Biology subjects

Croker, R.

Publications and source records attributed to Croker, R..

6 recordsLinked to original sources

bioRxiv2018

Why did some practices not implement new antibiotic prescribing guidelines on urinary tract infection? A cohort study and survey in NHS England primary care

ObjectivesTo describe prescribing trends and geographic variation for trimethoprim and nitrofurantoin; to describe variation in implementing guideline change; and to compare actions taken to reduce trimethoprim use in high- and low-using Clinical Commissioning Groups (CCGs).\n\nDesignA retrospective cohort study and interrupted time series analysis in English NHS primary care prescribing data; complemented by information obtained through Freedom of Information Act requests to CCGs. The main outcome measures were: variation in practice and CCG prescribing ratios geographically and over time, including an interrupted time-series; and responses to Freedom of Information requests.\n\nResultsThe amount of trimethoprim prescribed, as a proportion of nitrofurantoin and trimethoprim combined, remained stable and high until 2014, then fell gradually to below 50% in 2017; this reduction was more rapid following the introduction of the Quality Premium. There was substantial variation in the speed of change between CCGs. As of April 2017, for the 10 worst CCGs (with the highest trimethoprim ratios): 9 still had trimethoprim as first line treatment for uncomplicated UTI (one CCG had no formulary); none had active work plans to facilitate change in prescribing behaviour away from trimethoprim; and none had implemented an incentive scheme for change in prescribing behaviour. For the 10 best CCGs: 2 still had trimethoprim as first line treatment (all CCGs had a formulary); 5 (out of 7 who answered this question) had active work plans to facilitate change in prescribing behaviour away from trimethoprim; and 5 (out of 10 responding) had implemented an incentive scheme for change in prescribing behaviour. 9 of the best 10 CCGs reported at least one of: formulary change, work plan, or incentive scheme. None of the worst 10 CCGs did so.\n\nConclusionsMany CCGs failed to implement an important change in antibiotic prescribing guidance; and report strong evidence suggesting that CCGs with minimal prescribing change did little to implement the new guidance. We strongly recommend a national programme of training and accreditation for medicines optimisation pharmacists; and remedial action for CCGs that fail to implement guidance; with all materials and data shared publicly for both such activities.

microbiology↗

bioRxiv2018

Measuring the Impact of an Open Online Prescribing Data Analysis Service on Clinical Practice: a Cohort Study in NHS England Data

BackgroundOpenPrescribing is a freely accessible service that enables any user to view and analyse NHS primary care prescribing data at the level of individual practices. This tool is intended to improve the quality, safety, and cost-effectiveness of prescribing.\n\nObjectivesWe set out to measure the impact of OpenPrescribing being viewed on subsequent prescribing.\n\nMethodsHaving pre-registered our protocol and code, we measured three different metrics of prescribing quality (mean percentile across 34 existing OpenPrescribing quality measures, available \"price-per-unit\" savings, and total \"low-priority prescribing\" spend) to see if they changed after CCG and practice pages were viewed. We also measured whether practices whose data were viewed on OpenPrescribing differed in prescribing, prior to viewing, to those who were not. We used fixed effects and between effects linear panel regression, to isolate change over time and differences between practices respectively. We adjusted for month of prescribing in the fixed effects model, to remove underlying trends in outcome measures.\n\nResultsWe found a reduction in available price-per-unit savings for both practices and CCGs after their pages were viewed. The saving was greater at the practice level (-{pound}40.42 per thousand patients per month, 95% confidence interval -54.04 to -26.01) than at CCG level (-{pound}14.70 per thousand patients per month, 95% confidence interval -25.56 to -3.84). We estimate a total saving since launch of {pound}243k at practice level and {pound}1.47m at CCG level between the feature launch and end of follow-up (August to November 2017) among practices viewed. If the observed savings from practices viewed were extrapolated to all practices, this would generate {pound}26.8m in annual savings for the NHS, approximately 20% of the total possible savings from this method. The other two measures were not different after CCGs/practices were viewed. Practices which were viewed had worse prescribing quality scores overall, prior to viewing.\n\nConclusionsWe found a clinically significant positive impact from use of OpenPrescribing, specifically for the class of savings opportunities that can only be identified by using this tool. We also show that it is possible to conduct a robust analysis of the impact of such an online service on clinical practice.

epidemiology↗

bioRxiv2018

The clinician impact and financial cost to the NHS of litigation over pregabalin: an economic impact analysis

ObjectivesFollowing litigation over pregabalins second-use medical patent for neuropathic pain NHS England were required by the court to instruct GPs to prescribe the branded form (Lyrica) for pain. Pfizers patent was found invalid in 2015; a ruling subject to ongoing appeals. If the Supreme Court appeal in February 2018 is unsuccessful, the NHS can reclaim excess prescribing costs. We set out to describe the variation in prescribing of pregabalin as branded Lyrica, geographically and over time; to determine how clinicians responded to the NHS England instruction to GPs; and to model excess costs to the NHS attributable to the legal judgments.\n\nSettingEnglish primary care\n\nParticipantsEnglish general practices\n\nPrimary and secondary outcome measuresVariation in prescribing of branded Lyrica across the country before and after the NHS England instruction, by practice and by Clinical Commissioning Group (CCG); excess prescribing costs.\n\nResultsThe proportion of pregabalin prescribed as Lyrica increased, from 0.3% over six months before the NHS England instruction (September 2014-February 2015) to 25.7% afterwards (April - September 2015). Although 70% of pregabalin is estimated to be for neuropathic pain, only 11.6% of practices prescribed Lyrica at this level; the median proportion prescribed as Lyrica was 8.8% (IQR 1.1-41.9%). If pregabalin had come entirely off patent in September 2015, and Pfizer had not appealed, we estimate the NHS would have spent {pound}502m less on pregabalin to July 2017.\n\nConclusionNHS England instructions to GPs regarding branded prescription of pregabalin were widely ignored, and have created much debate around clinical independence in prescribing. Protecting revenue from \"skinny labels\" will pose a challenge. If Pfizers final appeal on the patent is unsuccessful the NHS can seek reimbursement of excess pregabalin prescribing costs, potentially {pound}502m.

epidemiology↗

bioRxiv2017

Trends, geographic variation, and factors associated with prescribing of gluten-free foods in English primary care: a cross sectional study

BackgroundThere is substantial disagreement about whether gluten-free foods should be prescribed on the NHS. We aim to describe time trends, variation and factors associated with prescribing gluten-free foods in England.\n\nMethodsWe described long-term national trends in gluten-free prescribing, and practice and Clinical Commissioning Group (CCG) level monthly variation in the rate of gluten-free prescribing (per 1000 patients) over time. We used a mixed effect poisson regression model to determine factors associated with gluten-free prescribing rate.\n\nResultsThere were 1.3 million gluten-free prescriptions between July 2016 and June 2017, down from 1.8 million in 2012/13, with a corresponding cost reduction from {pound}25.4m to {pound}18.7m. There was substantial variation in prescribing rates among practices (range 0 to 148 prescriptions per 1000 patients, interquartile range 7.3 to 31.8), driven in part by substantial variation at the CCG level, likely due to differences in prescribing policy. Practices in the most deprived quintile of deprivation score had a lower prescribing rate than those in the highest quintile (incidence rate ratio 0.89, 95% confidence interval 0.87-0.91). This is potentially a reflection of the lower rate of diagnosed coeliac disease in more deprived populations.\n\nConclusionGluten-free prescribing is in a state of flux, with substantial clinically unwarranted variation between practices and CCGs.\n\nStrengths and weaknesses of the studyO_LIWe were able to measure the prescribing of gluten-free foods across all prescribing in England, eliminating bias. We also removed seasonal variation by aggregating savings over 12 months.\nC_LIO_LIAs well as gluten-free prescribing variation at practice and CCG level, we have described long-term prescribing trends at national level, back to 1998.\nC_LIO_LIUsing the available data, we were unable to look at gluten-free prescribing at prescriber level, or investigate factors associated with prescribing to individual patients\nC_LI

epidemiology↗

bioRxiv2017

Trends and variation in Prescribing of Low-Priority Medicines Identified by NHS England: A Cross-Sectional Study and Interactive Data Tool in English Primary Care

BackgroundRoutine accessible audit of prescribing data presents significant opportunities to identify cost-saving opportunities. NHS England recently announced a consultation seeking to discourage use of medicines it considers to be low-value. We set out to produce an interactive data resource to show savings in each NHS general practice, and to assess the current use of these medicines, their change in use over time, and the extent and reasons for variation in such prescribing.\n\nResultsThe total NHS spend on all low-value medicines identified by NHS England was {pound}153.5m in the last year, across 5.8m prescriptions (mean {pound}26 per prescription). Among individual medications, liothyronine had the highest prescribing cost at {pound}29.6m, followed by trimipramine ({pound}20.2m) and gluten-free foods ({pound}18.7m). Over time, the overall total number of low-value prescriptions decreased, but the cost increased, although this varied greatly between medications. Annual practice level spending varied widely (median, {pound}2,262 per thousand patients, IQR {pound}1,439 to {pound}3,298). The proportion of patients over 65 showed the strongest association with low-value prescribing; CCG was also strongly associated. Our interactive data tool was deployed to OpenPrescribing.net where monthly updated figures and graphs can be viewed.\n\nConclusionsPrescribing of low-value medications is extensive but varies widely by medication, geographic area and individual practice. Despite a fall in prescription numbers, the overall cost of prescribing for low-value items has risen. Prescribing behaviour is clustered by CCG, which may represent variation in medicines optimisation efficiency, or in some cases access inequality.\n\nAbbreviations

epidemiology↗

bioRxiv2017

A New Mechanism for Cost Savings in NHS Prescribing: Minimising "Price-Per-Unit"

BackgroundMinimising prescription costs while maintaining quality is a core element of delivering high value healthcare. There are various strategies to achieve savings, but almost no research to date on determining the most effective approach. We describe a new method of identifying potential savings due to large national variations in drug cost, including variation in generic drug cost; and compare these with potential savings from an established method (generic prescribing).\n\nMethodsWe used English NHS Digital prescribing data, from October 2015 to September 2016. Potential cost savings were calculated by determining the price-per-unit (e.g. pill, ml) for each drug and dose within each general practice. This was compared against the same cost for the practice at the lowest cost decile, to determine achievable savings. We compared these price-per-unit savings to the savings possible from generic switching; and determined the chemicals with the highest savings nationally. A senior pharmacist manually assessed whether a random sample of savings were practically achievable.\n\nResultsWe identified a theoretical maximum of {pound}410M of savings over 12 months. {pound}273M of these savings were for individual prescribing changes worth over {pound}50 per practice per month; this compares favorably with generic switching, where only {pound}35M of achievable savings were identified. The biggest savings nationally were on glucose blood testing reagents ({pound}12M), fluticasone propionate ({pound}9M) and venlafaxine ({pound}8M). Approximately half of all savings were deemed practically achievable.\n\nDiscussionWe have developed a new method to identify and enable large potential cost savings within NHS community prescribing. Given the current pressures on the NHS, it is vital that these potential savings are realised. Our tool enabling doctors to achieve these savings is now launched in pilot form. However savings could potentially be achieved more simply through national policy change.\n\nAbbreviations

epidemiology↗