Download Infectious Diseases

NHS Right Care Deep Dive
Northern, Eastern and Western Devon Clinical
Commissioning Group
Infectious Diseases
South, Central and West Commissioning Support Unit
October 2015
NEW Devon Deep Dive - Summary Report
Table of figures
Figure 1: Programme budget expenditure on infectious diseases. 2013/14 ......................................... 3
Figure 2: Infectious Diseases Primary Care Prescribing items and spend compared to national quintile
performance……………………………………………………………………………………………………………………..………………E
rror! Bookmark not defined.
Figure 3: Infectious Diseases outpatient spend, NEW Devon (highlighted yellow) compared with all
CCGs in England. ..................................................................................................................................... 7
Figure 4: Infectious Diseases directly standardised non elective admission rates, NEW Devon
compared with CCGs across England…………………………………………………………………………………………………9
Figure 5: Infectious Diseases directly standardised non elective admission rates, for NEW Devon CCG
practice……………………………………………………………….........................…………………………………………………….9
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NEW Devon Deep Dive - Summary Report
Overview
Figure 1: Programme budget expenditure on Infectious Diseases. 2013/14
Source: NHS England




CCG Outpatient spend is in the highest quintile and so suggests some significant opportunity,
however the varied national picture means this should be interpreted with caution
There is some smaller opportunity in Elective/Day Case and Primary Care Prescribing,
although the CCG benchmarks well for antibacterial drugs – by far the highest spending
prescribing sub-category
Although not an outlier, there may be some opportunity in A&E and Non-elective admissions
for certain conditions
Outcomes for Infectious Diseases area are mixed, with room for improvement in antibiotic
prescribing and CD4 count tests for those diagnosed with HIV
Areas under investigation*
Septicaemia
Other viral infection
HIV/AIDS
Measles
Rubella
Tuberculosis
Mumps
Meningococcal
infection
Herpesviral infection
Retrovirus infections
Haemophilus
influenzae
Other infectious
diseases
*including but not limited to
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NEW Devon Deep Dive - Summary Report
Key messages
Outcomes are mixed with the CCG showing
opportunity for improvement in its antibiotic
prescribing and CD4 count test for those
diagnosed with HIV. Childhood immunisation
rates are good on the whole, however rates of
five-year-olds receiving their booster also
show room for improvement.
Infectious Diseases are split into two subcategories with HIV/AIDS separated from all
Other infectious Diseases. Data is not
available for the majority of care sectors for
HIV & AIDs, however the Programme Budget
data for 2013/14 suggests potential for some
savings in primary care prescribing - in the
region of £40,000 - £80,000 - as NEW Devon
CCG falls in the fourth highest spending
national quintile.
90% of admissions in three diagnosis groups
which is not a dis-similar pattern to national
picture. There is however, significant variation
between practices which may present
opportunity if this could be addressed.
The CCG benchmarks well on A&E spend in
this area, and volumes are steady or declining
and are fairly low.
It is worth noting however, that Septicaemia which shows high inpatient activity - isn’t
categorised under Infectious Diseases for A&E
but in Blood Disorders. When we view this
category it can be seen that A&E attendances
are rising, which may be impacting upon
admissions.
For Other Infectious Diseases more data is
available and the total spend is more
significant allowing better review.
Primary Care Prescribing spend falls within
the middle quintile, and whilst spend for the
largest sub-category – antibacterial drugs – is
relatively low, the other four categories all
show opportunity when viewed alongside the
national picture and similar CCGs.
The largest opportunity within the Infectious
Diseases category presents in outpatients,
although there is massive variation in the
levels of spend in this area across the country.
This could well be because of the availability
of specialist clinics, or the coding of data
across providers (or both), and so a moredetailed review of the pathway might be
required here.
In terms of non-elective admissions, the CCG
benchmarks around the national average. This
is true for both total Infectious Diseases and
for the most common diagnosis – Viral
Infection Unspecified. NEW Devon sees over
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NEW Devon Deep Dive - Summary Report
Population/Outcomes
The NHS Atlas of Variation in Healthcare 2015 includes a quality indicator for antibiotic prescribing the percentage of all antibiotic prescription items in primary care that were for key antibiotics
(2013). In primary care, antibiotics from these classes are widely considered to be ‘second-line’
treatment options for the most common community-acquired infections. Indiscriminate use creates
unnecessary selection pressure for resistant pathogens including Clostridium Difficile. The goal is
the reduction in proportion of broad-spectrum antibiotic items to less than 10% of total antibiotic
items by CCG by 2018. In England in 2013, the median proportion of prescription items for key
antibiotics (cephalosporin, fluoroquinolone and co-amoxiclav classes) in primary care by CCG was
11% of total antibiotic items.
In NEW Devon CCG, the value of this indicator is 12.3%, i.e. above the 10% goal and in the fourth
highest national quintile. The median for the 10 most similar CCGs was 10.9%, and for the best
performing quintile 7.6%. Therefore, there is room for improvement in this indicator in NEW Devon,
which as well as improving the quality of care may also generate financial savings, as - in general first line antibiotics have a lower cost than second line.
Another quality indicator in this area is the percentage of people newly diagnosed with HIV who had
a CD4 count test within one month of diagnosis. For optimal outcomes, people with newly
diagnosed HIV infection require rapid access to HIV specialist services for clinical assessment, so that
an appropriate management plan can be developed. The British HIV Association recommends that
people who have a new diagnosis of HIV should expect to have a clinical assessment within two
weeks of an HIV positive test result. Receipt of a CD4 count, a blood test measuring a patient’s
immune status, can be used to assess an individual’s linkage to HIV care and is therefore monitored;
the British HIV Association target is >95%.
In NEW Devon CCG the value for this indicator is 93.2%, in the second best national quintile and
exceeding the median for the 10 most similar CCGs, 90.3%. Although performing well from a
national perspective, the median for the best quintile is 100% and the target of >95% has yet to be
reached.
In 2014/15, for immunisations with the 5 in 1 vaccine (diphtheria, tetanus, whooping cough, polio
and Haemophilus influenzae type b) at 12 months age, 96.4% children in NEW Devon CCG had been
immunised. This puts NEW Devon CCG in the second highest national quintile. The median for the
10 most similar CCGS was 95.6% - bettered by NEW Devon CCG - but that for the best performing
quintile was 97.6%. For NEW Devon this would equate to the additional immunisation of 112
children.
The percentage of immunisations achieved with the 5 in 1 vaccine was 98.2% for children aged 24
months - in the top national quintile, exceeding the median of the 10 similar CCGs and close to the
median of the top quintile, 96.5%.
However, the percentage of children aged 5 years old in NEW Devon CCG who have received the
booster immunisation (diphtheria, tetanus, whooping cough and polio) was only 92.1% - in the third
national quintile. This was just below the median for the 10 similar CCGs, 92.5%, and 3.6% below
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NEW Devon Deep Dive - Summary Report
the highest quintile. To achieve this level of performance, an additional 357 children would have to
be immunised at age 5 years in NEW Devon CCG.
Primary care
Overall NEW Devon CCG spend on Primary Care Prescribing for infectious disease drugs falls within
the middle quintile when compared with CCGs nationwide (figure 1). Deeper analysis for different
categories of drugs reveals that NEW Devon CCG performs well on antibacterial drugs - by far the
largest category - being in the second lowest spending quintile. However, prescribing at the level of
the median of the lowest spending quintile would have the potential to save £340,000.
Items
Spend
Figure 2: Infectious Diseases Primary Care Prescribing items and spend compared to national quintile performance
Source: Health and Social Care Information Centre
NEW Devon CCG primary care prescribing for antifungal drugs, antiviral drugs, antiprotozoal drugs
and anthelmintics is in the two highest spending quintiles. However, as overall spend on these drug
categories is relatively small - £545,000, maximum savings if the median of the lowest spending
quintile was achieved would be £214,000.
Spend per 100,000
(£000s)
Difference with NEW
Devon spend per
100,000 (£000s)
Saving opportunity
(£000s)
National median
344.9
9.3
84.8
National best quintile
median
297.6
56.6
512.7
Similar 10 CCGs median
346.5
7.7
69.4
Reduction scenario
Table 1: Savings opportunities for NEW Devon CCG in infectious diseases primary care prescribing actual spend
Source: Health and Social Care Information Centre
Planned Care
Overall NEW Devon CCG spend on outpatients in this area is high, being in the highest national
quintile. There is however, significant variation between CCG spend across the country and so this
information should be treated with caution. Figure 3 below highlights such variation – which could
be driven by the availability of specialist outpatient clinics. The NEW Devon CCG rate of £179,033 per
100,000 of the population compares to the national top quintile median of £2,290, and the similar
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NEW Devon Deep Dive - Summary Report
CCGs median of £8,871.
Figure 3: Infectious Diseases outpatient spend, NEW Devon (highlighted yellow) compared with all CCGs in England
Source: NHS England
With the above in mind, based on moving to a series of selected benchmarks there may be
opportunity for savings of between £1.1M - £1.6M.
Spend per 100,000
(£000s)
Difference with NEW
Devon spend per
100,000 (£000s)
Saving opportunity
(£000s)
National median
56.0
123.1
1115.7
National best quintile
median
2.5
176.5
1600.4
Similar 10 CCGs median
13.7
165.3
1498.7
Reduction scenario
Table 2: Savings opportunities for NEW Devon CCG in Infectious diseases outpatient spend
In terms of elective/day case admissions, whilst the CCG’s spend is in the second highest quintile
nationally the associated savings are relatively small and there does not appear to be a pattern in
terms of specific high-spending areas. The opportunities in this area are summarised below:
Spend per 100,000
(£000s)
Difference with NEW
Devon spend per
100,000 (£000s)
Saving opportunity
(£000s)
National median
36.8
-3.1
None
National best quintile
median
9.3
24.4
221.5
Similar 10 CCGs median
27.8
6.0
54.1
Reduction scenario
Table 3: Savings opportunities for NEW Devon CCG in Infectious diseases elective/day case spend
Non Elective
The CCG does not benchmark high for non-elective spend, falling in the second lowest quintile
nationally. This is true for both the total infectious diseases category and for the most common
diagnosis, ‘Viral infection, unspecified’ when viewed alone. When reviewing admission rates and
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NEW Devon Deep Dive - Summary Report
standardising for the make-up of the population, the CCG still falls within the middle of all CCGs
nationally (figure 3).
Figure 4: Infectious Diseases directly standardised non elective admission rates, NEW Devon compared with CCGs across England
There is however, some fairly significant variation in standardised admission rates across the
practices within NEW Devon CCG. Figure 5 shows an almost six-fold variation between the highest
and the lowest practice which, if addressed, could deliver a significant reduction in non-elective
admissions.
Figure 5: Infectious Diseases directly standardised non elective admission rates, for NEW Devon CCG practices
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NEW Devon Deep Dive - Summary Report
Given NEW Devon does not benchmark significantly high when compared to the national median or
similar CCGs, table 4 below shows the opportunity if the CCGs were to move the national best
quintile by addressing some of the variation identified in figure 5.
Non-Elective admissions
Spend per
100,000
(£000s)
Difference to
NEW Devon
(£000s)
Saving
Opportunity
(£000s)
408.5
-50.5
None
306
52.1
472.2
389.8
-31.7
None
National Median
National best quintile Median
Similar 10 CCGs median
Table 4: Savings opportunities for NEW Devon CCG in Infectious diseases Non-elective spend
Table 5 below shows the diagnoses under which these non-elective admissions are falling.
Admissions for NEW Devon CCG fall largely under the main three diagnoses – a picture not dissimilar
to the national picture.
England
NEW
Devon
NEW
Devon
%
%
Adms
ICD 10
Code
B349
Viral infection, unspecified
49%
46%
1313
A419
Septicaemia, unspecified
23%
22%
629
R509
Fever, unspecified
14%
15%
442
A415
Septicaemia due to other Gram-negative organisms
3%
3%
93
B019
Varicella without complication
2%
1%
38
B279
Infectious mononucleosis, unspecified
1%
2%
52
B029
Zoster without complication
1%
1%
27
A410
Septicaemia due to Staphylococcus aureus
1%
1%
27
A418
Other specified septicaemia
1%
1%
15
Other
5%
8%
Diagnosis Description
Table 5: Non-elective Admissions for Infectious Diseases during 2014/15 by Primary Diagnosis
A&E
As with non-elective admissions, the CCG benchmarks well for A&E spend being in the lowest
national quintile (figure 1). Table 6 below shows the distribution of the relatively low numbers of
A&E attendances within the category (Note that Plymouth NHS Trust data is excluded from the A&E
data below because there was no coding for 2013-14 and 2014-15).
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NEW Devon Deep Dive - Summary Report
Diagnosis
2012-13
2013-14
2014-15
Infectious disease
404
330
318
Viral infection of unspecified site
10
6
2
Fever of unknown origin
4
1
3
Other septicaemia
2
4
1
Zoster [herpes zoster]
1
1
Unspecified parasitic disease
1
Bacterial infection of unspecified site
1
Other diseases caused by chlamydiae
1
Grand Total
422
343
325
Table 6: A&E Attendances for Infectious Diseases during 2014/15 by Diagnosis (excluding Plymouth NHS Trust)
Attendances appear to be falling across years, however it should be noted that Septicaemia
diagnoses - for which inpatient activity is high - are not categorised under 01X Infectious Diseases
but under PB Category 03X – Blood Disorders. Table 7 below shows A&E attendances for the
diagnoses which make up Blood Disorders, and show a doubling in attendances under Septicaemia in
two years. This may partly be a switch in coding as it shows the opposite impact to the information
in Table 6, however would warrant further investigation to understand the reasons for this rise and
whether there was opportunity in this area.
Diagnosis
2012-13
2013-14
2014-15
Septicaemia
84
123
199
Haematological conditions
20
20
30
Other
4
4
3
108
147
232
Grand Total
Table 7: A&E Attendances for Blood Disorders during 2014/15 by Diagnosis (excluding Plymouth NHS Trust)
Opportunities
Primary Prescribing
Reducing Primary Care Prescribing spend: between £69,400 – £512,700
Planned Care - Outpatients
Reducing Outpatient spend: between £1.1M - £1.6M
Planned Care – Elective and Day Case
Reducing Elective/Daycase spend: between £0 - £221,500
Unscheduled care – Non-electives
Reducing Non-elective spend: between £0 - £472,200
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NEW Devon Deep Dive - Summary Report
Data sources
Data source
Programme budgeting
Time period
2013/14
Link
https://www.england.nhs.uk/resources/resourcesfor-ccgs/prog-budgeting/
HSCIC CCG Prescribing
data (FP10)
HSCIC Lifestyle
Statistics
Hospital Episode
Statistics (HSCIC)
NHS Atlas of Variation
in Healthcare
ONS Population
Statistics
2014/15
http://www.hscic.gov.uk/gpprescribingdata
2013/14
http://www.hscic.gov.uk/lifestyles
2014/15
http://www.hscic.gov.uk/hes
(access by permission only)
http://www.rightcare.nhs.uk/index.php/atlas/nhsatlas-of-variation-in-healthcare-2015
http://ons.gov.uk/ons/taxonomy/
index.html?nscl=Population
2015
2014/15
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