What can prescribing data tell us about FLS? 

Findings from a new analysis’

3 March 2017

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Source dataPrescribing data for all CCGs in England is freely available in easily downloadable files:

https://openprescribing.net/

CCG registered population data is available from:

http://content.digital.nhs.uk/catalogue/

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This analysis (1)Looked at a range of data for 44 months, from Apr 2013 to Nov 2016. Available data include:•All major medicines prescribed for osteoporosis•Cost•Number of items•Quantity per item•Month of prescription•CCG

Note: the data are for medicines prescribed in primary care only

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This analysis (2)Using these data we were able to estimate the number of patients on treatment for each month.Population data were added to create rates of patients on treatments for the population aged 50 and over for each CCG. This is the denominator in every chart in this presentationThis analysis has yielded a number of findings

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‘Chemicals’ includedAlendronic Acid Denosumab Ibandronic Acid Risedronate Alendronic Acid plus Colecalciferol Zolendronic Acid Other Bisphosphonate

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Treatments have changed little

Table shows % of patients on treatment by chemical

Chemical 2013 2014 2015 2016Alendronic Acid 88.2% 88.2% 88.2% 88.0%Denosumab 0.1% 0.2% 0.4% 0.5%Ibandronic Acid 2.7% 2.5% 2.4% 2.3%Risedronate 8.7% 8.8% 8.8% 9.0%Alendronic Acid plus Colecalciferol 0.22% 0.20% 0.17% 0.14%Zolendronic Acid 0.002% 0.002% 0.002% 0.002%Other Bisphosphonate 0.01% 0.01% 0.01% 0.01%Grand Total 100% 100% 100% 100%

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Denosumab has made inroads in primary care prescribing/administration

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Cost per patient year of treatment has changed little

Table shows average cost per patient year of treatment

Chemical 2013 2014 2015 2016Alendronic Acid £13.80 £14.64 £15.15 £12.84Denosumab £187.24 £196.21 £194.91 £192.65Ibandronic Acid £149.90 £75.39 £55.14 £43.49Risedronate £29.38 £27.31 £26.88 £23.80Alendronic Acid plus Colecalciferol £326.97 £321.53 £316.16 £319.20Zolendronic Acid £189.31 £192.51 £190.81 £170.95Other Bisphosphonate £366.20 £337.59 £307.96 £339.42Grand Total £22.33 £23.19 £25.83 £25.84

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National trend

Notes

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National trend including confidence intervals

Notes

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44 months of decline in rate of PoTThis is equivalent to a decline of around 11.2%. Possible reasons:

Being stopped after 3/5years due to the concerns of the longer term complications (atypical fractures including in the ear and osteonecrosis of the jaw)• NICE’s recommendation of discussing stopping after 3 years and NOGGs recommendation

slightly different, as NOGG suggest that patients who go on this ‘drug holiday’ should be reviewed for fracture risk after 2 years if no fracture in that time (fracture before 2 years = automatic review) – this is something that is not represented in the NICE pathway for secondary prevention of Osteoporosis.

• GP’s only have to keep a list of patients who ARE on bisphosphonates. How are GP surgeries keeping track of all the people they might be stopping for a drug holiday to review in 2 years? Are people stopped and just not been reviewed again?

Poor adherence to treatment due to:• Patients perceive that the longer term complications of treatment carry a greater risk that

the complications of another fracture if they didn’t take the bisphosphonates (MHRA warning etc)

• Administration issues – patients cease to take medication or GPs stopping it as per the MHRA recommendation that states ‘alendronate, oral ibandronate and risedronate should be used with caution in patients with active or recent upper gastrointestinal problems’.

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Bucking the trend – some examples

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Portsmouth

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Oxford

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CCG – north of England

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Decommissioning?

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Will FLS make a difference?

All data from FLS Benefits Calculator and FLS Pathway and Costing Tool

Typical CCG population 300,000

Number of people 50 and over 106,456

FLS cases 1,212

Numbers onto treatment (year) 781

Numbers on treatment at 12 months follow up 625

FLS additional numbers on treatment (year) 312.5

FLS additional numbers on treatment (month) 26.0

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Will FLS make a difference?

Hypothetical example of a FLS covering 300,000 population typical for England

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When does the difference show?

Hypothetical example of a FLS covering 300,000 population typical for England

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Summary (1)Prescribing data are readily available thanks to https://openprescribing.net/. These are refreshed monthlyPopulation data are readily available and allow us to create rates of patients on treatment for the target populationThe Charity has this data for every CCG in England

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Summary (2)There is a long term and steady decline in rates of patients on treatmentThere are distinctive patterns for CCGs with FLS services in many casesCrude models suggest that rate of patients on treatment per 1000 population 50 and over is useful measure of effectiveness at a service level

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CautionData is for prescribing in primary care only and does not tell the whole storyThere are large underlying variations in ‘historical’ rates for which we have no explanationEffective services depend on effective primary care