate to view comparators in the context of other differences in practice, especially when making comparisons with areas in England or other nations. These could include local initiatives, dispensing GP practices, procurement costs, prescription charge exemptions and differences between local guidelines and formularies.

1) Disease prevalence Disease prevalence varies across the health boards in Wales and data on prevalence are available at GP cluster level from the GP Cluster Profiles 201313. The source of the data is Audit+ – a non-mandatory analysis tool for GP practices used by more than 95% of GP practices in Wales to submit data weekly. Audit+ provides a count of patients with the identified chronic condition by 10-year age groups and sex. Another possible source of disease prevalence data is the QOF, as chronic conditions are defined in the same way in both. QOF data is used primarily to monitor GP practice performance against a contract; secondary use of QOF data must be interpreted with caution.

2) Deprivation The link between poor health and deprivation is well recognised and people in the most deprived areas have higher levels of mental illness, hearing and sight problems, and in particular chronic conditions such as respiratory disease, cardiovascular disease and arthritis19. In Wales, the majority of deprived areas are found in areas of Cardiff, Swansea and Newport, the Welsh valleys and areas of the North Wales coast20.

While disease prevalence gives a straightforward measure of the proportion of the population with a condition, deprivation can have a more complex effect on prescribing levels through factors such as behavioural determinants, access to services and education21.

2a) Index of Multiple Deprivation Deprivation is multi-dimensional and takes into account many factors, which include income, housing, employment, general health, education, access to services, community safety and physical environment. The four countries of the UK each have their own index of multiple deprivation (IMD), each with slightly different ways of weighting certain factors. However, around half of the weight of each IMD comes from employment and income: factors which are common to all four countries and are major drivers of deprivation. Therefore, it may be appropriate to use the countries’ IMDs for purposes of comparison if the differences in weightings are adjusted for22.

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3) Analysis of diabetes therapeutic area by GP cluster comparators Figures 1a to 3 show prescribing of antidiabetic products for each of the 64 GP clusters in Wales. The GP clusters are grouped by colour with their most similar GP clusters in terms of disease prevalence and deprivation. The data show cost and items per 1,000 PUs for the period of January 2013–December 2014.

Figure 1a. All medicines used in diabetes prescribing – Cost per 1,000 PUs April 2014–March 2015

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Figure 1b. All medicines used in diabetes prescribing. Items per 1,000 PUs. April 2014–March 2015

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Figure 2a. Insulin prescribing. Cost per 1,000 PUs. April 2014–March 2015

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Figure 2b. Insulin prescribing. Items per 1,000 PUs. April 2014–March 2015

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thsh

ire S

outh

S

outh

Pem

brok

eshi

re

Mol

d, B

uckl

ey &

Cae

rgw

rle

Nor

th P

owys

Car

diff

Nor

th

Car

diff

Eas

t

Sou

th C

ynon

C

entra

l Val

e S

outh

Mer

thyr

Tyd

fil

Sou

th R

hond

da

Nor

th R

hond

da

Nor

th M

erth

yr T

ydfil

C

ity H

ealth

1 2 3 4 5 6 7 8

Item

s pe

r 1,0

00 P

Us

All Wales Medicines Strategy Group

Page 28 of 31

Figure 3. Items of long-acting insulin analogues as a percentage of total long- and intermediate-acting insulin (excluding biphasics) April 2014–March 2015

0

20

40

60

80

100

120

Bla

enau

Gw

ent E

ast

Bla

enau

Gw

ent W

est

Cae

rphi

lly N

orth

B

ridge

nd N

orth

Net

wor

k A

fan

Nor

th C

ynon

To

rfaen

Nor

th

Nea

th

Brid

gend

Wes

t Net

wor

k A

mm

an/G

wen

drae

th

Upp

er V

alle

ys

Pen

deri

New

port

Wes

t N

ewpo

rt E

ast

Nor

th D

enbi

ghsh

ire

Llan

elli

Torfa

en S

outh

N

orth

Taf

Ely

C

aerp

hilly

Sou

th

Car

diff

Wes

t C

wm

taw

e C

aerp

hilly

Eas

t A

ngle

sey

Con

wy

Eas

t H

olyw

ell &

Flin

t

City

& C

ardi

ff S

outh

A

rfon

Wes

tern

Val

e C

ardi

ff S

outh

Eas

t C

ardi

ff S

outh

Wes

t N

orth

Cer

edig

ion

Bay

Hea

lth

Mon

mou

thsh

ire N

orth

S

outh

Pow

ys

Sou

th T

af E

ly

Mid

Pow

ys

Brid

gend

Eas

t Net

wor

k W

rexh

am T

own

Dee

side

, Haw

arde

n &

Sal

tney

W

est &

Nor

th W

rexh

am

Sou

th W

rexh

am

Eas

tern

Val

e M

onm

outh

shire

Sou

th

Sou

th C

ered

igio

n N

ewpo

rt C

entra

l N

orth

Pem

brok

eshi

re

Mol

d, B

uckl

ey &

Cae

rgw

rle

Nor

th P

owys

D

wyf

or

Mei

rionn

ydd

Con

wy

Wes

t S

outh

Pem

brok

eshi

re

Cen

tral &

Sou

th D

enbi

ghsh

ire

Taf /

Tei

fi / T

ywi

Llw

chw

r

Car

diff

Eas

t C

ardi

ff N

orth

Nor

th M

erth

yr T

ydfil

S

outh

Mer

thyr

Tyd

fil

Sou

th C

ynon

S

outh

Rho

ndda

N

orth

Rho

ndda

C

entra

l Val

e C

ity H

ealth

Perc

enta

ge

Primary Care Prescribing Analysis – Drugs Used in Diabetes

Page 29 of 31

Figure 4. Items of biguanides and sulphonylureas as a percentage of all antidiabetic medicines as per Local Comparator April 2014–March 2015

0

10

20

30

40

50

60

70

80

90

100

Afa

n B

ridge

nd N

orth

Net

wor

k C

aerp

hilly

Nor

th

Bla

enau

Gw

ent W

est

Bla

enau

Gw

ent E

ast

Llan

elli

Am

man

/Gw

endr

aeth

To

rfaen

Nor

th

Upp

er V

alle

ys

Nea

th

Nor

th D

enbi

ghsh

ire

Brid

gend

Wes

t Net

wor

k P

ende

ri N

ewpo

rt W

est

Nor

th C

ynon

N

ewpo

rt E

ast

Torfa

en S

outh

C

wm

taw

e C

aerp

hilly

Sou

th

Cae

rphi

lly E

ast

Ang

lese

y C

ardi

ff W

est

Hol

ywel

l & F

lint

Nor

th T

af E

ly

Con

wy

Eas

t

City

& C

ardi

ff S

outh

A

rfon

Nor

th C

ered

igio

n C

ardi

ff S

outh

Wes

t C

ardi

ff S

outh

Eas

t W

este

rn V

ale

Bay

Hea

lth

Sou

th P

embr

okes

hire

Ll

wch

wr

Brid

gend

Eas

t Net

wor

k S

outh

Cer

edig

ion

Taf /

Tei

fi / T

ywi

Eas

tern

Val

e M

onm

outh

shire

Sou

th

Nor

th P

embr

okes

hire

N

ewpo

rt C

entra

l N

orth

Pow

ys

Mol

d, B

uckl

ey &

Cae

rgw

rle

Sou

th W

rexh

am

Wes

t & N

orth

Wre

xham

S

outh

Pow

ys

Cen

tral &

Sou

th D

enbi

ghsh

ire

Dee

side

, Haw

arde

n &

Sal

tney

W

rexh

am T

own

Mon

mou

thsh

ire N

orth

M

id P

owys

C

onw

y W

est

Sou

th T

af E

ly

Mei

rionn

ydd

Dw

yfor

Car

diff

Eas

t C

ardi

ff N

orth

Cen

tral V

ale

City

Hea

lth

Sou

th C

ynon

N

orth

Rho

ndda

S

outh

Rho

ndda

S

outh

Mer

thyr

Tyd

fil

Nor

th M

erth

yr T

ydfil

1 2 3 4 5 6 7 8

Perc

enta

ge

All Wales Medicines Strategy Group

Page 30 of 31

Figure 5. Screening and monitoring agents. Cost per 1,000 PUs. April 2014–March 2015

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Bla

enau

Gw

ent E

ast

Bla

enau

Gw

ent W

est

Afa

n C

aerp

hilly

Nor

th

Brid

gend

Nor

th N

etw

ork

New

port

Wes

t N

ewpo

rt E

ast

Pen

deri

Brid

gend

Wes

t Net

wor

k U

pper

Val

leys

To

rfaen

Nor

th

Nea

th

Am

man

/Gw

endr

aeth

Ll

anel

li N

orth

Cyn

on

Nor

th D

enbi

ghsh

ire

Cae

rphi

lly E

ast

Car

diff

Wes

t C

aerp

hilly

Sou

th

Cw

mta

we

Nor

th T

af E

ly

Torfa

en S

outh

H

olyw

ell &

Flin

t A

ngle

sey

Con

wy

Eas

t

City

& C

ardi

ff S

outh

A

rfon

Bay

Hea

lth

Car

diff

Sou

th E

ast

Wes

tern

Val

e N

orth

Cer

edig

ion

Car

diff

Sou

th W

est

New

port

Cen

tral

Mon

mou

thsh

ire S

outh

M

onm

outh

shire

Nor

th

Sou

th P

owys

E

aste

rn V

ale

Llw

chw

r W

est &

Nor

th W

rexh

am

Sou

th W

rexh

am

Sou

th T

af E

ly

Con

wy

Wes

t Ta

f / T

eifi

/ Tyw

i S

outh

Cer

edig

ion

Wre

xham

Tow

n M

id P

owys

N

orth

Pem

brok

eshi

re

Brid

gend

Eas

t Net

wor

k S

outh

Pem

brok

eshi

re

Mei

rionn

ydd

Nor

th P

owys

D

wyf

or

Cen

tral &

Sou

th D

enbi

ghsh

ire

Mol

d, B

uckl

ey &

Cae

rgw

rle

Dee

side

, Haw

arde

n &

Sal

tney

Car

diff

Nor

th

Car

diff

Eas

t

City

Hea

lth

Sou

th C

ynon

N

orth

Rho

ndda

S

outh

Rho

ndda

S

outh

Mer

thyr

Tyd

fil

Cen

tral V

ale

Nor

th M

erth

yr T

ydfil

1 2 3 4 5 6 7 8

Cos

t per

1,0

00 P

Us

Primary Care Prescribing Analysis – Drugs Used in Diabetes

Page 31 of 31

Figure 6. Screening and monitoring agents. Items per 1,000 PUs. April 2014–March 2015

0

20

40

60

80

100

120

140

160

Afa

n B

laen

au G

wen

t Eas

t B

laen

au G

wen

t Wes

t C

aerp

hilly

Nor

th

Brid

gend

Nor

th N

etw

ork

Upp

er V

alle

ys

Brid

gend

Wes

t Net

wor

k N

eath

N

ewpo

rt W

est

Llan

elli

Pen

deri

New

port

Eas

t N

orth

Cyn

on

Am

man

/Gw

endr

aeth

N

orth

Den

bigh

shire

To

rfaen

Nor

th

Car

diff

Wes

t C

aerp

hilly

Eas

t C

wm

taw

e A

ngle

sey

Nor

th T

af E

ly

Cae

rphi

lly S

outh

C

onw

y E

ast

Torfa

en S

outh

H

olyw

ell &

Flin

t

Arfo

n C

ity &

Car

diff

Sou

th

Bay

Hea

lth

Nor

th C

ered

igio

n C

ardi

ff S

outh

Eas

t W

este

rn V

ale

Car

diff

Sou

th W

est

Wes

t & N

orth

Wre

xham

E

aste

rn V

ale

New

port

Cen

tral

Wre

xham

Tow

n M

onm

outh

shire

Sou

th

Mon

mou

thsh

ire N

orth

S

outh

Wre

xham

N

orth

Pem

brok

eshi

re

Con

wy

Wes

t Ll

wch

wr

Sou

th P

owys

M

old,

Buc

kley

& C

aerg

wrle

S

outh

Cer

edig

ion

Dw

yfor

M

id P

owys

Ta

f / T

eifi

/ Tyw

i M

eirio

nnyd

d B

ridge

nd E

ast N

etw

ork

Sou

th P

embr

okes

hire

S

outh

Taf

Ely

N

orth

Pow

ys

Cen

tral &

Sou

th D

enbi

ghsh

ire

Dee

side

, Haw

arde

n &

Sal

tney

Car

diff

Nor

th

Car

diff

Eas

t

Sou

th C

ynon

C

ity H

ealth

C

entra

l Val

e N

orth

Rho

ndda

S

outh

Rho

ndda

N

orth

Mer

thyr

Tyd

fil

Sou

th M

erth

yr T

ydfil

1 2 3 4 5 6 7 8

Item

s pe

r 1,0

00 P

Us