Download 5. The Impact of Prescribing Combined with Improved Case Finding

‘DEEP DIVE’ on HYPERTENSION FOR THE
ARTERIAL LOCALITY
A Joint Strategic Needs Assessment (JSNA) Product
August 2012
Essex County Council Public Health Team
Report Author:
Ian Wake,
Consultant in Public Health for Basildon and Brentwood CCG
Project Team:
Ian Wake, Consultant in Public Health
Emma Sanford, Epidemiologist
Tom Fowler, Senior Public Health Information Analyst
Niall McDougall, Public Health Manager
1
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
Contents
1.
INTRODUCTION ................................................................................................................................................... 3
2.
BACKGROUND ..................................................................................................................................................... 3
3.
CASE FINDING AND CLINICAL MANAGEMENT OF HYPERTENSION ..................................................................... 4
4.
NATIONAL INSTITUTE OF CLINICAL EXCELLENCE (NICE) GUIDELINES ON HYPERTENSION PRESCRIBING ........... 8
5.
THE IMPACT ON SECONDARY CARE COSTS OF PRESCRIBING COMBINED WITH IMPROVED CASE FINDING OF
HYPERTENSIVE PATIENTS................................................................................................................................... 11
6.
DISCUSSION, CONCLUSIONS and RECOMMENDATIONS ................................................................................... 14
2
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
‘DEEP DIVE’ REPORT FOR HYPERTENSION WITHIN THE ARTERIAL LOCALITY
1. INTRODUCTION
This report details a ‘deep dive’ exercise undertaken by the Essex County Council Public Health Team on behalf
on the Basildon and Brentwood Clinical Commissioning Group (CCG) on the issue of Hypertension within the
Arterial Locality. The report examines case finding, clinical management and emergency admission rates of
Hypertension at locality and practice level. It also considers potential prescribing and secondary care events
savings that could be made by the Arterial locality and its practices if the latest National Institute of Clinical
Excellence (NICE) guidance (CG127) were followed by all practices, and case finding were increased to different
levels. A more comprehensive report detailing the Deep Dive across all CCG localities can be accessed at
www.essexinsight.org.uk. The report is under the ‘Themes’ and the ‘Health and Wellbeing’ sections.
2. BACKGROUND
The JSNA CCG profiles for Basildon and Brentwood identified five key clinical priority areas for the CCG in terms
of commissioning and QIPP; Circulatory Disease, Respiratory Disease, Diabetes, Lung Cancer and Lifestyles. At
£180 per head of weighted population, Circulatory Disease is the programme that has the highest spend per
head in NHS South West Essex (data not currently available at a level lower than PCT level), and spend is also
significantly greater than the PCT’s Office for National Statistics (ONS) cluster, making it a key QIPP priority.
(Figure 2.1).
Figure 2.1 Programme budgeting spend on problems of circulation
All PCT s expenditure per 100,000 population
Programme category
ONS Cluster level
Primary Care Trust
Population w eighting
Care Setting
Benchmark
1st quintile
2nd quintile
3rd quintile
4th quintile
5th quintile
South West Essex Teac hing PCT
PCTs within se lec ted cluste r level
National average
10.0
5.0
West Essex PCT
Sw indon PCT
Havering PCT
Peterborough PCT
Bexley PCT
15.0
Medw ay Teaching PCT
20.0
Milton Keynes PCT
Expenditure (£million per 100,000 population)
25.0
South West Essex Teaching PCT
Note on interpretation: PCTs with large amounts of expenditure in category 23x for a given care setting may have less expenditure allocated to disease
specific categories within that care setting. To aid comparison of expenditure on disease specific categories and within care settings the ‘All commissioner
chart with 23x’ sheet shows the same information as the chart below with additional information on the amount of expenditure in 23x for the chosen care
setting on the negative y axis.
Notes on intepretation of data:
budgeting returns to the Department of Health f or 2010/2011.
services purchased f rom healthcare providers. PCTs f ollow st
procedures and mappings w hen calculating programme budge
or services can be classif ied directly to a programme budgetin
setting. When it is not possible to reasonably estimate a progr
category, expenditure is classif ied as ‘Other: Miscellaneous’. T
expenditure to programme budgeting subcategories is not alw
and subcategory level data should theref ore be used w ith cau
be reasonably estimated at disease specif ic level, and is sepa
subcategory of ‘Other’ expenditure.
attendances a national split has been applied to PCT total A&
apportion it across programme budgeting categories.
f irst time in 2010/11. For this reason, programme budgeting da
care settings should be interpreted w ith caution.
to make direct comparisons w ith programme budgeting data f r
0.0
National Rank Lowest to Highest
If the PCT (or the two CCGs within it) were to reduce spend on the Circulatory Disease programme so that it were
in line with the ONS Cluster Average a potential QIPP saving of £11,847,304 would be released that could be reinvested into other areas of patient care.
3
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
The Circulatory System Programme Budgeting category covers all areas of Cardio-Vascular Disease (CVD),
including hypertension and is closely linked to the programme covering Endocrine, nutritional and metabolic
diseases (in relation to diabetes and blood lipids as risk factors). However, a separate ‘deep dive’ has been
agreed for Diabetes, and this condition is not therefore covered in this report.
3. Case Finding and Clinical Management of Hypertension
The clinical management of hypertension is one of the most common interventions in primary care, accounting
for approximately £1 billion in drug costs alone in 2006.
Although the earlier identification of patients at risk of Hypertension will further contribute to the rising
circulatory diseases prevalence, early clinical intervention and good clinical management of patients with
hypertension will reduce the incidence of more serious circulatory disease and overall healthcare costs
associated with it. Figure3.1 identified inadequate case finding of patients with Hypertension as all but one
practice fall below the 3SD line. Case finding ranges between 44.8% and 110.5% of expected numbers of
hypertensives.
Figure 3.1. Observed vs. Expected funnel plots for hypertension for all practices in the Arterial Locality
Figures 3.2 and 3.3 show funnel plots for the two
QOF clinical management indicators for
hypertension at BBCCG practice level; BP4 – The
Percentage of Patients with Hypertension for whom
there is a record of blood pressure within the
preceding 9 months and BP5 – The Percentage of
Patients with Hypertension in whom the last blood
pressure reading (measured in the preceding nine
months) was 150/90 or less.
Figure 3.2 Funnel Plot of QOF indicator BP4
The solid horizontal line in both figure 3.2 and 3.3
funnel plots represents the performance of the
poorest performing PCT in the top quintile of
performers in England. Whilst it could be argued
that performance at this level is a challenging target
for the CCG, achieving the aspiration of being in the
top quintile of performance in the county across all
areas of clinical practice will impact positively on
secondary care costs and patient care quality.
Six of the Arterial Locality practices fall within the
2SD funnels for the QOF indicator BP4 (figure 3.3)
suggesting that the aspiration to perform within
England’s top quintile is achievable and that almost
half of all of the locality’s practices are reaching this
excellent level of performance. The remaining seven
fall below the 3SD funnel line suggesting
considerable scope for improving blood pressure
monitoring for patients on the hypertension register
across the locality
4
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
Figure 3.3 Funnel Plot of QOF indicator BP5
For QOF indicator BP5, performance across the
locality is largely excellent. Seven practices fall above
lower 2SD line suggesting that their performance on
this indicator falls within the top quintile of practices
in England. A further three fall above the 2SD line,
suggesting performance is significantly better than
the poorest performer in the top quintile in England.
However five practices fall below the 2SD line
suggesting scope for improvement.
Figure 3.4 Funnel Plot of non elective admissions rate
Figure 3.4 shows a funnel plot of non-elective
admissions per 100 on the hypertension register for
each CCG practice. The mean emergency admission
rate per 100 hypertensive patients for the BBCCG
has been used in figure 3.4. This mean is less than
that for England and the East of England and so
represents a good clinical quality marker. All
practices fall below the upper 2SD funnel showing
that no practice within the locality has an emergency
admission rate due to hypertension that is
significantly greater than the CCG mean or that for
either England or the East of England. This is clearly
very positive. It is however worth noting that the
funnels themselves are wide, due to the relatively
small number of emergency admissions per practice,
which generate large statistical confidence intervals.
It is also worth remembering that inadequate case
finding and/or clinical management of hypertension
is likely to drive emergency admissions of other
circulatory diseases.
Table 1 summarises the results of this section by practice and makes recommendations for action at practice
level.
5
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
Table 1: Summary of Results on Case Finding and Clinical Management of Patients with Hypertension by Practice
F code
F81104
Practice
Dr. R. Rasheed
Obs /
Expected
0.64
Low(0.001)
BP4
Conclusion
74.59
Low
(0.001)
95.61
In top
performing
quintile in
England
1.24
No sig. diff.
to CCG
mean
79.08
Low
(0.001)
1.86
No sig. diff.
to CCG
mean
1
Ineffective
Case Finding
81.67
Low
(0.025)
1.87
No sig. diff.
to CCG
mean
1
Ineffective
Case Finding
1.64
No sig. diff.
to CCG
mean
3
Low Underlying
Risk
2.02
No sig. diff.
to CCG
mean
1
Ineffective
Case Finding
3.54
No sig. diff.
to CCG
mean
1
Ineffective
Case Finding
F81080
Dr. H.J.Cockcroft
and Partners
0.56
Low(0.001)
91.73
Low
(0.001)
94.05
In top
performing
quintile in
England
88.94
Low
(0.001)
74.68
Low
(0.001)
F81045
Dr. C.P. Gupta
0.45
Low(0.001)
86.36
Low
(0.001)
Low Underlying
Risk
87.86
In top
performing
quintile in
England
91.36
Low(0.001)
3
1.36
Low(0.001)
0.64
1.Improve Case Finding
2.Improve monitoring of patients with
Hypertension
3. Query Clinical Management
67.18
0.54
F81222
3
Low Underlying
Risk
No sig. diff.
to CCG
mean
F81013
Dr. R Dasgupta
Conclusions / Recommendations
Low
(0.001)
Low
(0.001)
Low(0.001)
Hypertension
Quadrant on Boston
Chart and meaning
BP5
Conclusion
Dr. A. Afifi and
Partners
0.82
Non
elective
admissions
per 100 on
disease
register
conclusion
BP5
Dr. J.O. Araymoi
F81651
Low(0.001)
BP4
Y00758
Dr. Sarfraz M U H
& Partner
0.70
Obs /
Expected
Conclusion
Nonelective
admissions
per 100 on
disease
register
85.95
82.37
In top
performing
quintile in
England
In top
performing
quintile in
England
F81150
Dr. A.J. Mitchell
& Partner
0.54
Low(0.001)
91.44
Low
(0.001)
80.43
Low
(0.001)
2.51
No sig. diff.
to CCG
mean
1
Ineffective
Case Finding
F81151
Dipple Medical
Centre
0.76
Low(0.001)
81.15
Low
(0.001)
65.14
Low
(0.001)
1.76
No sig. diff.
to CCG
mean
3
Low Underlying
Risk
95.31
In top
performing
quintile in
England
88.52
High
(0.001)
1.85
No sig. diff.
to CCG
mean
4
Effective Case
Finding, Well
Managed
Y00469
Dr. M. Sims
6
1.11
High(0.001)
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
1.Improve Case Finding
1.Improve Case Finding
2.Improve monitoring of patients with
Hypertension
3. Query Clinical Management
1.Improve Case Finding
2.Improve monitoring of patients with
Hypertension
3. Query Clinical Management
1.Improve Case Finding
1.Improve Case Finding
2.Improve monitoring of patients with
Hypertension
1.Improve Case Finding
2.Improve monitoring of patients with
Hypertension
3. Query Clinical Management
1.Improve Case Finding
2.Improve monitoring of patients with
Hypertension
3. Query Clinical Management
1.Improve Case Finding
2.Improve monitoring of patients with
Hypertension
3. Query Clinical Management
No action needed
F code
F81158
F81648
F81711
Practice
Dr. T.F. Nasah
Dr. H.U. Din
Dr. A.J.L. Holman
7
Obs /
Expected
Obs /
Expected
Conclusion
BP4
0.48
Low(0.001)
95.69
0.78
Low(0.001)
94.14
0.66
Low(0.001)
94.75
BP4
Conclusion
In top
performing
quintile in
England
In top
performing
quintile in
England
In top
performing
quintile in
England
Non
elective
admissions
per 100 on
disease
register
conclusion
Hypertension
Quadrant on Boston
Chart and meaning
BP5
BP5
Conclusion
Nonelective
admissions
per 100 on
disease
register
90.30
High
(0.001)
3.20
No sig. diff.
to CCG
mean
1
Ineffective
Case Finding
92.33
High
(0.001)
2.66
No sig. diff.
to CCG
mean
1
Ineffective
Case Finding
In top
performing
quintile in
England
3.49
No sig. diff.
to CCG
mean
1
83.18
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
Ineffective
Case Finding
Conclusions / Recommendations
1.Improve Case Finding
1.Improve Case Finding
1.Improve Case Finding
4. National Institute of Health and Clinical Excellence (NICE) Guidelines on
Hypertension Prescribing
NICE Guidance of Hypertension (CG127) sets out an antihypertensive drug treatment schedule based on
the latest evidence of best of practice (figure 3.5)
http://guidance.nice.org.uk/CG127/NICEGuidance/doc
Figure 3.5 Summary of antihypertensive drug treatment schedule
Aged over 55 years or
black person of African or
Caribbean family origin of
any age
Aged under
55 years
First Line
41% of
cohort
Key
A or B
70% or 30%
C
A – ACE inhibitor
Rampril £20.98
Second Line
41% of
cohort
B- Angiotensin II receptor
blocker (ARB)12
(A or B) + C
Losartan (generic) £15.00
Candesartan £165 (off patent
next 6 months)
Third Line
18% of
cohort
(Aor B) + C + D
C – Calcium-channel blocker
(CCB)13
Amlodipine £13.00
D – Thiazide-like diuretic
Resistant hypertension
A + C + D + consider further diuretic
beta-blocker16
14, 15
Consider seeking expert advice
or alpha- or
Indapamide 1.5mg modified
release £44.50
Indapamide 2.5mg £13.80
12 Choose
a low-cost ARB.
A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of
heart failure or a high risk of heart failure.
14 Consider a low dose of spironolactone 15 or higher doses of a thiazide-like diuretic.
15 At the time of publication (August 2011), spironolactone did not have a UK marketing authorisation for this indication.
Informed consent should be obtained and documented.
16 Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective .
13
8
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
The NICE costing template for Hypertension suggests that of the cohort of patients who are hypertensive and do
not have Heart Failure, 41% should be on first line treatment, 41% on second line treatment and 18% on third
line treatment.1Fourth line treatment is not used within the model as numbers are likely to be very small. This is
shown in figure 3.5 above. Figure 3.5 also shows the costs of the most cost effective anti-hypertensive drugs to
be used at each stage of the prescribing pathway.
Public Health have compared the prescribing behaviour of practices within the BBCCG against that recommended
in the NICE prescribing pathway (figure 3.5), to ascertain the potential for cost savings and improved patient
outcomes. By running SystmOne reports remotely, we have extracted the number of patients on each CCG
Practice’s Hypertension register who are not on the Heart Failure register. Heart Failure patients have been
excluded as they are also likely to be being prescribed and ACE inhibitor or ARB, which feature in in the pathway.
Through liaison with the PCT’s Medicines Management Team, we have also obtained the total current annual
prescribing cost for each CCG practice resulting from patients with Hypertension who do not have heart failure.
We then calculated the expected prescribing cost for the number of Hypertensive patients who do not have
heart failure by practice, if NICE prescribing guidance were being followed, and the most cost effective drugs
were being used, making the assumption suggested by NICE that 41% of patients should be on first line
treatment, 41% on second line and 18% on third line treatment. We also obtained the percentage of
Hypertensive patients under 55 on each practice register and applied this to our model.
Using this model, we are able to calculate the total potential cost saving (or increase) if each practice within the
CCG were to follow NICE prescribing guidance and prescribe the most cost effective hypertensive drugs. We
appreciate that this is a theoretical model and there may be good clinical reasons in some cases why a GP may
decide to adopt a slightly different prescribing regime. Savings are also not necessarily immediate as they will
require GP practice time to review patients’ current drug regimens with a view to a potential change. Table 2
summarises the results for each practice within the Arterial Locality.
As Table 2 shows, there is a potential for the Arterial Locality to save almost £589K by changing prescribing of
anti-hypertensive drugs to meet NICE guidelines and using the most cost effective drugs.
1
NICE Guidance CG127 Costing Template
9
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
Table 2 Potential Savings in Prescribing Costs using NICE prescribing guidelines – Arterial
Locality
Practice
Current Prescribing Prescribing Cost
Potential for Savings
Costs if NICE guidance
in Prescribing
followed
Potential for
Savings in
Prescribing per
diagnosed
Hypertensive
patient
Arterial
F81711
£54,220.45
£7,908.55
-£46,311.90
-£142.50
Arterial
Y00758
£40,102.95
£8,015.72
-£32,087.23
-£100.92
Arterial
F81222
£72,600.10
£16,500.64
-£56,099.46
-£85.68
Arterial
F81151
£81,082.84
£19,384.58
-£61,698.25
-£80.97
Arterial
F81104
£78,023.83
£19,783.31
-£58,240.52
-£73.22
Arterial
F81045
£38,440.64
£9,810.06
-£28,630.58
-£72.30
Arterial
F81648
£27,330.13
£7,165.74
-£20,164.39
-£69.29
Arterial
F81158
£40,021.99
£11,418.56
-£28,603.43
-£62.91
Arterial
F81150
£78,852.18
£22,694.51
-£56,157.67
-£62.60
Arterial
F81651
£48,299.02
£16,857.88
-£31,441.13
-£46.72
Arterial
F81013
£95,826.46
£33,462.32
-£62,364.14
-£46.62
Arterial
Y00469
£92,066.44
£33,015.72
-£59,050.72
-£44.81
Arterial
F81080
£82,568.07
£34,757.17
-£47,810.90
-£33.48
Arterial Total
10
-£588,660.33
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
5. The Impact of Prescribing Combined with Improved Case Finding of
Hypertensive Patients on Secondary Care Costs
Figure 3.1 (page 4) identified inadequate case finding of hypertensive patients within the Arterial Locality. Failing
to identify and therefore clinically manage hypertensive patients within primary care will inevitably drive
increased secondary care costs. The project team wished to model the potential impact that improved case
finding of hypertensive patients would have on secondary care costs at a CCG, locality and practice level. Current
prescribing, although not 100% compliant with the latest NICE guidance will be having an impact on preventing
secondary care costs. However, this is impossible to quantify accurately. However, by adapting the NICE costing
template for Hypertension we have been able to model the potential savings that would result in current
secondary care costs related to hypertension, if case finding were improved from current levels. We have
therefore used as a baseline, the current savings resulting from clinical management of hypertension within
primary care if current NICE prescribing guidance were adhered to, but case finding did not improve, and then
applied the model to an increased ratio of observed/expected number of hypertensive patients at 70%, 80%,
90% and 100%. At no change in increased case finding we have therefore assumed a £0 saving in secondary care
events. This is likely to result in an under-estimation of increased secondary care saving costs, as we know
current prescribing behaviour of individual practices does not follow NICE guidelines in every case
Figure 5.1 and table 3 show the results of this health economic modeling for the Arterial Locality. Table 4 breaks
savings down to practice level.
Significant additional savings are delivered to the locality as case finding increases. Even though prescribing
savings reduce as case finding increases, saving in secondary care events increase at a much greater rate. The
difference between the secondary care savings baseline figure (which we have treated as £0 at no increase in
case finding) and the secondary care events savings at 100% case finding is a net overall saving of £738,687.
However this figure is likely to be an under estimation of potential savings as it assumes that current savings in
secondary care events equal that which would have been obtained if current prescribing practice is 100%
compliant with current NICE guidelines on prescribing for hypertension, which we know not to be true. Please
note also, that the secondary care events savings look only at circulatory conditions and do not consider savings
that may derive from other conditions such as diabetes, so in this sense are likely to be an underestimation.
Figure 5.1 Summary of Potential Cost Savings for Arterial Locality through implementation of NICE Guidance CG127- Hypertension plus
improved case finding
11
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
Table 3 Summary of Potential Cost Savings for the Arterial Locality through implementation of NICE Guidance CG127- Hypertension
plus improved case finding
Current
Prescribing
Cost
Arterial
Locality
Prescribing Change Only
Prescribing Change Plus 70% Case
Finding
Prescribing Change Plus 80% Case
Finding
Prescribing Change Plus 90% Case
Finding
Prescribing Change Plus 100% Case
Finding
Prescribing
Costs if
NICE
Guidance
Followed
Change In
prescribing
cost
Secondary Care
Events Cost if
NICE prescribing
and guidance
followed (allows
for increased
prescribing costs)
Net Overall
Savings
(Prescribing
plus secondary
care events)
£829,435
£240,775
-£588,660
£0
-£588,660
£829,435
£263,516
-£565,919
-£48,196
-£614,115
£829,435
£301,162
-£528,273
-£127,365
-£655,639
£829,435
£338,807
-£490,628
-£206,534
-£697,163
£829,435
£376,452
-£452,983
-£285,704
-£738,687
Table 4 - Summary of Potential Cost Savings for the Arterial Locality through implementation of NICE Guidance CG127- Hypertension
plus improved case finding by Practice
Current
Prescribing
Costs
If NICE prescribing guidelines followed and no
improvements to disease register
Change in
spend on
secondary
care events Total Change
avoided
in spend
Prescribing
(Stroke and (Prescribing
Costs if NICE Net Savings in Ischeamic plus events
Guidance
Prescribing - Heart
avoided)
Followed
[A]
Disease) [B] [A]+[B])
If NICE prescribing guidelines followed and 70% Disease
register completeness
Change in
spend on
secondary
care events Total Change in
avoided
Spend
Prescribing
(Stroke and (Prescribing
Cost if NICE Net Savings in Ischeamic
savings plus
Guidance
Prescribing Heart
events avoided
Followed
[C]
Disease) [D] [C]+[D])
If NICE prescribing guidelines followed and 80% Disease
register completeness
Change in
spend on
secondary
Total Change
care events in Spend
avoided
(Prescribing
Prescribing
(Stroke and savings plus
Cost if NICE Net Savings in Ischeamic
events
Guidance
Prescribing Heart
avoided
Followed
[E]
Disease) [F] [E]+[F])
Locality
Practice
Arterial
F81080
82568.07125
£34,757.17
-£47,810.90
£0.00
-£47,810.90
£43,546.56
-£39,021.51
-£18,934.14
-£57,955.65
£49,767.50
-£32,800.57
-£32,335.30
-£65,135.87
Arterial
F81045
38440.64
£9,810.06
-£28,630.58
£0.00
-£28,630.58
£15,329.46
-£23,111.18
-£11,682.03
-£34,793.21
£17,519.38
-£20,921.26
-£16,317.08
-£37,238.35
Arterial
F81013
95826.45732
£33,462.32
-£62,364.14
£0.00
-£62,364.14
£43,140.53
-£52,685.93
-£20,286.47
-£72,972.40
£49,303.47
-£46,522.99
-£33,204.57
-£79,727.57
Arterial
F81222
72600.09815
£16,500.64
-£56,099.46
£0.00
-£56,099.46
£17,973.20
-£54,626.90
-£3,063.62
-£57,690.53
£20,540.80
-£52,059.30
-£8,405.46
-£60,464.76
Arterial
F81104
78023.83176
£19,783.31
-£58,240.52
£0.00
-£58,240.52
£21,631.56
-£56,392.28
-£3,896.58
-£60,288.86
£24,721.78
-£53,302.05
-£10,411.58
-£63,713.63
Arterial
F81648
27330.13
£7,165.74
-£20,164.39
£0.00
-£20,164.39
£6,412.23
-£20,917.90
£1,604.44
-£19,313.45
£7,328.27
-£20,001.86
-£346.06
-£20,347.92
Arterial
F81651
48299.01824
£16,857.88
-£31,441.13
£0.00
-£31,441.13
£14,401.52
-£33,897.50
£5,141.54
-£28,755.96
£16,458.88
-£31,840.14
£835.17
-£31,004.96
Arterial
F81150
78852.17795
£22,694.51
-£56,157.67
£0.00
-£56,157.67
£29,389.39
-£49,462.78
-£13,875.01
-£63,337.80
£33,587.88
-£45,264.30
-£22,576.29
-£67,840.59
Arterial
F81158
40021.99355
£11,418.56
-£28,603.43
£0.00
-£28,603.43
£16,485.55
-£23,536.44
-£10,579.03
-£34,115.47
£18,840.63
-£21,181.36
-£15,496.04
-£36,677.41
Arterial
Y00469
92066.44187
£33,015.72
-£59,050.72
£0.00
-£59,050.72
£20,905.95
-£71,160.49
£25,341.35
-£45,819.15
£23,892.51
-£68,173.93
£19,091.56
-£49,082.37
Arterial
Y00758
40102.95478
£8,015.72
-£32,087.23
£0.00
-£32,087.23
£8,058.17
-£32,044.78
-£88.28
-£32,133.07
£9,209.34
-£30,893.61
-£2,482.34
-£33,375.96
Arterial
F81711
54220.45
£7,908.55
-£46,311.90
£0.00
-£46,311.90
£8,380.63
-£45,839.82
-£1,017.20
-£46,857.02
£9,577.86
-£44,642.59
-£3,596.89
-£48,239.48
Arterial
F81151
81082.83675
£19,384.58
-£61,698.25
£0.00
-£61,698.25
£17,861.69
-£63,221.15
£3,138.84
-£60,082.31
£20,413.36
-£60,669.48
-£2,120.41
-£62,789.89
TOTALS
829435.1016
£0.00 -£588,660.33 £263,516.44 -£565,918.66
-£48,196.19
12
£240,774.78 -£588,660.33
-£614,114.85 £301,161.65 -£528,273.46 -£127,365.31 -£655,638.76
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
If NICE prescribing guidelines followed and 90% Disease
register completeness
Change in
spend on
secondary
Total Change
care events in Spend
avoided
(Prescribing
Prescribing
(Stroke and
savings plus
Cost if NICE Net Savings in Ischeamic
events
Guidance
Prescribing
Heart
avoided
Followed
[G]
Disease) [H] [G]+[H])
If NICE prescribing guidelines followed and 100% Disease
register completeness
Change in
spend on
secondary
Total Change
care events in Spend
avoided
(Prescribing
Prescribing
(Stroke and
savings plus
Cost if NICE Net in savings Ischeamic
events
Guidance
in Prescribing Heart
avoided
Followed
[I]
Disease) [J]
[I]+[J])
Locality
Practice
Arterial
F81080
£55,988.44
-£26,579.63
-£45,736.47
-£72,316.10
£62,209.37
-£20,358.70
-£59,137.64
-£79,496.33
Arterial
F81045
£19,709.30
-£18,731.34
-£20,952.14
-£39,683.48
£21,899.22
-£16,541.42
-£25,587.20
-£42,128.62
Arterial
F81013
£55,466.40
-£40,360.06
-£46,122.67
-£86,482.73
£61,629.33
-£34,197.13
-£59,040.78
-£93,237.90
Arterial
F81222
£23,108.40
-£49,491.70
-£13,747.30
-£63,239.00
£25,676.00
-£46,924.10
-£19,089.14
-£66,013.24
Arterial
F81104
£27,812.00
-£50,211.83
-£16,926.57
-£67,138.40
£30,902.22
-£47,121.61
-£23,441.57
-£70,563.18
Arterial
F81648
£8,244.30
-£19,085.83
-£2,296.56
-£21,382.39
£9,160.33
-£18,169.80
-£4,247.06
-£22,416.85
Arterial
F81651
£18,516.24
-£29,782.78
-£3,471.19
-£33,253.97
£20,573.60
-£27,725.42
-£7,777.56
-£35,502.97
Arterial
F81150
£37,786.36
-£41,065.82
-£31,277.57
-£72,343.39
£41,984.85
-£36,867.33
-£39,978.85
-£76,846.18
Arterial
F81158
£21,195.71
-£18,826.28
-£20,413.06
-£39,239.34
£23,550.79
-£16,471.20
-£25,330.07
-£41,801.28
Arterial
Y00469
£26,879.07
-£65,187.37
£12,841.76
-£52,345.60
£29,865.64
-£62,200.80
£6,591.97
-£55,608.83
Arterial
Y00758
£10,360.51
-£29,742.45
-£4,876.40
-£34,618.85
£11,511.68
-£28,591.28
-£7,270.46
-£35,861.74
Arterial
F81711
£10,775.10
-£43,445.35
-£6,176.58
-£49,621.94
£11,972.33
-£42,248.12
-£8,756.28
-£51,004.40
Arterial
F81151
£22,965.03
-£58,117.81
-£7,379.66
-£65,497.47
£25,516.70
-£55,566.14
-£12,638.91
-£68,205.05
TOTALS
13
£338,806.85 -£490,628.25 -£206,534.42 -£697,162.67 £376,452.06 -£452,983.04 -£285,703.53 -£738,686.57
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
6. DISCUSSION, CONCLUSIONS and RECOMMENDATIONS
This report highlights the potential for cost savings in the Hypertension Care Pathway within the Arterial Locality,
through improved case finding and changes in prescribing behaviour within CCG practices to match the latest
NICE Guidelines on Hypertension (CG127).
It is based on a NICE theoretical costing model which states that 41% on hypertensive patients are likely to be on
first line treatment, 41% on second line treatment and 18% on third line treatment, and assumes that the most
cost effective drug is prescribed in each case. It compares the costs of these drugs to the current prescribing
costs of individual practices which have been derived from prescribing data obtained SystmOne remote reporting
and applying PCT current drug costs obtained from the PCT’s Medicines Management Team.
Several caveats need to be borne in mind when interpreting the results of contained within the report:
Firstly, the prescribing and secondary care savings are based on a NICE health economic model that itself makes
assumptions in terms of the percentages of patients at each part of the pathway. This may not completely
accurately reflect the situation within the locality.
Secondly the report is designed to scope the potential for savings and although savings are based on a costing
model that calculates return over a year, does not pretend to conclude that such savings could be realised
immediately. It assumes that every GP adopts the formulary recommended first choice most cost effective drug
for every patient in every case. Individual patient responses to the same drug obviously differ on a case by case
basis, and it may not be clinically practical to prescribe the first choice most cost effective drug for every patient
in every case.
Thirdly, it must be recognised that both improving case finding of hypertensive patients and changing current
prescriptions of known hypertensive patients requires additional GP practice time, and this in itself will have a
cost to the system. It is therefore important to recognise that achieving even a percentage of the potential
savings highlighted within this report is likely to take time and a ‘step change’ process is more practical over a
longer time period. For example, individual practices may want to consider whether to concentrate on
improving monitoring of known hypertensive patients before looking to increase case finding, or equally to
review current prescribing against the latest guidance. However practices should not attempt to increase register
sizes without first committing to follow the new NICE prescribing recommendations. Failure to do so could result
in a reduction in over-all savings. It is likely to be more difficult to shift a patient from one drug than to prescribe
the cost effective drug(s) initially.
Bearing the above caveats in mind, the report does make the following conclusions:
-
Modeling against NICE guidance on prescribing and using NICE assumptions of 41%, 41%, 18% of patients
on first, second and third line treatment respectively, gives a potential of up to £588,680 worth of
savings in prescribing costs if all practices prescribed to the latest NICE guidance and adopted the
formulary recommended first choice drugs of NICE (although this may not be suitable for every patient).
14
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG
-
Case finding of hypertensive patients across the Arterial locality is generally low and there is considerable
potential to improve this. The pay back in terms money saved in Ischaemic Heart Disease and Stroke
secondary care costs more than out-weighs the additional prescribing cost. Practices within the locality
should investigate ways to ‘systemise’ the recording of blood pressure in all patient consultations with
patients over 40 where BP is not known, in order to improve case finding. Participating in the Local
Enhanced Service for NHS Health Checks may be another mechanism to increase case finding. Other
mechanisms for improving case finding should also be explored, for example commissioning blood
pressure monitoring through community pharmacy for stable hypertensives which would free up
practice time to concentrate on the more difficult cases.
-
There is a theoretical potential saving of just under £285,704 in reduced secondary care events costs if
case finding were increased to 100% in all practices and a total potential saving of just under £738,687 if
prescribing cost savings are added.
-
There is variation between different practices within the CCG in terms of QOF indicators BP4 and BP5
(monitoring of blood pressure in known hypertensives every 9 months and reducing it to 150/90) with
many practices performing at levels that place them within the highest performing quintile of England,
whilst others falling well below this level. There is therefore potential to improve clinical management of
hypertension within primary care across the locality. Individual practices with poorer scores in BP4 and 5
should seek to learn from locality practices in the top quintile of performance in England.
-
The rate of non-elective admissions for hypertension remains lower than both England and regional
averages for all practices which is positive. However, because the actual number of events on this
indicator is very small, confidence intervals are wide. It is likely that improving case finding and clinical
management of hypertension within primary care will reduce the rate of non-elective admissions for
other circulatory disease. This will be explored in the next ‘deep dive’ report undertaken for the CCG.
15
‘Deep Dive’ Report on Hypertension for Arterial Locality of the Basildon and Brentwood CCG