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
[email protected] 029 2071 6900
This document should be cited as: All Wales Medicines Strategy Group. Primary Care Prescribing Analysis – Medicines Used in Diabetes. September 2015.
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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
50,000
100,000
150,000
200,000
2008-09 2009-10 2010-11 2011-12 2012-13 2013-14
Num
ber o
f pat
ient
s
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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
0
100000
200000
300000
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500000
600000
700000
800000
900000
Tota
l ite
ms
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
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
Tota
l cos
t (£)
Insulins Antidiabetic drugs Blood glucose testing
0 20 40 60 80
100 120 140 160 180 200
Item
s pe
r 1,0
00 P
Us
Wales England NE England
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Wales England NE England
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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
Tota
l ite
ms
Human analogue insulins Other insulins Metformin
Sulfonylureas Other antidiabetic drugs Blood glucose testing
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
Tota
l cos
t
Human analogue insulins Other insulins Metformin
Sulfonylureas Other antidiabetic drugs Blood glucose testing
0.00
10.00
20.00
30.00
40.00
50.00
60.00
Aver
age
cost
per
item
(£)
Human analogue insulins Other insulins Metformin
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
Cos
t per
1,0
00 P
Us
(£)
Insulins Antidiabetic drugs Blood glucose testing
0 100 200 300 400 500 600 700 800 900
Item
s pe
r 1,0
00 P
Us
Insulins Antidiabetic drugs Blood glucose testing
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
Item
s
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
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Item
s
Liaglutide Exenitide Lixisenatide
0 5000
10000 15000 20000 25000 30000 35000
Tota
l ite
ms
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
l cos
t (£)
Insulin detemir Insulin glargine Isophane insulin Insulin degludec
78.00
83.00
88.00
93.00
98.00
Perc
enat
ge
ABMU Aneurin Bevan BCU Cardiff and Vale
Cwm Taf Hywel Dda Powys
Pow
ys
Hyw
el D
da
Bet
si C
adw
alad
r
Car
diff
and
Val
e
Ane
urin
Bev
an
AB
MU
Cw
m T
af
0
10
20
30
40
50
60
70
80
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100
Perc
enta
ge
CCG / HB
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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
50000
100000
150000
200000
250000
300000
350000
400000
Tota
l ite
ms
Metformin Sulphonylureas Other antidiabetic drugs
0 500000
1000000 1500000 2000000 2500000 3000000 3500000 4000000 4500000 5000000
Tota
l cos
t (£)
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
20.00
40.00
60.00
80.00
100.00
120.00
Item
s pe
r 1,0
00 P
Us
DPP-4 inhibitors GLP-1s Thiazolidinediones
0 500
1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500
Cos
t per
1,0
00 P
Us
(£)
DPP-4 inhibitors GLP-1s Thiazolidinediones
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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
100
200
300
400
500
600
Aneurin Bevan
ABMU Wales Powys Hywel Dda Cwm Taf Cardiff And Vale
Betsi Cadwaladr
Cos
t per
1,0
00 P
Us/
diab
etes
pr
eval
ence
(£)
15.50
16.00
16.50
17.00
17.50
18.00
18.50
19.00
ABMU Hywel Dda
Aneurin Bevan
Wales Cardiff And Vale
Powys Cwm Taf Betsi Cadwaladr
Item
s pe
r 1,0
00 P
Us/
diab
etes
pr
eval
ence
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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
10 12 14 16 18 20
ABMU Aneurin Bevan
Betsi Cadwaladr
Cardiff and Vale
Cwm Taf Hywel Dda Powys
Adm
issi
ons
per 1
00,0
00 d
iabe
tic
popu
latio
n
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Page 19 of 31
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
0
500
1000
1500
2000
2500
3000
0
2
4
6
8
10
12
14
16
18
20
ABMU Aneurin Bevan
Betsi Cadwaladr
Cardiff and Vale
Cwm Taf Hywel Dda Powys
Cos
t of d
iabe
tes
pres
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ing
per 1
,000
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s
Dia
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s re
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d H
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r 100
,000
po
pula
tion
Admissions per 100,000 diabetic population Cost per 1,000 PUs
0
5
10
15
20
25
0 2 4 6 8
10 12 14 16 18 20
ABMU Aneurin Bevan
Betsi Cadwaladr
Cardiff and Vale
Cwm Taf Hywel Dda Powys
% lo
ng-a
ctin
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ue in
sulin
pr
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Dia
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RG
adm
issi
ons
per
100,
000
diab
etic
pop
ulat
ion
Admissions per 100,000 diabetic population % Long-acting analogue insulin prescribing
All Wales Medicines Strategy Group
Page 20 of 31
Figure 27. Percentage of patients achieving HbA1c target compared with the cost of diabetes prescribing per 1,000 PUs 2014–2015
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
60
65
70
75
80
85
90
95
Con
wy
Wes
t A
rfon
Car
diff
Nor
th
Dw
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W
est &
Nor
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am
Mei
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Wes
t M
onm
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shire
Nor
th
Mid
Pow
ys
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Tow
n S
outh
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S
outh
Pow
ys
Cen
tral &
Sou
th D
enbi
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th T
af E
ly
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tern
Val
e M
old,
Buc
kley
& C
aerg
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orth
Cer
edig
ion
New
port
Cen
tral
Eas
tern
Val
e D
eesi
de, H
awar
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altn
ey
Llw
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r C
ardi
ff S
outh
Eas
t A
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sey
Nor
th P
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okes
hire
N
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rt E
ast
Taf /
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Nor
th P
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N
orth
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S
outh
Cer
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Mon
mou
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ire S
outh
U
pper
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S
outh
Mer
thyr
Tyd
fil
New
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t B
ridge
nd W
est N
etw
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Nor
th M
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A
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Nea
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Con
wy
Eas
t C
ityH
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C
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Eas
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laen
au G
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ri H
olyw
ell &
Flin
t N
orth
Cyn
on
Sou
th R
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Cw
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we
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lly S
outh
B
ridge
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ast N
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Am
man
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outh
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brok
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re
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ity &
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th
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est
Nor
th R
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ire
Torfa
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orth
To
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Eas
t C
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Nor
th
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tral V
ale
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t per
1,0
00 P
Us
of d
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ing
Perc
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ing
HbA
1c ta
rget
<59 mmol/mol <64 mmol/mol <75 mmol/mol 2014/15 data Cost per 1,000 PUs
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Page 21 of 31
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.
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Page 23 of 31
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.
All Wales Medicines Strategy Group
Page 24 of 31
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
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000 A
fan
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
New
port
Eas
t U
pper
Val
leys
N
ewpo
rt W
est
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Wes
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k N
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P
ende
ri N
orth
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on
Am
man
/Gw
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orth
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bigh
shire
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th
Car
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sey
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ly
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th
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outh
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n C
ity &
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th
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tern
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e N
orth
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th E
ast
Car
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th W
est
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wy
Wes
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Wes
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orth
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onm
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shire
Nor
th
Mid
Pow
ys
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xham
Tow
n S
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S
outh
Pow
ys
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tral &
Sou
th D
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ire
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Cae
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tral
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ey
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chw
r N
orth
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brok
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re
Taf /
Tei
fi / T
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S
outh
Cer
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ion
Mon
mou
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ire S
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B
ridge
nd E
ast N
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ork
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th P
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hire
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diff
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th
Car
diff
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t
Sou
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erth
yr T
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N
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City
Hea
lth
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th C
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ndda
C
entra
l Val
e
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 25 of 31
Figure 1b. All medicines used in diabetes prescribing. Items per 1,000 PUs. April 2014–March 2015
0
200
400
600
800
1,000
1,200
Afa
n B
laen
au G
wen
t Eas
t B
ridge
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orth
Net
wor
k B
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est
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ast
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ast
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aste
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ale
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Sal
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ast N
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Tei
fi / T
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th P
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hire
C
entra
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diff
Nor
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Car
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Eas
t
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tral V
ale
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th R
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ity H
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1 2 3 4 5 6 7 8
Item
s pe
r 1,0
00 P
Us
All Wales Medicines Strategy Group
Page 26 of 31
Figure 2a. Insulin prescribing. Cost per 1,000 PUs. April 2014–March 2015
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
Cae
rphi
lly N
orth
B
ridge
nd N
orth
Net
wor
k A
fan
Bla
enau
Gw
ent W
est
Bla
enau
Gw
ent E
ast
Torfa
en N
orth
U
pper
Val
leys
N
ewpo
rt E
ast
New
port
Wes
t A
mm
an/G
wen
drae
th
Llan
elli
Nor
th D
enbi
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ire
Brid
gend
Wes
t Net
wor
k P
ende
ri N
orth
Cyn
on
Nea
th
Nor
th T
af E
ly
Cae
rphi
lly S
outh
C
aerp
hilly
Eas
t C
wm
taw
e H
olyw
ell &
Flin
t To
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Sou
th
Con
wy
Eas
t A
ngle
sey
Car
diff
Wes
t
City
& C
ardi
ff S
outh
A
rfon
Wes
tern
Val
e N
orth
Cer
edig
ion
Bay
Hea
lth
Car
diff
Sou
th W
est
Car
diff
Sou
th E
ast
Mid
Pow
ys
Wes
t & N
orth
Wre
xham
E
aste
rn V
ale
Con
wy
Wes
t C
entra
l & S
outh
Den
bigh
shire
B
ridge
nd E
ast N
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ork
New
port
Cen
tral
Dee
side
, Haw
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Sal
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D
wyf
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th P
owys
N
orth
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brok
eshi
re
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r Ta
f / T
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i S
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xham
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d S
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outh
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ion
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mou
thsh
ire S
outh
S
outh
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brok
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re
Mon
mou
thsh
ire N
orth
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ity H
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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 27 of 31
Figure 2b. Insulin prescribing. Items per 1,000 PUs. April 2014–March 2015
0
20
40
60
80
100
120
140
160
Cae
rphi
lly N
orth
B
ridge
nd N
orth
Net
wor
k A
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enau
Gw
ent W
est
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ast
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orth
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pper
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leys
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ast
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shire
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on
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th
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ay H
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ale
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Mon
mou
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
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