Using big data to identify opportunity and drive informed change in secondary care

Using big data to identify opportunity and drive informed change in secondary care Exploring the changing patterns of Non-Steroidal Anti-Inflammatory Drug dispensing in UK hospitals

ABOUT IMS HEALTH IMS Health is a leading global information and technology services company providing clients in the healthcare industry with comprehensive solutions to measure and improve their performance. By applying sophisticated analytics hosted on the IMS One intelligent cloud, the company connects more than ten petabytes of complex healthcare data on diseases, treatments, costs and outcomes to help its clients run their operations more efficiently. Drawing on information from 100,000 suppliers and on insights from more than 45 billion healthcare transactions processed annually, IMS Health s approximately 10,000 employees drive results for healthcare clients globally. Customers include pharmaceutical, consumer health and medical device manufacturers and distributors, providers, payers, government agencies, policymakers, researchers and the financial community. As a global leader in protecting individual patient privacy, IMS Health uses anonymous healthcare data to deliver critical, disease and treatment insights. These help biotech and pharmaceutical companies, medical researchers, government agencies, payers and other healthcare stakeholders to identify unmet treatment needs and understand the effectiveness and value of pharmaceutical products in improving overall health outcomes. IMS HEALTH HOSPITAL PHARMACY AUDIT (HPA) IMS Health Hospital Pharmacy Audit (HPA) provides a measure of dispensing from hospital pharmacies within the UK. Collecting data from more than 300 suppliers each month, HPA provides coverage of 98.54% of all UK NHS beds and includes inpatient, outpatient and homecare usage, where department level information is assigned to 64 specialty departments. The results can be expressed in volume terms or in value calculated from standard NHS pricing models. All four UK nations are covered within the HPA panel to provide a comprehensive view of the market. Additional information is available at: WWW.IMSHEALTH.COM/ HOSPITAL-ANALYSER

Introduction 3 Information to allow hospitals to effectively manage the changing patterns of hospital dispensing Do your clinicians, pharmacists and prescribing committees understand what is being prescribed and can they use this information to manage changing patterns? We ve been collaborating with hospitals to make this possible. Tim Sheppard General Manager UK & Ireland, IMS Health "This is the first in a series of briefings using a new and comprehensive data set to measure the impact of treatment decisions, enabling improved patient safety and the uptake of therapeutic advances." Over recent years, analysis of prescribing patterns within England has largely been informed by data collected through GP systems and published as a part of the NHS transparency programme. This data has provided some interesting insight, including highlighting an increased use of statins in primary care. We understand the valuable opportunity that hospital data could also bring in answering questions about prescribing patterns in outpatient and inpatient care, in homecare and within outsourced outpatient pharmacies. Therefore we have been working in partnership with hospitals to develop a comprehensive data set, capturing over 98% of activity. In presenting this data to a selection of chief pharmacists, it allowed them to clearly identify cost savings, more effectively monitor patient safety, and track trends within their trust. What s more; this data can also benefit prescribing committees and individual clinicians, giving them the ability to track changes that are often occurring due to therapeutic advances and prescribing guidelines. They are then able to undertake the necessary risk-benefit analyses and ensure delivery of the optimum treatment. In producing this report our goal was to illustrate the valuable insight that can be obtained through comparative prescribing data; as a tool to review and monitor variation. We believe that appropriate use of these tools will lead to informed change and delivery of better patient outcomes. The first in a series, this report focuses on Non- Steroidal Anti-Inflammatory Drugs (NSAIDs); in particular capturing dispensing rates of diclofenac. Medical authorities issued a patient safety alert in 2013 advising caution in prescribing this NSAID as it can increase the risk of heart attack and stroke particularly with long-term use of high doses and in patients who are already at risk. Over the four-year period examined diclofenac was dispensed in 50% of doses. Whilst the majority of this time period was prior to the patient safety alert (after which doses of diclofenac fell by 62%) over 8 million doses were still dispensed in 2013/14. This data set is a tangible example of the power of 'Big Data', and is something that is available today, to every hospital in the UK. There is the opportunity for those managing prescribing to examine this information, evaluate opportunities and ultimately drive more informed decision-making allowing for more effective patient outcomes. I hope you find the information contained both informative and insightful, and I look forward to sharing future reports with you as we continue to develop our understanding of dispensing activity within hospitals.

4 e x p l o r i n g the changing pat t e r n s of nsaid dispensing in uk hospita l s Comprehensive analysis of big data can monitor changes in treatment patterns IMS uses Hospital Pharmacy Audit (HPA) data to measure drug dispensing. The data set is the broadest and most comprehensive analysis of hospital dispensing activity and covers about 98% of UK NHS beds. WHAT DID WE MEASURE? IMS Health has hospital dispensing data for about 98% of activity in the UK. We have analysed dispensing patterns across four financial years: 2010/11 to 2013/14. Hospitals across England, Scotland, Wales and Northern Ireland were included. To compare hospitals meaningfully we converted actual prescriptions dispensed to a defined daily dose. This is a calculated average dose per day for a drug used for the main reason it is prescribed to adults. 1 We compared the use of diclofenac to four other NSAIDs. We have measured performance across England using the former Strategic Health Authority regions which existed formally until April 2013. 2 Please visit www.imshealth.com/hospitalanalyser to find our full methodologies and a list of hospital trusts we included and excluded. It enables staff such as hospital chief pharmacists and medical directors to benchmark their trust s drug use against peers, monitor spending and analyse trends. This is the first in the series of reports exploring hospital dispensing patterns within the IMS hospital data set. This report focuses on Non-Steroidal Anti- Inflammatory Drugs (NSAIDs) and in particular the dispensing patterns of diclofenac, which can increase 62% The fall in dispensing of diclofenac across our four-year period the risk of heart attack and stroke, especially with longterm use of high doses and in patients who are already at high risk. Our specific focus is on NHS hospital dispensing of these drugs and how patterns have changed over the last four financial years. In addition, it is this kind of information that can be used by prescribing committees and clinicians to monitor and measure the drugs dispensed in hospitals. 8m The number of doses of diclofenac still being dispensed in 2013/14 (29% of all NSAIDs) WHAT ARE NON-STEROIDAL ANTI-INFLAMMATORY DRUGS? NSAIDs are used to relieve pain, reduce inflammation and swelling and bring down high temperatures. Common long-term conditions that can be treated with NSAIDs include: most types of arthritis, chronic back pain and chronic neck pain. They can also be used to treat sprains, headache and other muscle pains. 3 These type of drugs are commonly prescribed in hospitals for arthritis and chronic pain. For this study we have looked at five different NSAIDs: celecoxib, diclofenac, ibuprofen, mefenamic acid and naproxen.

Comprehensive analysis of big data can monitor changes in treatment patterns 5 HOW DO THE FOUR UK NATIONS COMPARE? HOW DOES DISPENSING DIFFER ACROSS ENGLAND? -23% -8% NORTHERN IRELAND Dispensing rates for hospitals in Northern Ireland fell from 69% of all NSAIDs in 2010/11 to 46% in 2013/14 SCOTLAND Rates in Scotland have hardly fallen. Diclofenac accounted for 49% of all NSAIDs dispensed in 2010/11 and this remained at 41% in 2013/14 All regions There has been a year-on-year fall in the rate of dispensing of diclofenac 64% 28% Dispensing rates of diclofenac as a proportion of all NSAIDs across England have fallen from 2010/11 to 2013/14 75% 21% South East Coast has had the largest fall in dispensing rates between 2010/11 and 2013/14 13% The difference across England in 2013/14 with East of England, East Midlands and West Midlands dispensing the highest (34%) proportion of diclofenac and South East Coast dispensing the lowest (21%) proportion 30 % London, North West, South East Coast and South West have the lowest rates of diclofenac dispensing (as a proportion of all NSAIDs) -46% -36% WHY ARE WE CONCERNED ABOUT DICLOFENAC? Drug use in England is regulated by the Medicines and Healthcare Products Regulation Agency (MHRA). It ensures that drugs used in the NHS work and are acceptably safe. 4 In June 2013 it responded to a warning about diclofenac from the European Medicines Agency about a small increased risk of heart attacks and strokes for patients taking diclofenac. In light of this, the MHRA recommended that diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (e.g. high blood pressure, high cholesterol, diabetes and smokers). 5 WALES Wales had the largest fall in dispensing of diclofenac, from 56% of all NSAIDs in 2010/11 to 10% in 2013/14 ENGLAND England also had a sharp fall, with dispensing rates declining from 64% of all NSAIDs in 2010/11 to 28% in 2013/14

6 e x p l o r i n g the changing pat t e r n s of nsaid dispensing in uk hospita l s Are hospitals dispensing safely? WHAT HAVE WE FOUND? Overall dispensing of NSAIDs has fallen Dispensing of diclofenac has fallen the most sharply; particularly after the issue of the MHRA alert Dispensing of ibuprofen and naproxen have increased CHANGES IN DISPENSING OF NSAIDS Diclofenac 2010 11 2011 12 2012 13 2013 14 20,491,182 18,079,252 14,269,671 MHRA alert issued 7,746,723 Ibuprofen 10,107,101 10,660,596 11,559,041 13,123,511 Naproxen 1,469,615 2,043,673 3,381,127 5,414,394 IMS EXPERT VIEW Why are NSAIDs prescribed and what do they do? Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat pain and inflammation. They are effective for acute or chronic pain, and are important medicines for treatment of arthritis and many other conditions. Cyclo-oxygenase-2 inhibitors (coxibs) are a newer type of anti-inflammatory, developed to cause fewer gastric side effects than traditional NSAIDs. However, although coxibs cause fewer gastric problems, they are associated with a small increased risk of cardiovascular adverse events, such as stroke or heart attack. Celecoxib 368,501 306,796 282,241 257,000 Mefenamic Acid 378,378 360,632 335,463 328,289

Are hospitals dispensing safely? 7 HOW HAVE DISPENSING PATTERNS CHANGED? NSAIDs 121m doses of NSAIDs were dispensed over our four-year period 6 & 6m Doses of NSAIDs fell by six million over our time period Diclofenac 50 % of patients were dispensed diclofenac over our four-year period 62% The dispensing rate of diclofenac fell by 62% across our four-year period 8m doses of diclofenac were still being dispensed in 2013/14 (29% of all NSAIDs) { } Prescribing committees should use this information to inform decision making and monitor their compliance with changing guidance

8 e x p l o r i n g the changing pat t e r n s of nsaid dispensing in uk hospita l s Differences between the UK nations WHAT HAVE WE FOUND? All four countries have reduced the rate of diclofenac dispensing Rates in Wales and England have fallen more sharply than in Scotland and Northern Ireland DISPENSING RATES FOR DICLOFENAC BY COUNTRY 2010-2014 IMS EXPERT VIEW 80% 70% 60% 50% 40% 30% 20% Y2010_11 Y2011_12 Y2012_13 Y2013_14 Should patients prescribed diclofenac be worried? Most patients don t have side effects with NSAIDs or coxibs. However, they all occasionally cause serious side effects, so need to be used carefully, balancing individual risks and benefits. General advice with any drug is to take the lowest effective dose for the shortest time needed to control symptoms. In practice it is important that ongoing treatment is regularly reviewed for both safety and efficacy. If patients are prescribed diclofenac or coxibs and have any concerns about this, the best advice is to make an appointment to discuss this with their pharmacist or GP. 10% 0 England Northern Ireland Scotland Wales

Differences between the UK nations 9 DIFFERENT PATTERNS IN DIFFERENT NATIONS -8% SCOTLAND -23% Rates in Scotland have hardly fallen. Diclofenac accounted for 49% of all NSAIDs dispensed in 2010/11 and this remained at 41% in 2013/14 NORTHERN IRELAND Dispensing rates for hospitals in Northern Ireland fell from 69% of all NSAIDs in 2010/11 to 46% in 2013/14-46% WALES Wales had the largest fall in dispensing of diclofenac, from 56% of all NSAIDs in 2010/11 to 10% in 2013/14-36% ENGLAND England also had a sharp fall, with dispensing rates declining from 64% of all NSAIDs in 2010/11 to 28% in 2013/14

10 e x p l o r i n g the changing pat t e r n s of nsaid dispensing in uk hospita l s Patterns across England DISPENSING RATES FOR DICLOFENAC BY FORMER ENGLISH SHA 2010 TO 2014 2010 11 2011 12 2012 13 2013 14 20 30% 70 80% % is diclofenac: 20 30% 30 40% 40 50% 50 60% 60 70% 70 80% Regions: North East North West East of England East Midlands West Midlands East of England South West South Central London South East Coast

Patterns across England 11 WHAT HAVE WE FOUND? All regions have seen a year-on-year fall but London, North West, South East Coast and South West are doing better than other regions showing the biggest reductions in comparison to other regions IMPROVEMENTS IN EVERY REGION -36% Dispensing rates of diclofenac as a proportion of all NSAIDs across England have fallen from 2010/11 to 2013/14 13% The difference across England in 2013/14 with East of England, East Midlands and West Midlands dispensing the highest (34%) proportion of diclofenac and South East Coast dispensing the lowest (21%) proportion All regions IMS EXPERT VIEW How have the regions managed to make reductions? There are a number of drivers which may have led to the improvements across each region. These include repeated safety warnings from the MHRA; regular feedback on comparative NSAID use; sharing implementation experience; financial and quality incentives and practical tools to support change. Comparative prescribing data can be a useful tool to identify variation, and to drive and monitor change, as can regular audits and multidisciplinary review meetings. -54 % South East Coast has had the largest fall in dispensing rates between 2010/11 and 2013/14 There has been a year-on-year fall in the rate of dispensing of diclofenac 30% London, North West, South East Coast and South West have the lowest rates of diclofenac dispensing (as a proportion of all NSAIDs)

12 e x p l o r i n g the changing pat t e r n s of nsaid dispensing in uk hospita l s NSAID methodology INCLUDED AND EXCLUDED DATA This analysis of rates of dispensing for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) is based on an anonymised, patient-level data set containing dispensing data from the following four full years of data: 2010/11 Q2 2010 to Q1 2011 inclusive 2011/12 Q2 2011 to Q1 2012 inclusive 2012/13 Q2 2012 to Q1 2013 inclusive The following single-molecule NSAIDs were included in the analysis: Celecoxib Diclofenac Ibuprofen 2013/14 Q2 2013 to Q1 2014 inclusive DEFINED DAILY DOSES (DDDs) The source data set contains 436 different NSAID packs that were included in this analysis. In order to enable comparison between dispensing rates of the NSAIDs, all prescriptions were converted to defined daily doses (DDDs). A DDD is defined as the assumed average maintenance dose per day for a drug used for its main indication in adults. For the purposes of this analysis, converting all prescriptions to DDDs allowed us to use a single unit of measurement across the data set. The process of calculating a DDD may be best illustrated by an example. The DDD for diclofenac is 0.1g. A 100mg tablet is therefore the equivalent of one DDD; a 75mg tablet is the equivalent of 0.75 DDDs. A prescription of a pack of 56 diclofenac tablets, each weighing 75mg, is equivalent to 42 DDDs (0.75 x 56 = 42). This prescription would therefore be included in the analysis as 42 DDDs. Full details of DDDs can be found on the website of the World Health Organisation Collaborating Centre for Drugs Statistics Methodology (www.whocc.no/atc_ddd_index/). Mefenamic Acid Naproxen Combination NSAIDs (i.e. those containing more than one of the above NSAIDs) were excluded from the analysis.

NSAID methodology 13 COUNTS AND RATES The analysis contains both counts (i.e. the sum of all DDDs for each molecule) and rates. The denominator for the calculation of rates is the total count of DDDs for all five molecules for the relevant time period. The numerator is the count of diclofenac DDDs for the relevant time period. COMPARISON BY NATION AND REGION The analysis includes a comparison of rates of diclofenac dispensing across the nations of the UK and English regions. The English regions are based on the pre-2013 Strategic Health Authorities (SHAs), with hospital trusts allocated to region following the rules used by those SHAs. The comparison between the nations of the UK and the regions of England is restricted to NHS hospitals, but does include dispensing for private patients treated in NHS hospitals. Dispensing in non-nhs hospitals are excluded from these comparisons. This follows the conventions of the source data set, in which private hospitals are not coded as part of the regions and nations. BINOMIAL OUTLIERS Binomial outliers were calculated using an Association of Public Health Observatories template for public health data (www.apho.org.uk/resource/item. aspx?rid=47241). However, this resulted in such great over-dispersion that we concluded that this was not explicable by statistical modeling, and was therefore not appropriate for inclusion. The source data set contains 436 different NSAID products that were included in this analysis.

14 e x p l o r i n g the changing pat t e r n s of nsaid dispensing in uk hospita l s References and acknowledgements Footnotes For further reading please see: Have hospitals got the message about NSAIDs and cardiovascular risk? Carina Livingstone BPharm, PhD, Julia Wright BSc and Marion Fyfe BA IMS Health would like to thank the following people for contributing to this report: Professor Sir Alasdair Breckenridge Dr Carina Livingstone, Associate Director, NHS East and South East England Specialist Pharmacy Services Colleagues at every NHS acute hospital trust who have been working with IMS Health to supply data to Hospital Pharmacy Analyser 1 www.whocc.no/ddd/definition_and_general_considera/ 2 www.nhs.uk/nhsengland/aboutnhs/documents/ MapofSHAsFeb09.pdf 3 www.nhs.uk/conditions/anti-inflammatories-nonsteroidal/pages/introduction.aspx 4 www.mhra.gov.uk 5 www.mhra.gov.uk/safetyinformation/ DrugSafetyUpdate/CON286975 6 Based on defined daily dose, please visit: www.imshealth.com/hospital-analyser for our full methodology IMS team: Laura-Jane Bedding David Franks Joanne Grimley Olivia Rees Editorial and analysis team: Alex Kafetz, ZPB Associates David Mullet, ZPB Associates Professor Simon Jones, ZPB Associates Phil Reid, design to communicate Stefania Biagini, design to communicate Copyright October 2014. Unless explicitly stated otherwise, all rights including copyright in the content of this report are owned by IMS Health. The content of this report may not be copied, reproduced, republished, posted, broadcast or transmitted in any way without first obtaining IMS Health s written permission. This report may be referenced or quoted (but not for commercial purposes) as long as copyright is acknowledged.

Additional information is available at: WWW.IMSHEALTH.COM/ HOSPITAL-ANALYSER