Prescribing for Diabetes in England - An Update: An analysis of volume, expenditure and trends

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1 Prescribing for Diabetes in England - An Update: An analysis of volume, expenditure and trends June 2009 diabetes Health Intelligence YHPHO YORKSHIRE & HUMBER PUBLIC HEALTH OBSERVATORY Diabetes Diabetes Health Intelligence is a strategic programme within Yorkshire and Humber Public Health Observatory providing national diabetes health intelligence

2 Foreword Managing diabetes and its complications already consumes a significant proportion of available healthcare resource. This valuable report about prescribing for diabetes highlights important issues that should be considered by providers, commissioners and planners of diabetes healthcare. Diabetes is increasing relentlessly, driven by lifestyle (inactivity and obesity) and an ageing population. Furthermore it is a progressive disorder in which the need for treatment increases with time from diagnosis. This report identifies changes in prescribing, both in the items prescribed and their resulting costs, that invite explanation and discussion. For example: Is the change in pattern and quantity of oral diabetes and obesity drug use consistent with maximising efficacy and minimising adverse effects? Are the shifts in types and costs of insulin justified by need, efficacy and reduced side effects? Why are there such large variations in diabetes drug expenditure between health economies that have similar population characteristics and levels of glucose control? There is abundant evidence that effective treatment minimises the adverse impact of diabetes on people's lives and reduces pressures on the National Health Service. The information from this report should stimulate debate about how glucose lowering medications might best and most affordably be used as components of that treatment. Dr Bob Young Consultant Diabetologist Clinical Lead for the National Diabetes Information Service (NDIS) Copyright 2009, The Health and Social Care Information Centre, Prescribing Support Unit and the Yorkshire and Humber Public Health Observatory. All Rights Reserved. This work remains the sole and exclusive property of The Information Centre and Yorkshire and Humber Public Health Observatory (YHPHO) and may only be reproduced where there is explicit reference to the ownership of The Information Centre and YHPHO. Any modification to the information or use of the information for commercial gain must be granted by the Information Centre and YHPHO. 2

3 Executive Summary Diabetes Prevalence and the Impact of Obesity: Points to Consider In million people aged 17 years and over had a registered diagnosis of diabetes. The prevalence of diabetes is predicted to rise considerably over the next 10 years due to rising levels of obesity and an ageing population. The introduction of the Vascular Checks Programme is likely to result in an increase in the number of people being diagnosed earlier with diabetes. Even modest weight reductions provide significant health benefits, particularly in cardiovascular disease and can reduce the risk of developing diabetes. Prescribing for Diabetes in Primary Care: Points to Consider Between the beginning of 2002 and September 2008 the number of diabetes items prescribed has increased by 73.3% and the total cost has risen by 93.2%. Despite a reduction in the extent of variation in expenditure on diabetes related items, the highest spending PCT is still spending two thirds more than the lowest spending PCT. The rise in prescriptions for obesity drugs may be due to both the rising prevalence of obesity and increasing awareness of therapeutic interventions. Orlistat is the most commonly prescribed drug. Insulins: Points to Consider In the year ending September 2008 there were 1.5 million short-acting insulin items prescribed at a cost of 77.1 million. This represents an increase of 10.5% in the number of items and 12.1% in the total cost compared to the year ending September Between September 2007 and September 2008 there were 1.9 million biphasic insulin items prescribed at a cost of 95.2 million. Prescriptions for non-biphasic intermediate and long-acting insulins have increased by 8.6% over the year to September The cost of these items has increased by 13.4% over the same period. Oral Anti Diabetic Drugs: Points to Consider In the year to September million oral anti-diabetic drug items were prescribed at a cost of million. This is an increase of 10.0% in the number of items and a 19.8% decrease in costs compared to the year ending September In the year ending September 2008 there were 2.3 million prescriptions for glitazones at a cost of 96.0 million. This is a decrease of 2.5% in the number of items dispensed but an 11.3% decrease in costs compared to the year ending September Diagnostic and Monitoring Agents: Points to Consider The volume and cost of prescriptions for blood glucose monitoring has risen steadily over the last six years. The drop in expenditure in late 2006 relates to a reduction in the cost applied to all these products. Self monitoring agents are essential for people with Type 1 diabetes but their value to people with Type 2 diabetes (excluding those using insulin) is controversial. 3

4 Prescribing for Diabetes in Secondary Care: Points to consider The cost of medicines for diabetes dispensed in hospitals is far less than that in primary care. It is about 2.1% of the total cost of prescribing for diabetes in primary care. The majority of these drugs are insulins because patients are acutely unwell or have advanced disease. Expenditure is increasing, particularly for oral anti - diabetic drugs reflecting the high proportion (approximately 10%) of hospital inpatients that have diabetes (M J Sampson, et al. Trends in bed occupancy for inpatients with diabetes before and after the introduction of a diabetes inpatient specialist nurse service in Diabetic Medicine 2006: 23; ). 4

5 Contents Foreword 2 Executive Summary 3 Introduction 6 Additional Resources Available 6 The Increasing Prevalence of Diabetes and its Potential Impact on Prescribing 7 Prescribing for Diabetes in Primary Care 10 Prescribing for Obesity 13 Insulins 14 Oral Anti-Diabetic Drugs 19 Prescribing for Diabetes in Secondary Care 24 Acknowledgements 26 5

6 Introduction This report presents national level data on prescribing for diabetes in England. It is an update to the report produced by Yorkshire and Humber Public Health Observatory (YHPHO) and the Information Centre for Health and Social Care in November 2007 ( The original report was produced as a result of evidence that: Diabetes is a clinical area of high expenditure; The growth in expenditure on prescribing for diabetes is greater than any other major clinical area; There are large variations in primary care drug utilisation and spend on prescribing for diabetes across the country. This report aims to review diabetes prescribing trends and highlight recent changes in prescribing patterns. It considers the rising prevalence of diabetes and the impact of obesity on diabetes in England. It reports on prescribing data for the period from January 2002 to September It is hoped that this will prompt discussion of prescribing patterns at a local level. Additional Resources Available Further details of prescribing for diabetes at Primary Care Trust (PCT) level is available in map, chart and tabular formats through the YHPHO web site ( The 'Diabetes Community Health Profiles - An Overview' provide a summary of diabetes related information including information on prescribing spend in relation to outcomes for each PCT in England. These can be accessed at 6

7 The Increasing Prevalence of Diabetes and its Potential Impact on Prescribing It has been estimated that there were 2.4 million people (4.8% prevalence) with diabetes living in England in However, there were 2.1 million people aged 17 years and over registered with a diagnosis of diabetes at their GP practice. This excludes people with diabetes aged less than 17 years, as these patients are generally cared for by hospital specialists. These figures suggest that there are approximately 350,000 people with undiagnosed diabetes in England. Early diagnosis and treatment leads to improved health outcomes for people with diabetes. People with diabetes have a reduced life expectancy and an increased risk of vascular damage leading to a range of co-morbidities including heart disease, stroke, kidney failure, blindness, lower limb amputation and neuropathy. Figure 1 shows the prevalence of diabetes in those aged 17 years and over, based on registrations in general practice by Strategic Health Authority (SHA) for England. Data is presented from the Quality and Outcomes Framework (QOF) for 2004/05, 2005/06, 2006/07 and 2007/08. Although most of the observed increase in diabetes prevalence is likely to be due to increases in the underlying prevalence of the disease, improved case-finding and recording in general practice may also be contributory factors. The prevalence of diabetes (both diagnosed and undiagnosed) is forecast to increase due to an ageing population and the increasing prevalence of obesity. By 2020 it is estimated that 3.2 million people will have diabetes (5.9% prevalence). The introduction in April 2009 of the Vascular Checks Programme which includes screening for diabetes among high risk groups is likely to lead to an increase in the number of people diagnosed earlier with diabetes and therefore an increase in prescribing to support their management. 7

8 The Impact of Rising Obesity Being obese and having a sedentary lifestyle significantly increase the risk of developing diabetes. The National Audit Office suggests that 47% of Type 2 diabetes can be attributed to obesity. Body Mass Index data from the Health Survey for England indicates that the proportion of obese adults has risen dramatically since In % of men and 24.4% of women were obese. A linear extrapolation of this trend is shown in Figure 2. It shows that, if current trends persist, by % of men and 34.2% of women will be obese. Figure 3 shows obesity prevalence by SHA for 2004 to The expected rise in obesity combined with an ageing population are predicted to result in a steady increase in the prevalence of diabetes. It is estimated that approximately half of the increase in diabetes prevalence between 2005 and 2020 will be due to the changing age structure of the population and half will be due to the rising prevalence of obesity. 8

9 Diabetes Prevalence and the Impact of Obesity: Points to Consider In million people aged 17 years and over had a registered diagnosis of diabetes. The prevalence of diabetes is predicted to rise considerably over the next 10 years due to rising levels of obesity and an ageing population. The introduction of the Vascular Checks Programme is likely to result in an increase in the number of people being diagnosed earlier with diabetes. Even modest weight reductions provide significant health benefits, particularly in cardiovascular disease and can reduce the risk of developing diabetes. 9

10 Prescribing for Diabetes in Primary Care The data presented within this section covers prescriptions issued in primary care in England and dispensed in the community in the United Kingdom. The figures show information relating to prescription items and Net Ingredient Costs. Prescription items are written on prescription forms known as FP10. Each single item for a different drug or formulation written on the form is counted as one prescription item. Net Ingredient Cost (NIC) is the basic cost of a drug. It does not take account of discounts, dispensing costs, fees or prescription charges income. Prescription items are classified using the therapeutic classification in the British National Formulary (BNF). Drugs used in diabetes are BNF 6.1 Figure 4 shows the total number of items by quarter prescribed to treat diabetes split into insulins, oral anti-diabetic drugs and diagnostic monitoring agents between January 2002 and September Figure 5 illustrates the total cost of these items over the same time period. There has been growth in both the number and cost of items prescribed to treat diabetes. A comparison based upon the January - March 2002 quarter and the July - September 2008 quarter shows a 73.3% increase in the number of items, from 4.7 million to 8.2 million, and a 93.2% increase in total costs from 76.7 million to million. In the most recent 12 months, the number of diabetes items prescribed increased from 29.8 million to 31.9 million (7.0%). During this time the costs fell from million to million (-1.7%). There have been some changes in unit costs for some products over this time period. More details are given in the relevant sections. 10

11 As the number of people diagnosed with diabetes has increased over recent years it is useful to consider changes to the number of items and costs per person receiving treatment. Figures 6, 7 and 8 use registrations in primary care taken from the Quality and Outcomes Framework data. This excludes people with diabetes aged less than 17 years, as these are generally managed by specialists. Figure 6 shows the number of items and associated costs per person diagnosed with diabetes for 2004/05, 2005/06, 2006/07 and 2007/08. This suggests that the number of items per person has increased. The cost of items prescribed per person registered with diabetes also increased between 2004/05 and 2007/08, but declined between 2006/07 and 2007/08. 11

12 There is considerable variation in the number and cost of diabetes prescribing at PCT level in England. Figure 7 shows the association between the number of persons registered with diabetes and the total prescribing cost between April 2008 and September 2008 for diabetes by Primary Care Trust (PCT). Although these two variables are highly correlated, it is clear that some PCTs spent more on diabetes drugs despite having similar number of people diagnosed with the condition. Figure 8 illustrates the range (from to ) in the total NIC per person diagnosed with diabetes by PCT for the period April 2008 to September This equates to the highest spending PCT spending two-thirds more than the lowest spending organisation. Variation in prescribing spending on diabetes by PCTs has reduced since 2005 when there was a two-fold range in spend per person with diabetes. This shift will be due in some part to changes in prescribing behaviour, but may also be affected by changes in the unit cost of some products. 12

13 Prescribing for Obesity Obesity is a major risk factor for type 2 diabetes and its prevention and treatment can reduce the future burden of diabetes. Significant numbers of people with type 2 diabetes are referred to weight management clinics. Two drugs - sibutramine and orlistat - are currently licensed for use as an adjunct to diet and other lifestyle advice in the management of obesity. The licences state when these drugs can be used, the monitoring required and when they should be withdrawn as long term use is not recommended. Sibutramine and orlistat have been reviewed by NICE. There has been an increase in the prescribing of these drugs over the last four years as shown in Figure 9. In the year ending September 2008 total spending on obesity drugs was 46.1 million. This may reflect the rise in obesity, the availability of appropriately trained staff and increasing awareness of the availability of therapeutic interventions. The marketing authorisation for rimonabant was suspended in October 2008 due to concern about the risk of psychiatric adverse reactions. Prescribing for Diabetes in Primary Care: Points to Consider Between the beginning of 2002 and September 2008 the number of diabetes items prescribed has increased by 73.3% and the total cost has risen by 93.2%. Despite a reduction in the extent of variation in expenditure on diabetes related items, the highest spending PCT is still spending two thirds more than the lowest spending PCT. The rise in prescriptions for obesity drugs may be due to both the rising prevalence of obesity and increasing awareness of therapeutic interventions. Orlistat is the most commonly prescribed drug. 13

14 Insulins Insulin is categorised by the British National Formulary (BNF) into two groups: (a) short-acting and rapid-acting insulins and (b) intermediate and long-acting insulins. The use of human insulin analogues produced synthetically by recombinant DNA technology is increasing rapidly and replacing the cheaper isophane and soluble insulins. Figure 10 shows the cost for 28 days treatment for a range of insulins based upon World Health Organisation (WHO) Defined Daily Doses. (Please be aware that these may not reflect an actual prescribed dosage). These data are provided by NHS Prescription Services, NHS Business Services Authority. 14

15 Short-Acting and Rapid-Acting Insulins In the year to September million short-acting insulin items were prescribed with a NIC of 77.1 million. These are increases of 10.5% in items and 12.1% in cost when compared to the year ending September Figure 11 shows the number of items prescribed for selected short-acting insulins. The use of Insulin Aspart has increased substantially to replace soluble insulin as the most frequently prescribed formulation. The use of Insulin Lispro has increased at a slower rate over the same period. Over the year to September 2008 the use of Insulin Glulisine has increased but still represents only a small minority of prescriptions for short-acting insulin. 15

16 Continuous subcutaneous insulin infusion (insulin pump) is an appropriate route of administration for a small number of patients who are able to use it safely and effectively and are supported by specialist care services. There is no evidence that human analogue insulin provides any benefit over soluble insulins for use in pumps. Data on the number of pumps and associated equipment are not collected, so it is not possible to estimate the numbers of patients or costs. Intermediate and Long-Acting Insulins Intermediate and long-acting insulins can be further divided into two groups: (a) Biphasic and (b) Non-Biphasic insulins. Biphasic Insulin These are ready mixed combinations of short-acting and longer-acting insulins. Figure 13 and Figure 14 show the number of items and associated cost for Biphasic Insulin Lispro, Biphasic Isophane Insulin and Biphasic Insulin Aspart. 16

17 In the year to September million biphasic insulin items were prescribed with a NIC of 95.2 million. This was a decrease of 0.9% in the number of items and 3.7% increase in the NIC compared to the year ending September The formulation containing Insulin Aspart has increased over recent years and has now overtaken Isophane Insulin items as the most commonly prescribed formulation. Non-Biphasic Intermediate and Long-Acting Insulin The BNF section covers all non-biphasic intermediate and long-acting insulin but the data presented in this section show Insulin Determir, Insulin Glargine and Isophane Insulin only as these drugs represent the majority of prescribing. In the year ending September million non biphasic intermediate and long-acting insulin items were prescribed at a total cost of million. This represents an increase of 8.6% in the number of items and 13.4% in costs. 17

18 Figure 15 illustrates the significant shifts in product choice over the last six years. Insulin Glargine has replaced Isophane Insulin as the most commonly prescribed long-acting insulin. This shift has produced a substantial increase in costs as Insulin Glargine and Insulin Determir are more expensive than Isophane Insulin. The overall impact of this change on costs is shown in Figure

19 Insulins: Points to Consider In the year ending September 2008 there were 1.5 million short-acting insulin items prescribed at a cost of 77.1 million. This represents an increase of 10.5% in the number of items and 12.1% in the total cost compared to the year ending September Between September 2007 and September 2008 there were 1.9 million biphasic insulin items prescribed at a cost of 95.2 million. Prescriptions for non-biphasic intermediate and long-acting insulins have increased by 8.6% over the year to September The cost of these items has increased by 13.4% over the same period. Oral Anti-Diabetic Drugs In the year to September million oral anti-diabetic drug items were prescribed at a cost of million. This is an increase of 10.0% in the number of items and a 19.8% decrease in costs compared to the year ending September The numbers of items and the associated NIC are shown in Figures 18 and 19. Metformin (a biguanide) is the most commonly prescribed oral antidiabetic drug and has a relatively low cost. The use of sulphonylureas has increased slightly over the time period examined. Prices for generic formulations are centrally controlled, and were reduced significantly in October Metformin and sulphonylurea drugs are all available as generic formulations, so their costs per item are lower than for the other anti-diabetic agents, though are subject to some fluctuation. Figure 17 shows the cost for 28 days treatment for the oral anti-diabetic drugs based upon World Health Organisation (WHO) Defined Daily Doses (DDD) (please be aware that these may not reflect an actual prescribed dosage) *. These data are provided by NHS Prescription Services, NHS Business Services Authority. * Vildagliptin does not have a Defined Daily Dose therefore the cost has been calculated on the most commonly prescribed dosage. 19

20 20

21 Other anti-diabetic drugs include acarbose, exenatide, nateglinide, pioglitazone, repaglinide, rosiglitazone, sitagliptin and vildagliptin. The glitazones account for most of the prescribing in this group and account for the majority of spending on oral anti-diabetic drugs. Although the number of items prescribed in this group has increased the associated cost has fallen compared to the year ending September In the year ending September 2008 there were 2.3 million prescriptions for glitazones at a cost of 96.0 million. This is a decrease of 2.5% in the number of items dispensed but an 11.3% decrease in costs compared to the year ending September Since April 2007 there has been a sharp decline in the number of items prescribed for rosiglitazone 21

22 and rosiglitazone plus metformin. This follows safety warnings from the MHRA, and recommendations to avoid rosiglitazone in patients with ischaemic heart disease, peripheral arterial disease and acute coronary syndrome. The data suggests that pioglitazone has been substituted, as it now the most commonly prescribed glitazone. 22

23 Oral anti-diabetic drugs: Points to consider In the year to September million oral anti-diabetic drug items were prescribed at a cost of million. This is an increase of 10.0% in the number of items and a 19.8% decrease in costs compared to the year ending September In the year ending September 2008 there were 2.3 million prescriptions for glitazones at a cost of 96.0 million. This is a decrease of 2.5% in the number of items dispensed but an 11.3% decrease in costs compared to the year ending September Diagnostic Monitoring Agents The volume and cost of prescriptions for blood glucose monitoring has risen steadily over the last six years. In November 2006 central price reductions were introduced which reduced the cost slightly. However, the total costs for these items has begun to increase again as shown in Figure 22. Diagnostic and Monitoring Agents: Points to Consider The volume and cost of prescriptions for blood glucose monitoring has risen steadily over the last six years. The drop in expenditure in late 2006 relates to a reduction in the cost applied to all these products. Self monitoring agents are essential for people with Type 1 diabetes but their value to people with Type 2 diabetes (excluding those using insulin) is controversial (J.D. Belsey et al. Self blood glucose monitoring in type 2 diabetes. A financial impact analysis based on UK primary care. International Journal of Clinical Practice: Volume 63; Issue 3, ) and (M.Gulliford. Self monitoring of blood glucose in type 2 diabetes, British Medical Journal 2008: 336; ). 23

24 Prescribing for Diabetes in Secondary Care Data on drugs used in hospitals are supplied on a commercial contract by IMS Health. The costs stated here are calculated from the volumes of drugs issued from pharmacy departments but based on the cost of the drugs in primary care. This may not reflect the true costs paid by the hospitals as these are not controlled centrally and are commercially sensitive. The costs of some drugs in hospitals may be lower than in primary care due to discounts particularly in high profile therapeutic areas, where there is competition for market share between pharmaceutical companies. Figure 23 shows the total NIC spent on drugs used to treat diabetes in hospitals between January 2002 and September The cost of medicines for diabetes dispensed in hospitals is far less than that in primary care. It is about 2.1% of the total cost of prescribing for diabetes in primary care. People with diabetes, particularly type 2 diabetes, receive most of their care and support in primary care, although general practice prescribers may be advised and influenced by specialists in secondary care. As shown in Figure 24 the expenditure on insulins is much greater than for oral anti-diabetic drugs due to hospital inpatients being acutely unwell, peri-operative or more likely to have advanced disease. 24

25 Figure 24 shows the total spend in hospitals on short-acting and intermediate and long-acting insulins. This is a similar pattern to that seen in primary care where expenditure on short-acting insulins is also substantially lower than that on intermediate and long-acting insulins. Prescribing for Diabetes in Secondary Care: Points to consider The cost of medicines for diabetes dispensed in hospitals is far less than that in primary care. It is about 2.1% of the total cost of prescribing for diabetes in primary care. Expenditure is increasing, particularly for oral anti-diabetic drugs reflecting the large proportion (approximately 10%) of hospital inpatients that have diabetes. (M.J.Sampson et al. Trends in bed occupancy for inpatients with diabetes before and after the introduction of a diabetes inpatient specialist nurse service. Diabetic Medicine 2006: 23; ). Treatment regimens are often initiated in specialist clinics and continued in general practice, hence drug choice in secondary care may influence primary care prescribing. 25

26 Data on Diabetes Prescribing at PCT Level An on-line tool to access PCT level diabetes prescribing data has been developed to accompany this report. The tool presents data in a tabular, graphical and map format and allows comparisons across PCTs and is available through the YHPHO website at: Diabetes prescribing data is also shown in relation to HbA1c outcomes in the Diabetes Community Health Profiles - An Overview. These can be found at: Additional support may also be available through your PCT Prescribing Lead. Acknowledgements: Sue Faulding Programme Manager, Prescribing Support Unit, Information Centre for Health and Social Care Ross Ambler Information Officer, Prescribing Support Unit, Information Centre for Health and Social Care Naomi Holman Health Information Specialist, Diabetes Health Intelligence, Yorkshire and Humber Public Health Observatory Lorraine Oldridge Assistant Director, Diabetes Health Intelligence, Yorkshire and Humber Public Health Observatory James Carpenter Analyst, Yorkshire and Humber Public Health Observatory The NHS Information Centre is England's central, authoritative source of health and social care information. Acting as a 'hub' for high quality, national, comparative data, we deliver information for local decision makers, to improve the quality and efficiency of care. Diabetes Health Intelligence is a strategic programme within Yorkshire and Humber Public Health Observatory providing national level diabetes health intelligence to the diabetes community. This report has been produced as part of the National Diabetes Information Service (NDIS) which is a collaboration between diabetes related organisations. NDIS is wholly funded by NHS Diabetes. 26

27 Published by The NHS Information Centre (Part of the Government Statistical Service) and The Yorkshire and Humber Public Health Observatory ISBN: For further information: or YHPHO Innovation Centre York Science Park The University of York York Yo10 5DG Copyright 2009, Health and Social Care Information Centre, Prescribing Support Unit, and Yorkshire and Humber Public Health Observatory. All rights reserved. This work remains the sole and exclusive property of the Health and Social Care Information Centre and the Yorkshire and Humber Public Health Observatory, and may only be reproduced where there is explicit reference to the ownership of the Health and Social Care Information Centre and the Yorkshire and Humber Public Health Observatory. This work may be re-used by NHS and government organisations without permission. This work is subject to the Re-Use of Public Sector Information Regulations and permission for commercial use must be obtained from the copyright holder. 27

28 diabetes Health Intelligence YHPHO YORKSHIRE & HUMBER PUBLIC HEALTH OBSERVATORY Diabetes Diabetes Health Intelligence is a strategic programme within Yorkshire and Humber Public Health Observatory providing national diabetes health intelligence

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