Primary Care
Prescribing Analysis –
Medicines Used in
Diabetes
September 2015
This report has been prepared by the Welsh Analytical Prescribing Support Unit
(WAPSU) with the support of a multiprofessional collaborative group, which includes
members of the All Wales Prescribing Advisory Group (AWPAG) and the All Wales
Therapeutics and Toxicology Centre (AWTTC), and has subsequently been endorsed
by the All Wales Medicines Strategy Group (AWMSG).
Please direct any queries to AWTTC:
All Wales Therapeutics and Toxicology Centre
University Hospital Llandough
Penlan Road
Llandough
Vale of Glamorgan
CF64 2XX
[email protected]
029 2071 6900
This document should be cited as:
All Wales Medicines Strategy Group. Primary Care Prescribing Analysis – Medicines
Used in Diabetes. September 2015.
Primary Care Prescribing Analysis – Drugs Used in Diabetes
EXECUTIVE SUMMARY
•
Medicines used in diabetes account for approximately 10% of primary care
prescribing.
•
Services for diabetes account for 10% of all NHS expenditure in the UK, and
the incidence of diabetes is increasing in Wales1.
•
Prescribing of medicines used in diabetes in 2014–2015 accounted for £57.2
million (9.8% of total medicines expenditure in NHS Wales) and 3,273,664
items (4.2%) in primary care, and £2.6 million (1.5%) in secondary care.
Prescribing via the WP10HP route amounted to £78,668 (6,319 items).
•
The prescribing of insulins accounted for £20.7 million and 442,107 items in
2014–2015, while antidiabetic drugs accounted for £25.2 million and 2.4 million
items. Monitoring and screening agents accounted for £11 million and 452,565
items in the same period.
•
Items of long-acting insulin analogues as a percentage of total long- and
intermediate-acting insulin (excluding biphasics) are monitored as part of the
Clinical Effectiveness Prescribing Programme (CEPP) Local Comparators for
2015–2016. Long-acting insulin analogues accounted for £8.5 million and
157,297 items in primary care in 2014.
•
There is variation between the health boards in a number of areas including
blood glucose monitoring agents, long-acting insulin analogues as a percentage
of total long- and intermediate-acting insulin, and sulphonylureas and metformin
items as a percentage of all diabetic treatment agents.
•
There has been a 14% increase in the cost of prescribing of ‘other antidiabetic
drugs’ such as GLP-1s, DPP-4 inhibitors and thiazolidinediones within NHS
Wales in 2014–2015 compared to 2013–2014, with variation between health
boards. There may be opportunities for cost savings to be made through
prescribing in line with national guidance, such as the first- and second-line use
of metformin and sulphonylureas.
•
Outcome measures are explored in the document, and outcomes data are
analysed alongside prescribing data for diabetes medicines. Diabetes-related
admissions and prescribing vary across the health boards, but the relationship
between the two is complex and more work is needed to understand how
prescribing can influence measurable outcomes.
•
GP cluster data are presented in this document, in which GP clusters are
grouped together based on diabetes prevalence and deprivation scores to
produce comparators for the purpose of benchmarking.
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CONTENTS
1.0 INTRODUCTION .................................................................................................... 4
1.1 Diabetes overview .............................................................................................. 4
1.2 Diabetes complications ....................................................................................... 4
2.0 BACKGROUND...................................................................................................... 5
3.0 CURRENT DIABETES GUIDANCE........................................................................ 6
3.1 Welsh Government Report – Together for Health – A Diabetes Delivery Plan .... 6
3.2 National Institute of Health and Care Excellence (NICE) guidance ..................... 6
3.3 Clinical Effectiveness Prescribing Programme (CEPP) Local Comparators ........ 6
3.4 Driver and Vehicle Licensing Agency (DVLA) guidance ...................................... 6
4.0 DIABETES PREVALENCE ..................................................................................... 7
4.1 Diabetes prescribing data ................................................................................... 8
4.1.1 Total diabetes prescribing data..................................................................... 8
4.2 Insulins ..............................................................................................................12
4.3 Antidiabetic drugs ..............................................................................................14
4.4 Diagnostic and monitoring devices for diabetes .................................................16
5.0 OUTCOMES DATA ...............................................................................................17
REFERENCES ............................................................................................................21
APPENDIX 1. GP CLUSTER COMPARATORS ..........................................................23
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Primary Care Prescribing Analysis – Drugs Used in Diabetes
TABLE OF FIGURES
Figure 1. Number of patients on QOF diabetes register in Wales 2008–2009 to 2013–2014 ...... 7
Figure 2. Prescribing for the three major sub-sections within Drugs used in diabetes (BNF 6.1) –
Total items in Wales ...................................................................................................................... 8
Figure 3. Prescribing for the three major sub-sections within Drugs used in diabetes (BNF 6.1) –
Total cost in Wales ........................................................................................................................ 9
Figure 4. Prescribing for all diabetes medicines – Items per 1,000 PUs in Wales, England and
NE England ................................................................................................................................... 9
Figure 5. Prescribing for all diabetes medicines – Cost per 1,000 PUs in Wales, England and
NE England ................................................................................................................................... 9
Figure 6. Prescribing for all diabetic medicines by category – Total items in Wales .................. 10
Figure 7. Prescribing for all diabetic medicines by category – Total cost in Wales .................... 10
Figure 8. Average cost per item for different diabetic medicine categories in Wales ................. 10
Figure 9. Diabetes prescribing cost breakdown April 2014–March 2015 ................................... 11
Figure 10. Diabetes prescribing items breakdown April 2014–March 2015 ............................... 11
Figure 11. Prescribing for DPP-4 inhibitors – Total items in Wales ............................................ 11
Figure 12. Prescribing for GLP-1s – Total items in Wales .......................................................... 12
Figure 13. Prescribing of selected non-biphasic intermediate- and long-acting insulins – Total
items in Wales ............................................................................................................................. 12
Figure 14. Prescribing of selected non-biphasic intermediate- and long-acting insulins – Total
cost in Wales ............................................................................................................................... 13
Figure 15. Local Comparator: Items of long-acting insulin analogues as a percentage of total
long- and intermediate-acting insulin (excluding biphasics) in Wales ......................................... 13
Figure 16. Prescribing of long-acting insulin analogues as a percentage of total long- and
intermediate-acting insulin (excluding biphasics) – Welsh health boards compared to English
CCGs – Quarter ending March 2015 .......................................................................................... 13
Figure 17. Prescribing of antidiabetic medicines – Total items in Wales .................................... 14
Figure 18. Prescribing of antidiabetic medicines – Total cost in Wales ...................................... 14
Figure 19. Local Comparator: Sulphonylureas and metformin items as a percentage of all
diabetic treatment agents (excluding insulin) June 2012–March 2015 ....................................... 14
Figure 20. Breakdown of ‘Other antidiabetic drugs’ – Items per 1,000 PUs April 2014–March
2015............................................................................................................................................. 15
Figure 21. Breakdown of ‘Other antidiabetic drugs’ – Cost per 1,000 PUs April 2014–March
2015............................................................................................................................................. 15
Figure 22. Prescribing of glucose blood testing reagents– Cost per 1,000 PUs weighted by
diabetes prevalence April 2013–March 2015 .............................................................................. 16
Figure 23. Prescribing of glucose blood testing reagents – Items per 1,000 PUs weighted by
diabetes prevalence April 2013–March 2015 .............................................................................. 16
Figure 24. Admissions for diabetes-related HRGs per 100,000 diabetic population 2013–2014 18
Figure 25. Diabetes-related HRG admissions per 100,000 population against the cost of
prescribing in diabetes 2013–2014 ............................................................................................. 19
Figure 26. Diabetes-related HRG admissions per 100,000 population against the prescribing of
long-acting insulin analogues as a percentage of total long- and intermediate-acting insulins
(excluding biphasics) 2013–2014................................................................................................ 19
Figure 27. Percentage of patients achieving HbA1c target compared with the cost of diabetes
prescribing per 1,000 PUs 2014–2015........................................................................................ 20
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1.0 INTRODUCTION
1.1 Diabetes overview
Diabetes has a significant impact on the population of Wales, affecting 5.6% of the
adult population2. This percentage increases with age, and in the older age group (over
65 years) a higher proportion of men than women are reported as being treated for
diabetes. The prevalence of type 2 diabetes mellitus is increasing in the UK and
worldwide3, and projections estimate that UK prevalence will increase by 50% over the
next decade. Although diabetes can result in ill health, disability and even premature
death, these can often be prevented by effective self-management, education and
high-quality care.
The diabetic therapeutic area is complex and encompasses a wide range of specific
indications and treatment areas. Prescribing data presented in this report relate to the
use of medicines across the diabetic therapeutic area and the term ‘diabetes
medicines’ refers to medicines that are listed in the British National Formulary (BNF)
under Section 6.1 Drugs used in diabetes. However, we can assume that the main
indications for treatment, representing the majority of prescribing, will be type 1 and
type 2 diabetes mellitus. Therefore, although the treatment of diabetes may cover a
wider range of medicines, e.g. medicines used in diabetic neuropathy, nephropathy
and retinopathy, as well as medicines used for foot care, for the purposes of this report,
diabetic medicines refers to medicines used directly in diabetes.
1.2 Diabetes complications
Diabetes is associated with raised blood pressure, a disturbance of blood lipid levels
and a tendency to develop cardiovascular disease and stroke. The increased
cardiovascular risks associated with type 2 diabetes include coronary artery disease,
peripheral artery disease and carotid artery disease. Specific complications of diabetes
include eye damage, kidney damage and nerve damage. The wide ranging
complications of diabetes mean that the condition draws on many areas of healthcare
management and that the pharmacological treatment is often complex. Management of
type 2 diabetes often involves a large element of self-care and therefore treatment will
be tailored for the individual4. While the prescribing for these complications is beyond
the scope of this report, safe, effective and cost-effective prevention and treatment of
diabetes will influence the impact of these complications.
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Primary Care Prescribing Analysis – Drugs Used in Diabetes
2.0 BACKGROUND
The Primary Care Prescribing Analysis – Medicines Used in Diabetes is the latest in a
series of prescribing analysis reports produced by WAPSU:
• Respiratory Prescribing Analysis with Cluster Level Comparators (Feb 2015)
• GP Cluster Level Comparators (October 2014)
• BNF Chapter Analysis of the Eye, Respiratory and Cardiovascular Therapeutic
Areas (March 2014)
• BNF Chapter Analysis (September 2013)
Diabetes medicines have been chosen as the next area for analysis as they account
for a large proportion, approximately 10%, of prescribing expenditure and services in
the UK5, and diabetes incidence is increasing in Wales6. The Diabetes Delivery Plan
describes the current rate of increase in spend on diabetes as unsustainable and
recommends that action needs to be taken to address this6. This report aims to provide
prescribing leads with analysis of the diabetes therapeutic area, and in particular
focuses on:
• Primary care prescribing analysis of the BNF diabetes chapter;
• Prescribing trends, cost and items per patient;
• Wales, England and North East (NE) England comparative prescribing trends;
• Influence of measurable variables on prescribing e.g. demographics;
• Outcomes data;
• GP cluster level comparators.
Diabetes prescribing GP cluster data for Wales are presented in eight groups of the
most similar GP clusters based on diabetes prevalence and deprivation. This method
for presenting data should enable GP cluster groups and health boards to make
meaningful comparisons of their prescribing rates with areas of a similar disease
prevalence and deprivation profile.
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3.0 CURRENT DIABETES GUIDANCE
3.1 Welsh Government Report – Together for Health – A Diabetes Delivery Plan
It is important that ongoing work in NHS Wales addresses the number of people
affected by diabetes and the complications arising from the condition by promoting
healthy lifestyles and ensuring that those affected by any kind of diabetes are well
informed about their condition and have timely access to services1.
The Welsh Government report, Together for Health – A Diabetes Delivery Plan,
describes aims to have effective plans in place in Wales to prevent diabetes and
reduce the risk of long-term diabetic complications6. The report sets out new Welsh
Government commitments to the public and supports the continuing delivery of service
standards established in the Diabetes National Service Framework, published in 20037.
The report describes the outcome indicators below to measure success:
• Incidence of type 2 diabetes mellitus per 100,000 population
• Circulatory disease mortality rate for < 75 year olds/100,000 population
• Age group specific diabetes mortality rate for < 75 year olds/100,000 population
• Variations in incidence of complications of diabetes by geography and
deprivation6
3.2 National Institute of Health and Care Excellence (NICE) guidance
There are a number of specific NICE Clinical Guidelines (CGs) and NICE Technology
Appraisals (TAs) relating to the use of diabetes medicines and patient treatment. See
the Diabetes topic page on the NICE website for more information.
Current diabetes guidance recommends a patient-centred care approach and the
management of diabetes typically involves a considerable element of self-care. The
advice, therefore, should be aligned with the perceived needs and preferences of
people with diabetes and their carers. People with diabetes should be able to make
informed decisions about their care and treatment, in partnership with their healthcare
professionals. Communication between healthcare professionals and patients is
essential and should be supported by evidence-based written information tailored to
the patient’s needs. New NICE guidance on type 2 diabetes is due in October 2015.
3.3 Clinical Effectiveness Prescribing Programme (CEPP) Local Comparators
Diabetes treatment is included in the CEPP Local Comparators for Wales 2015–20168
to promote the appropriate use of the newer diabetic treatment agents and long-acting
insulin analogues in type 2 diabetes mellitus in line with NICE CG87, TA203 and
TA2484,9,10. The Local Comparators are measures produced to allow health boards to
benchmark across a range of prescribing indicators. They are not reported nationally
but are available for both local and national comparative measurement as necessary in
accordance with local prioritisation. Caution should be exercised in the interpretation of
Local Comparator data, as some comparators may be more relevant to benchmark for
one health board than another. The list of comparators is circulated directly to Chief
Pharmacists and Medicines and Therapeutics Committees.
The diabetes-related Local Comparators include:
• Sulphonylureas and metformin items as a percentage of all diabetic treatment
agents (excluding insulin).
• Glucagon-like peptide-1 agonists – exenatide, liraglutide and lixisenatide – as a
percentage of diabetic treatment agents (excluding insulin).
• Items of long-acting insulin analogues as a percentage of total long- and
intermediate-acting insulin (excluding biphasics).
• Cost of diabetic self-monitoring agents per 1,000 PUs (weighted by diabetes
prevalence).
3.4 Driver and Vehicle Licensing Agency (DVLA) guidance
The DVLA gives advice on driving requirements relating to blood glucose control.
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Primary Care Prescribing Analysis – Drugs Used in Diabetes
4.0 DIABETES PREVALENCE
Table 1 shows diabetes percentage prevalence for Wales and the Welsh health boards
from 2008–2009 to 2013–2014. Diabetes prevalence data are from the Quality and
Outcomes Framework (QOF), Wales. The data are taken from the GP register and
include patients aged 17 and over and does not distinguish between type 1 and type 2
diabetes2.
Table 1. Diabetes prevalence
Year
QOF figures for diabetes prevalence (%)
ABMU
Aneurin Bevan
Betsi
Cadwaladr
Cardiff and
Vale
Cwm
Taf
Hywel
Dda
Powys
All
Wales
2008/09
5.1
5.1
4.4
3.8
4.7
4.8
4.6
4.6
2009/10
5.3
5.4
4.6
4.0
4.9
5.1
4.8
4.9
2010/11
5.5
5.6
4.8
4.1
5.1
5.3
5.0
5.1
2011/12
5.6
5.9
5.0
4.3
5.3
5.4
5.3
5.3
2012/13
5.8
6.1
5.2
4.4
5.5
5.6
5.5
5.4
2013/14
6.0
6.2
5.4
4.5
5.7
5.8
5.7
5.6
Figure 1. Number of patients on QOF diabetes register in Wales 2008–2009 to 2013–2014
Number of patients
200,000
150,000
100,000
50,000
0
2008-09
2009-10
2010-11
2011-12
2012-13
2013-14
Table 2 shows a selection of health-related indicators relevant to the diabetes
therapeutic area for Wales, England and NE England and for the Welsh health boards.
Table 2. Prevalence of health-related indicators (percentage of population)
ABMU
Aneurin
Bevan
BCU
Cardiff
& Vale
Cwm
Taf
Hywel
Dda
Powys
Wales
England
NE
England
9.9
11.8
10.2
7.9
12.0
10.1
10.8
10.3
7.7
10.2
15.2
16.2
16.2
12.5
16.8
16.3
17.3
15.5
13.7
15.6
Heart failure
1.0
0.9
1.0
0.7
0.8
1.0
1.1
0.9
0.7
0.9
Coronary heart
disease2
4.0
3.9
4.1
2.9
4.0
4.2
4.1
3.9
3.3
4.5
Adults smoking
daily or
occasionally11,12
23
24
23
22
27
23
23
24
20
21
26.7
24.1
12.7
23.5
35.5
8.1
1.7
20
20.3
32.4
Obesity2
Hypertension2
2
% in most
deprived 5th13
It should be noted that the data in Table 2 are taken from a variety of sources and that
data collection methods may vary between England and Wales. Smoking prevalence
figures, for example, vary from source to source and year to year depending on how
prevalence is measured e.g. Welsh smoking prevalence rates vary from 25% in the
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All Wales Medicines Strategy Group
2010 ONS general lifestyle survey to 20% in the Welsh Government Welsh health
survey. Some of the data are taken from surveys, which rely on people being honest
about their habits, while QOF data are recorded by the GP. Likewise, the Welsh and
English Indices of Multiple Deprivation are calculated slightly differently and this should
be taken into account when making comparisons.
4.1 Diabetes prescribing data
The data presented in this report include:
• Overall prescribing for Wales
• Prescribing trends for health boards, Wales, England and NE England
• Comparisons of health boards with CCGs
Most recent data represent the year or quarter to March 2015, and trend data date
back to the quarter ending June 2009.
The figures were provided by NHS Wales Shared Services Partnership (NWSSP) and
were accessed via the Comparative Analysis System for Prescribing Audit (CASPA)
database.
The figures in the document represent items prescribed and cost, and relate to
prescriptions that were dispensed and forwarded for reimbursement. Information on
prescriptions that were not dispensed is not available, therefore the term “prescribed” is
used here to represent items which were both prescribed and dispensed.
4.1.1 Total diabetes prescribing data
Table 3. Prescribing for all medicines included in Drugs used in diabetes (BNF 6.1) in
Wales
Items
Total items
Cost
Change on
previous
year
% change
on previous
year
Total cost (£)
Change on
previous
year
% change
on previous
year
2010/11
2,666,389.00
181,985
7.33
45,459,650.16
4,768,031
11.72
2011/12
2,826,009.00
159,620
5.99
48,763,885.73
3,304,236
7.27
2012/13
2,955,880.00
129,871
4.60
49,564,275.31
800,390
1.64
2013/14
3,119,112.00
163,232
5.52
52,666,259.72
3,101,984
6.26
2014/15
3,273,664.00
154,552
4.96
57,235,757.82
4,569,498
8.68
Figure 2. Prescribing for the three major sub-sections within Drugs used in diabetes
(BNF 6.1) – Total items in Wales
900000
800000
Total items
700000
600000
500000
400000
300000
200000
100000
0
Insulins
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Antidiabetic drugs
Blood glucose testing
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Figure 3. Prescribing for the three major sub-sections within Drugs used in diabetes
(BNF 6.1) – Total cost in Wales
16000000
14000000
Total cost (£)
12000000
10000000
8000000
6000000
4000000
2000000
0
Insulins
Antidiabetic drugs
Blood glucose testing
Figure 4. Prescribing for all diabetes medicines – Items per 1,000 PUs in Wales, England
and NE England
200
Items per 1,000 PUs
180
160
140
120
100
80
60
40
20
0
Wales
England
NE England
Figure 5. Prescribing for all diabetes medicines – Cost per 1,000 PUs in Wales, England
and NE England
4000
Cost per 1,000 PUs
3500
3000
2500
2000
1500
1000
500
0
Wales
England
NE England
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Figure 6. Prescribing for all diabetic medicines by category – Total items in Wales
400,000
Total items
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
Human analogue insulins
Other insulins
Metformin
Sulfonylureas
Other antidiabetic drugs
Blood glucose testing
Figure 7. Prescribing for all diabetic medicines by category – Total cost in Wales
6,000,000
Total cost
5,000,000
4,000,000
3,000,000
2,000,000
1,000,000
0
Human analogue insulins
Other insulins
Metformin
Sulfonylureas
Other antidiabetic drugs
Blood glucose testing
Average cost per item (£)
Figure 8. Average cost per item for different diabetic medicine categories in Wales
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Human analogue insulins
Other insulins
Metformin
Sulfonylureas
Other antidiabetic drugs
Blood glucose testing
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Primary Care Prescribing Analysis – Drugs Used in Diabetes
Cost per 1,000 PUs (£)
Figure 9. Diabetes prescribing cost breakdown April 2014–March 2015
£16,000.00
£14,000.00
£12,000.00
£10,000.00
£8,000.00
£6,000.00
£4,000.00
£2,000.00
£0.00
Insulins
Antidiabetic drugs
Blood glucose testing
Items per 1,000 PUs
Figure 10. Diabetes prescribing items breakdown April 2014–March 2015
900
800
700
600
500
400
300
200
100
0
Insulins
Antidiabetic drugs
Blood glucose testing
Figure 11. Prescribing for DPP-4 inhibitors – Total items in Wales
45,000
40,000
35,000
Items
30,000
25,000
20,000
15,000
10,000
5,000
0
Vildagliptin
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin
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Figure 12. Prescribing for GLP-1s – Total items in Wales
14,000
12,000
Items
10,000
8,000
6,000
4,000
2,000
0
Liaglutide
Exenitide
Lixisenatide
4.2 Insulins
This section examines the prescribing of injectable insulin products. Insulin is
inactivated by gastro-intestinal enzymes and therefore cannot be orally administered14.
The use of human sequence insulins, produced bio-synthetically by recombinant DNA
technology and commonly known as human analogue insulins, has replaced some use
of more established and less expensive insulins.
The BNF describes and categorises these human analogue insulins as:
• Short-acting insulin
− Insulin aspart
− Insulin glulisine
− Insulin lispro
• Intermediate- and long-acting insulin
− Insulin degludec
− Insulin detemir
− Insulin glargine
− Biphasic insulin aspart
− Biphasic insulin lispro
Figures 13 and 14 show the prescribing of selected non-biphasic intermediate and long
acting insulins. AWMSG advice states that insulin degludec is not recommended for
use within NHS Wales for the treatment of diabetes mellitus in adults. This advice was
ratified by the Minister for Health and Social Services in July 201415.
Figure 13. Prescribing of selected non-biphasic intermediate- and long-acting insulins –
Total items in Wales
35000
Total items
30000
25000
20000
15000
10000
5000
0
Insulin detemir
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Insulin glargine
Isophane insulin
Insulin degludec
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Total cost (£)
Figure 14. Prescribing of selected non-biphasic intermediate- and long-acting insulins –
Total cost in Wales
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
Insulin detemir
Insulin glargine
Isophane insulin
Insulin degludec
Figure 15. Local Comparator: Items of long-acting insulin analogues as a percentage of
total long- and intermediate-acting insulin (excluding biphasics) in Wales
Percenatge
98.00
93.00
88.00
83.00
78.00
ABMU
Aneurin Bevan
BCU
Cwm Taf
Hywel Dda
Powys
Cardiff and Vale
Percentage
70
Hywel Dda
Betsi Cadwaladr
80
Cardiff and Vale
ABMU
90
Cwm Taf
100
Powys
Aneurin Bevan
Figure 16. Prescribing of long-acting insulin analogues as a percentage of total long- and
intermediate-acting insulin (excluding biphasics) – Welsh health boards compared to
English CCGs – Quarter ending March 2015
60
50
40
30
20
10
0
CCG / HB
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4.3 Antidiabetic drugs
NICE CG87 on blood glucose lowering therapy for type 2 diabetes recommends that
metformin should be used first-line and a sulphonylurea second-line unless contraindicated16.
Figures 17 and 18 show prescribing of metformin and sulphonylureas alongside other
anti-diabetic drugs, and Figure 19 shows the proportion of metformin and
sulphonylurea prescribing that is in line with the CEPP Local Comparator 2015–2016.
Figure 17. Prescribing of antidiabetic medicines – Total items in Wales
400000
350000
Total items
300000
250000
200000
150000
100000
50000
0
Metformin
Sulphonylureas
Other antidiabetic drugs
Total cost (£)
Figure 18. Prescribing of antidiabetic medicines – Total cost in Wales
5000000
4500000
4000000
3500000
3000000
2500000
2000000
1500000
1000000
500000
0
Metformin
Sulphonylureas
Other antidiabetic drugs
% of items
Figure 19. Local Comparator: Sulphonylureas and metformin items as a percentage of all
diabetic treatment agents (excluding insulin) June 2012–March 2015
88
86
84
82
80
78
76
74
72
70
68
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Aneurin Bevan
Cardiff and Vale
Hywel Dda
ABMU
Powys
Cwm Taf
Betsi Cadwaladr
Primary Care Prescribing Analysis – Drugs Used in Diabetes
There has been a 14% increase in the cost of prescribing of ‘other antidiabetic drugs’
such as GLP-1s, DPP-4 inhibitors and thiazolidinediones within NHS Wales in 2014–
2015 compared to 2013–2014, with variation between health boards. There may be
opportunities for cost savings to be made through prescribing in line with national
guidance, such as the first- and second-line use of metformin and sulphonylureas.
*
Figure 20. Breakdown of ‘Other antidiabetic drugs’ – Items per 1,000 PUs April 2014–
March 2015
Items per 1,000 PUs
120.00
100.00
80.00
60.00
40.00
20.00
0.00
DPP-4 inhibitors
GLP-1s
Thiazolidinediones
Cost per 1,000 PUs (£)
Figure 21. Breakdown of ‘Other antidiabetic drugs’* – Cost per 1,000 PUs April 2014–
March 2015
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
DPP-4 inhibitors
GLP-1s
Thiazolidinediones
*
‘Other antidiabetic drugs’ are grouped together as per the BNF and include thiazolidinediones, DPP-4
inhibitors and GLP-1s.
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4.4 Diagnostic and monitoring devices for diabetes
Diagnostic monitoring for diabetes comprises a significant cost in NHS Wales primary
care prescribing, accounting for almost £11 million and 452,565 items in 2014–2015.
This included glucose blood testing reagents, ketone blood testing reagents and urine
testing reagents. The majority of the cost was for glucose blood testing reagents
accounting for £10.8 million and 440,118 items.
Figure 22. Prescribing of glucose blood testing reagents – Cost per 1,000 PUs weighted
by diabetes prevalence April 2013–March 2015
Cost per 1,000 PUs/diabetes
prevalence (£)
600
500
400
300
200
100
0
Aneurin
Bevan
ABMU
Wales
Powys
Hywel Dda Cwm Taf
Cardiff
Betsi
And Vale Cadwaladr
Figure 23. Prescribing of glucose blood testing reagents – Items per 1,000 PUs weighted
by diabetes prevalence April 2013–March 2015
Items per 1,000 PUs/diabetes
prevalence
19.00
18.50
18.00
17.50
17.00
16.50
16.00
15.50
ABMU
Page 16 of 31
Hywel
Dda
Aneurin
Bevan
Wales
Cardiff
And Vale
Powys
Cwm Taf
Betsi
Cadwaladr
Primary Care Prescribing Analysis – Drugs Used in Diabetes
5.0 OUTCOMES DATA
Outcomes data have been analysed here using healthcare resource groups (HRGs).
These are groups of patient-anonymised data, which refer to secondary care
procedures and admissions. They comprise standard groupings of clinically similar
treatments, which use common levels of healthcare resource17. HRGs help
organisations to understand their activity in terms of the types of patients they care for
and the treatments they undertake. The data are also linked back to GP practices.
They cover a wide range of diabetes outcomes from admissions with a primary
diagnosis of diabetes mellitus to lower limb complication admissions and amputation
procedures. They enable the comparison of activity within and between different
organisations and provide an opportunity to benchmark treatments and services to
support trend analysis over time.
Table 4. Selected diabetes-related HRG codes
HRG code
Description
KB01C
Diabetes with Hypoglycaemic Disorders, with CC Score 8+
KB01D
Diabetes with Hypoglycaemic Disorders, with CC Score 5-7
KB01E
Diabetes with Hypoglycaemic Disorders, with CC Score 3-4
KB01F
Diabetes with Hypoglycaemic Disorders, with CC Score 0-2
KB02G
Diabetes with Hyperglycaemic Disorders, with CC Score 8+
KB02H
Diabetes with Hyperglycaemic Disorders, with CC Score 5-7
KB02J
Diabetes with Hyperglycaemic Disorders, with CC Score 2-4
KB02K
Diabetes with Hyperglycaemic Disorders, with CC Score 0-1
KB03C
Diabetes with Lower Limb Complications, with CC Score 9+
KB03D
Diabetes with Lower Limb Complications, with CC Score 5-8
KB03E
Diabetes with Lower Limb Complications, with CC Score 0-4
YQ23A
Multiple Amputation Stump or Partial Foot Amputation Procedures, for Diabetes or Arterial
Disease, with CC Score 8+
YQ23B
Multiple Amputation Stump or Partial Foot Amputation Procedures, for Diabetes or Arterial
Disease, with CC Score 0-7
YQ24A
Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial
Disease, with Other Open Blood Vessel Procedure, with CC Score 8+
YQ24B
Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial
Disease, with Other Open Blood Vessel Procedure, with CC Score 0-7
YQ25A
Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial
Disease, with Imaging Intervention, with CC Score 8+
YQ25B
Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial
Disease, with Imaging Intervention, with CC Score 0-7
YQ26A
Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial
Disease, with CC Score 8+
YQ26B
Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial
Disease, with CC Score 5-7
YQ26C
Single Amputation Stump or Partial Foot Amputation Procedure, for Diabetes or Arterial
Disease, with CC Score 0-4
Page 17 of 31
All Wales Medicines Strategy Group
Figure 24 shows admissions per 100,000 health board population for the diabetesrelated HRGs detailed in Table 4 for April 2013–March 2014.
Admissions per 100,000 diabetic
population
Figure 24. Admissions for diabetes-related HRGs per 100,000 diabetic population 2013–
2014
20
18
16
14
12
10
8
6
4
2
0
ABMU
Aneurin
Bevan
Betsi
Cardiff and
Cadwaladr
Vale
Cwm Taf
Hywel Dda
Powys
There are limitations to the outcomes data available through the HRGs. For example,
although diabetes may be the underlying reason for the admission to hospital, and the
complexity of the condition may affect length of stay, the primary reason for admission
may be coded as something different and unrelated. A National Diabetes Inpatient
Audit in 201318 reported the percentage of beds occupied by people with diabetes as
15.8%, although only 8.1% of these patients were recorded as having been admitted
due to diabetes or a diabetes-related complication. This may indicate that the HRG
admission figures which are directly related to diabetes would only cover a small
proportion of admissions for which diabetes was a contributing factor. The correlation
between admissions directly related to diabetes and prescribing of diabetes medicines,
as represented in Figures 25 and 26, is not significant (p>0.05). Further relationships
between diabetes-related admissions and prescribing related to diabetes were
examined, for example the relationship between admissions due to hypoglycaemic or
hyperglycaemic disorders and various prescribing measures, but showed no significant
correlations. This highlights that the link between prescribing and admissions may be
complex.
Page 18 of 31
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Figures 25 and 26 show diabetes-related HRGs per 100,000 population against the
cost of prescribing in diabetes per 1,000 PUs. The outcomes data and the prescribing
data have been adjusted to account for variation in disease prevalence between the
health boards.
There is variation between the health boards in the relationship between diabetesrelated HRGs and the cost of medicines prescribed for diabetes, and this further
highlights that the association between prescribing and outcomes is complex.
Diabetes related HRGs per 100,000
population
20
3000
18
2500
16
14
2000
12
10
1500
8
1000
6
4
500
2
0
0
ABMU
Aneurin
Bevan
Betsi
Cardiff and
Cadwaladr
Vale
Cwm Taf
Admissions per 100,000 diabetic population
Hywel Dda
Cost of diabetes prescribing per 1,000
PUs
Figure 25. Diabetes-related HRG admissions per 100,000 population against the cost of
prescribing in diabetes 2013–2014
Powys
Cost per 1,000 PUs
25
20
18
20
16
14
15
12
10
10
8
6
5
4
2
0
0
ABMU
Aneurin
Bevan
Betsi
Cardiff and Cwm Taf
Cadwaladr
Vale
Admissions per 100,000 diabetic population
Hywel Dda
% long-acting analogue insulin
prescribing
Diabetes related HRG admissions per
100,000 diabetic population
Figure 26. Diabetes-related HRG admissions per 100,000 population against the
prescribing of long-acting insulin analogues as a percentage of total long- and
intermediate-acting insulins (excluding biphasics) 2013–2014
Powys
% Long-acting analogue insulin prescribing
Page 19 of 31
Conwy West
Arfon
Cardiff North
Dwyfor
West & North Wrexham
Meirionnydd
Cardiff West
Monmouthshire North
Mid Powys
Wrexham Town
South Wrexham
South Powys
Central & South Denbighshire
South Taf Ely
Western Vale
Mold, Buckley & Caergwle
North Ceredigion
Newport Central
Eastern Vale
Deeside, Hawarden & Saltney
Llwchwr
Cardiff South East
Anglesey
North Pembrokeshire
Newport East
Taf / Teifi / Tywi
North Powys
North Taf Ely
South Ceredigion
Monmouthshire South
Upper Valleys
South Merthyr Tydfil
Newport West
Bridgend West Network
North Merthyr Tydfil
Afan
Neath
Conwy East
CityHealth
Caerphilly East
Blaenau Gwent East
Penderi
Holywell & Flint
North Cynon
South Rhondda
Cwmtawe
Caerphilly South
Bridgend East Network
Amman/Gwendraeth
South Pembrokeshire
South Cynon
Llanelli
City & Cardiff South
Blaenau Gwent West
North Rhondda
Cardiff South West
North Denbighshire
Torfaen North
Torfaen South
Cardiff East
Caerphilly North
Central Vale
Bridgend North Network
Percentage of patients achieving HbA1c target
95
14,000
85
12,000
80
10,000
75
8,000
6,000
70
4,000
65
2,000
60
0
<59 mmol/mol
Page 20 of 31
<64 mmol/mol
<75 mmol/mol
2014/15 data Cost per 1,000 PUs
Cost per 1,000 PUs of diabetes prescribing
All Wales Medicines Strategy Group
Figure 27. Percentage of patients achieving HbA1c target compared with the cost of diabetes prescribing per 1,000 PUs 2014–2015
18,000
90
16,000
Primary Care Prescribing Analysis – Drugs Used in Diabetes
REFERENCES
1 Welsh Government. Together for Health Diabetes Delivery Plan. Annual Report
2014. 2014. Available at:
http://gov.wales/docs/dhss/publications/150116reporten.pdf. Accessed Feb 2015.
2 Welsh Government. General medical services contract: Quality and outcomes
framework 2012-2013. 2014. Available at: http://gov.wales/statistics-andresearch/general-medical-services-contract/?lang=en. Accessed Feb 2015.
3 Gillett M, Royle P, Snaith A et al. Non-pharmacological interventions to reduce
the risk of diabetes in people with impaired glucose regulation: a systematic
review and economic evaluation. Health Technology Assessment 2012; 16 (33).
Available at:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0048463/pdf/summ1633.pdf.
Accessed: Feb 2015.
4 National Institute for Health and Care Excellence. Clinical Guideline 87. Type 2
diabetes: The management of type 2 diabetes (CG87). 2014. Available at:
http://www.nice.org.uk/guidance/cg87. Accessed Jul 2015.
5 NHS Wales Shared Services Partnership. Comparative Analysis System for
Prescribing Audit. 2015. Accessed Aug 2015.
6 Welsh Government. Together for Health - A Diabetes Delivery Plan. 2013.
Available at: http://gov.wales/docs/dhss/publications/130923diabetesen.pdf.
Accessed Feb 2015.
7 Welsh Assembly Government. National Service Framework for Diabetes in
Wales. 2003. Available at:
http://www.wales.nhs.uk/documents/diabetesnsf_eng.pdf. Accessed Feb 2015.
8 Welsh Analytical Prescribing Support Unit. Clinical Effectiveness Prescribing
Programme Local Comparators 2015-2016. 2015. Accessed Feb 2015.
9 National Institute for Health and Care Excellence. Technology Appraisal 203.
Liraglutide for the treatment of type 2 diabetes mellitus (TA203). 2010. Available
at: http://www.nice.org.uk/guidance/ta203. Accessed Feb 2015.
10 National Institute for Health and Care Excellence. Technology Appraisal 248.
Exenatide prolonged-release suspension for injection in combination with oral
antidiabetic therapy for the treatment of type 2 diabetes (TA248). 2012. Available
at: http://www.nice.org.uk/guidance/TA248. Accessed Feb 2015.
11 Welsh Government. Welsh Health Survey 2014: Health-related lifestyle results.
2015. Available at: http://gov.wales/docs/statistics/2015/150603-welsh-healthsurvey-2014-health-related-lifestyle-en.pdf. Accessed Aug 2015.
12 Office for National Statistics. General Lifestyle Survey Overview. 2012. Available
at: http://harridanic.com/w/images/1/16/Glfreport2010_tcm77-259420.pdf.
Accessed Aug 2015.
13 Public Health Wales Observatory. GP Cluster Profiles 2013. 2014. Available at:
http://www.wales.nhs.uk/sitesplus/922/page/67714. Accessed Feb 2015.
14 BMA, Royal Pharmaceutical Society. British National Formulary. 2015.
15 All Wales Medicines Strategy Group. insulin degludec (Tresiba®). 2015. Available
at: http://www.awmsg.org/awmsgonline/app/appraisalinfo/840. Accessed Jul
2015.
16 National Institute for Health and Care Excellence. Blood glucose lowering therapy
for type 2 diabetes. 2015. Available at:
http://pathways.nice.org.uk/pathways/diabetes#path=view%3A/pathways/diabete
s/blood-glucose-lowering-therapy-for-type-2-diabetes.xml&content=view-index.
Accessed Jul 2015.
17 Health and Social Care Information Centre. Introduction to Healthcare Resource
Groups. 2015. Available at: http://www.hscic.gov.uk/hrg. Accessed Feb 2015.
18 Health and Social Care Information Centre. National Diabetes Inpatient Audit.
2013. Available at: http://www.hscic.gov.uk/catalogue/PUB13662/nati-diab-inpaudi-13-nat-rep.pdf. Accessed Jul 2015.
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All Wales Medicines Strategy Group
19 Commission on Human Medicines, Medicines and Healthcare Products
Regulatory Agency. Current Problems in Pharmacovigilance. 2006. Available at:
https://assets.digital.cabinetoffice.gov.uk/media/547307e5e5274a1301000030/con2023860.pdf. Accessed
Feb 2015.
20 Public Health Wales Observatory. Wales and its Local Health Boards:
Demography Profile. 2015. Available at:
http://www.wales.nhs.uk/sitesplus/922/page/49931. Accessed Feb 2015.
21 National Public Health Service for Wales. Deprivation and Health. 2004. Available
at:
http://www2.nphs.wales.nhs.uk:8080/HIATDocs.nsf/public/2EAEBE01733430F88
02576EA004BC063/$file/Deprivationreport10Dec04.pdf. Accessed Feb 2015.
22 Office for National Statistics. UK indices of multiple deprivation - a way to make
comparisons across constituent countries easier. 2012. Available at:
http://www.ons.gov.uk/ons/rel/hsq/health-statistics-quarterly/no--53--spring2012/uk-indices-of-multiple-deprivation.html. Accessed Feb 2015.
Page 22 of 31
Primary Care Prescribing Analysis – Drugs Used in Diabetes
APPENDIX 1. GP CLUSTER COMPARATORS
To make realistic comparisons of prescribing between Wales and England, between
the health boards and between the 64 established GP clusters in Wales, consideration
of confounding factors is essential. WAPSU has developed cluster comparators based
on disease prevalence and socio-economic variables, in order to appropriately
benchmark prescribing data and influence prescribing behaviour accordingly.
The intention is to utilise this method of presenting prescribing data for a range of
therapeutic areas, such as cardiovascular and mental health. The method could also
potentially be applied to CCGs in England in order to make comparisons between
Welsh health boards and English CCGs.
In this paper, diabetic product prescribing for GP clusters is analysed and therefore
relevant variables for comparators are diabetes prevalence and deprivation. Other
variables that could influence variation in diabetes therapeutic area prescribing were
also considered, such as cardiovascular disease, obesity, smoking status and ethnicity.
However, there could be an element of double counting as many of the variables also
closely correlate with each other. Diabetes prevalence and deprivation were chosen to
produce GP cluster comparators as this data is readily available at cluster level.
Other considerations – It may be appropriate to view comparators in the context of
other differences in practice, especially when making comparisons with areas in
England or other nations. These could include local initiatives, dispensing GP
practices, procurement costs, prescription charge exemptions and differences between
local guidelines and formularies.
1) Disease prevalence
Disease prevalence varies across the health boards in Wales and data on prevalence
are available at GP cluster level from the GP Cluster Profiles 201313. The source of the
data is Audit+ – a non-mandatory analysis tool for GP practices used by more than
95% of GP practices in Wales to submit data weekly. Audit+ provides a count of
patients with the identified chronic condition by 10-year age groups and sex. Another
possible source of disease prevalence data is the QOF, as chronic conditions are
defined in the same way in both. QOF data is used primarily to monitor GP practice
performance against a contract; secondary use of QOF data must be interpreted with
caution.
2) Deprivation
The link between poor health and deprivation is well recognised and people in the most
deprived areas have higher levels of mental illness, hearing and sight problems, and in
particular chronic conditions such as respiratory disease, cardiovascular disease and
arthritis19. In Wales, the majority of deprived areas are found in areas of Cardiff,
Swansea and Newport, the Welsh valleys and areas of the North Wales coast20.
While disease prevalence gives a straightforward measure of the proportion of the
population with a condition, deprivation can have a more complex effect on prescribing
levels through factors such as behavioural determinants, access to services and
education21.
2a) Index of Multiple Deprivation
Deprivation is multi-dimensional and takes into account many factors, which include
income, housing, employment, general health, education, access to services,
community safety and physical environment. The four countries of the UK each have
their own index of multiple deprivation (IMD), each with slightly different ways of
weighting certain factors. However, around half of the weight of each IMD comes from
employment and income: factors which are common to all four countries and are major
drivers of deprivation. Therefore, it may be appropriate to use the countries’ IMDs for
purposes of comparison if the differences in weightings are adjusted for22.
Page 23 of 31
1
Page 24 of 31
2
3
4
5
6
7
South Merthyr Tydfil
North Merthyr Tydfil
City Health
South Rhondda
South Cynon
North Rhondda
Central Vale
Cardiff North
Cardiff East
Conwy West
Dwyfor
West & North Wrexham
Meirionnydd
Monmouthshire North
Mid Powys
Wrexham Town
South Wrexham
South Powys
Central & South Denbighshire
South Taf Ely
Mold, Buckley & Caergwrle
Newport Central
Eastern Vale
Deeside, Hawarden & Saltney
Llwchwr
North Pembrokeshire
Taf / Teifi / Tywi
North Powys
South Ceredigion
Monmouthshire South
Bridgend East Network
South Pembrokeshire
Bay Health
Western Vale
North Ceredigion
Cardiff South East
Cardiff South West
Arfon
City & Cardiff South
Cardiff West
Anglesey
North Taf Ely
Conwy East
Caerphilly East
Holywell & Flint
Cwmtawe
Caerphilly South
Torfaen South
Newport East
Upper Valleys
Newport West
Bridgend West Network
Neath
Penderi
North Cynon
Amman/Gwendraeth
Llanelli
North Denbighshire
Torfaen North
Afan
Blaenau Gwent East
Blaenau Gwent West
Caerphilly North
Bridgend North Network
Cost per 1,000 PUs
All Wales Medicines Strategy Group
3) Analysis of diabetes therapeutic area by GP cluster comparators
Figures 1a to 3 show prescribing of antidiabetic products for each of the 64 GP clusters in Wales. The GP clusters are grouped by colour with
their most similar GP clusters in terms of disease prevalence and deprivation. The data show cost and items per 1,000 PUs for the period of
January 2013–December 2014.
Figure 1a. All medicines used in diabetes prescribing – Cost per 1,000 PUs April 2014–March 2015
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
8
1
2
3
4
5
6
7
Central Vale
South Rhondda
North Merthyr Tydfil
City Health
South Merthyr Tydfil
North Rhondda
South Cynon
Cardiff North
Cardiff East
West & North Wrexham
Eastern Vale
Conwy West
Dwyfor
Mold, Buckley & Caergwrle
North Pembrokeshire
Wrexham Town
Newport Central
Mid Powys
Deeside, Hawarden & Saltney
Monmouthshire North
South Taf Ely
South Wrexham
Meirionnydd
Monmouthshire South
North Powys
South Powys
Bridgend East Network
Taf / Teifi / Tywi
Llwchwr
South Ceredigion
South Pembrokeshire
Central & South Denbighshire
Bay Health
North Ceredigion
Western Vale
Cardiff South East
Cardiff South West
Arfon
City & Cardiff South
Cardiff West
Anglesey
Caerphilly East
North Taf Ely
Cwmtawe
Conwy East
Holywell & Flint
Caerphilly South
Torfaen South
Neath
Upper Valleys
Bridgend West Network
Penderi
Newport East
North Denbighshire
North Cynon
Llanelli
Amman/Gwendraeth
Torfaen North
Newport West
Afan
Blaenau Gwent East
Bridgend North Network
Blaenau Gwent West
Caerphilly North
Items per 1,000 PUs
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Figure 1b. All medicines used in diabetes prescribing. Items per 1,000 PUs. April 2014–March 2015
1,200
1,000
800
600
400
200
0
8
Page 25 of 31
1
Page 26 of 31
2
3
4
5
6
7
South Cynon
South Rhondda
Central Vale
South Merthyr Tydfil
North Rhondda
North Merthyr Tydfil
City Health
Cardiff North
Cardiff East
Mid Powys
West & North Wrexham
Eastern Vale
Conwy West
Central & South Denbighshire
Bridgend East Network
Newport Central
Deeside, Hawarden & Saltney
Dwyfor
South Powys
North Pembrokeshire
Llwchwr
Taf / Teifi / Tywi
South Wrexham
Meirionnydd
South Taf Ely
South Ceredigion
Monmouthshire South
South Pembrokeshire
Monmouthshire North
Mold, Buckley & Caergwrle
Wrexham Town
North Powys
Western Vale
North Ceredigion
Bay Health
Cardiff South West
Cardiff South East
City & Cardiff South
Arfon
North Taf Ely
Caerphilly South
Caerphilly East
Cwmtawe
Holywell & Flint
Torfaen South
Conwy East
Anglesey
Cardiff West
Torfaen North
Upper Valleys
Newport East
Newport West
Amman/Gwendraeth
Llanelli
North Denbighshire
Bridgend West Network
Penderi
North Cynon
Neath
Caerphilly North
Bridgend North Network
Afan
Blaenau Gwent West
Blaenau Gwent East
Cost per 1,000 PUs
All Wales Medicines Strategy Group
Figure 2a. Insulin prescribing. Cost per 1,000 PUs. April 2014–March 2015
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
8
1
2
3
4
5
6
7
South Cynon
Central Vale
South Merthyr Tydfil
South Rhondda
North Rhondda
North Merthyr Tydfil
City Health
Cardiff North
Cardiff East
Mid Powys
South Powys
Eastern Vale
Newport Central
West & North Wrexham
Central & South Denbighshire
Deeside, Hawarden & Saltney
Conwy West
Taf / Teifi / Tywi
Bridgend East Network
North Pembrokeshire
Dwyfor
Llwchwr
Monmouthshire North
South Ceredigion
South Taf Ely
South Wrexham
Meirionnydd
Wrexham Town
Monmouthshire South
South Pembrokeshire
Mold, Buckley & Caergwrle
North Powys
Western Vale
Bay Health
Cardiff South West
North Ceredigion
Cardiff South East
City & Cardiff South
Arfon
Caerphilly East
North Taf Ely
Caerphilly South
Cwmtawe
Cardiff West
Anglesey
Conwy East
Holywell & Flint
Torfaen South
Torfaen North
Upper Valleys
Newport East
Newport West
Llanelli
North Denbighshire
Penderi
Amman/Gwendraeth
Bridgend West Network
North Cynon
Neath
Caerphilly North
Bridgend North Network
Afan
Blaenau Gwent West
Blaenau Gwent East
Items per 1,000 PUs
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Figure 2b. Insulin prescribing. Items per 1,000 PUs. April 2014–March 2015
160
140
120
100
80
60
40
20
0
8
Page 27 of 31
Page 28 of 31
North Merthyr Tydfil
South Merthyr Tydfil
South Cynon
South Rhondda
North Rhondda
Central Vale
City Health
Cardiff East
Cardiff North
Monmouthshire North
South Powys
South Taf Ely
Mid Powys
Bridgend East Network
Wrexham Town
Deeside, Hawarden & Saltney
West & North Wrexham
South Wrexham
Eastern Vale
Monmouthshire South
South Ceredigion
Newport Central
North Pembrokeshire
Mold, Buckley & Caergwrle
North Powys
Dwyfor
Meirionnydd
Conwy West
South Pembrokeshire
Central & South Denbighshire
Taf / Teifi / Tywi
Llwchwr
Western Vale
Cardiff South East
Cardiff South West
North Ceredigion
Bay Health
City & Cardiff South
Arfon
Torfaen South
North Taf Ely
Caerphilly South
Cardiff West
Cwmtawe
Caerphilly East
Anglesey
Conwy East
Holywell & Flint
North Cynon
Torfaen North
Neath
Bridgend West Network
Amman/Gwendraeth
Upper Valleys
Penderi
Newport West
Newport East
North Denbighshire
Llanelli
Blaenau Gwent East
Blaenau Gwent West
Caerphilly North
Bridgend North Network
Afan
Percentage
All Wales Medicines Strategy Group
Figure 3. Items of long-acting insulin analogues as a percentage of total long- and intermediate-acting insulin (excluding biphasics) April 2014–
March 2015
120
100
80
60
40
20
0
1
2
3
4
5
6
7
Central Vale
City Health
South Cynon
North Rhondda
South Rhondda
South Merthyr Tydfil
North Merthyr Tydfil
Cardiff East
Cardiff North
South Pembrokeshire
Llwchwr
Bridgend East Network
South Ceredigion
Taf / Teifi / Tywi
Eastern Vale
Monmouthshire South
North Pembrokeshire
Newport Central
North Powys
Mold, Buckley & Caergwrle
South Wrexham
West & North Wrexham
South Powys
Central & South Denbighshire
Deeside, Hawarden & Saltney
Wrexham Town
Monmouthshire North
Mid Powys
Conwy West
South Taf Ely
Meirionnydd
Dwyfor
North Ceredigion
Cardiff South West
Cardiff South East
Western Vale
Bay Health
City & Cardiff South
Arfon
Torfaen South
Cwmtawe
Caerphilly South
Caerphilly East
Anglesey
Cardiff West
Holywell & Flint
North Taf Ely
Conwy East
Llanelli
Amman/Gwendraeth
Torfaen North
Upper Valleys
Neath
North Denbighshire
Bridgend West Network
Penderi
Newport West
North Cynon
Newport East
Afan
Bridgend North Network
Caerphilly North
Blaenau Gwent West
Blaenau Gwent East
Percentage
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Figure 4. Items of biguanides and sulphonylureas as a percentage of all antidiabetic medicines as per Local Comparator April 2014–March 2015
100
90
80
70
60
50
40
30
20
10
0
8
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1
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2
3
4
5
6
7
City Health
South Cynon
North Rhondda
South Rhondda
South Merthyr Tydfil
Central Vale
North Merthyr Tydfil
Cardiff North
Cardiff East
Newport Central
Monmouthshire South
Monmouthshire North
South Powys
Eastern Vale
Llwchwr
West & North Wrexham
South Wrexham
South Taf Ely
Conwy West
Taf / Teifi / Tywi
South Ceredigion
Wrexham Town
Mid Powys
North Pembrokeshire
Bridgend East Network
South Pembrokeshire
Meirionnydd
North Powys
Dwyfor
Central & South Denbighshire
Mold, Buckley & Caergwrle
Deeside, Hawarden & Saltney
Bay Health
Cardiff South East
Western Vale
North Ceredigion
Cardiff South West
City & Cardiff South
Arfon
Caerphilly East
Cardiff West
Caerphilly South
Cwmtawe
North Taf Ely
Torfaen South
Holywell & Flint
Anglesey
Conwy East
Newport West
Newport East
Penderi
Bridgend West Network
Upper Valleys
Torfaen North
Neath
Amman/Gwendraeth
Llanelli
North Cynon
North Denbighshire
Blaenau Gwent East
Blaenau Gwent West
Afan
Caerphilly North
Bridgend North Network
Cost per 1,000 PUs
All Wales Medicines Strategy Group
Figure 5. Screening and monitoring agents. Cost per 1,000 PUs. April 2014–March 2015
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
8
1
2
3
4
5
6
7
South Cynon
City Health
Central Vale
North Rhondda
South Rhondda
North Merthyr Tydfil
South Merthyr Tydfil
Cardiff North
Cardiff East
West & North Wrexham
Eastern Vale
Newport Central
Wrexham Town
Monmouthshire South
Monmouthshire North
South Wrexham
North Pembrokeshire
Conwy West
Llwchwr
South Powys
Mold, Buckley & Caergwrle
South Ceredigion
Dwyfor
Mid Powys
Taf / Teifi / Tywi
Meirionnydd
Bridgend East Network
South Pembrokeshire
South Taf Ely
North Powys
Central & South Denbighshire
Deeside, Hawarden & Saltney
Bay Health
North Ceredigion
Cardiff South East
Western Vale
Cardiff South West
Arfon
City & Cardiff South
Cardiff West
Caerphilly East
Cwmtawe
Anglesey
North Taf Ely
Caerphilly South
Conwy East
Torfaen South
Holywell & Flint
Upper Valleys
Bridgend West Network
Neath
Newport West
Llanelli
Penderi
Newport East
North Cynon
Amman/Gwendraeth
North Denbighshire
Torfaen North
Afan
Blaenau Gwent East
Blaenau Gwent West
Caerphilly North
Bridgend North Network
Items per 1,000 PUs
Primary Care Prescribing Analysis – Drugs Used in Diabetes
Figure 6. Screening and monitoring agents. Items per 1,000 PUs. April 2014–March 2015
160
140
120
100
80
60
40
20
0
8
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