Select Committee on Health Minutes of Evidence


APPENDIX 1

Report on the impact of NICE Guidance on the use Donezepil, Rivastigmine and Galantamine for the treatment of Alzheimer's Disease

AN ANALYSIS OF HEALTH AUTHORITY SPENDING PREPARED FOR THE ALZHEIMER'S SOCIETY BY IMS HEALTH

KEY FINDINGS BASED ON ANALYSIS OF PURCHASES BY COMMUNITY PHARMACISTS

  Significant increase in prescribing across all Health Authorities

No reduction in the variability in the spend by Health Authority

The guidance has not affected the relative "ranking " of Health Authorities—lower spending Health Authorities remain lower spending Health Authorities

The presence or absence of memory clinics does not so far seem to have made a difference to uptake

Declaration of interest: These data and analyses were provided free of charge by IMS HEALTH. No funding was received from any party.

1.  INTRODUCTION

  The National Institute of Clinical Excellence (NICE) published guidance on the use of donepezil, rivastigmine and galantamine for the treatment of Alzheimer's disease (AD) in January 2001. NICE indicated that assessment in a specialist clinic should be made before any of the drugs were prescribed. The Alzheimer's Society report that Health Authorities have varied in the extent to which they are prepared to encourage prescribing of the three medicines.

  This short analysis is tests two hypotheses:

    (a)  If NICE guidance was being followed there would be less variation between Health Authorities post guidance publication than previously

    (b)  That prescribing of the three medicines would be higher in those Health Authorities in which a memory clinic had been established.

  Up to date information was only available by Health Authority for the data collected from retail pharmacy.

2.  METHODOLOGY

  1.  Information was extracted from IMS HEALTH's database of retail pharmacy purchases relating to the 10 months prior to the guidance and the 10 months after.

  2.  The total spend for the three medicines by Health Authority was divided by an estimate of the number of people with dementia in each Health Authority. These estimates were provided by the Alzheimer's Society based on figures for percentage of the population of different ages with Alzheimer's disease nationally. This provided an estimate for the spend per patient with dementia by Health Authority.

  3.  To examine the effect of memory clinics on prescribing, a list of the memory clinics in England and Wales was provided by the Alzheimer's Society. This list provided the location of the memory clinic. The location was used to identify in which Health Authority the memory clinics were located. Total sales in the Health Authorities with memory clinics were then compared to sales in Health Authorities without memory clinics.

3.  DATA SOURCE

  Community Pharmacy: Regional Sales Analysis: This database is drawn from analysis of 97 per cent of the invoices issued by wholesalers and manufacturers to retail pharmacies. The remaining 3 per cent is projected from the invoices sent directly to IMS HEALTH from a panel of 500 pharmacies. The database allows information on therapy class, molecule and pack to be extracted. There is no information on diagnosis.

  Data is aggregated into small geographic areas, called bricks. These contain a minimum of three pharmacies of different ownership. This ensures that pharmacy confidentiality is maintained. Each brick is assigned to a Health Authority based on the area it covers. Where the brick cuts across two Health Authorities the brick is assigned to the Health Authority that actually contains the most pharmacies.

4.  RESULTS

Analysis of variability

  Pre-guidance the mean spend per patient with dementia was £8.76 (range 38.79). Post guidance the mean spend per patient was £16.06 (range 89.22).

Table 1

SPEND PER PATIENT WITH DEMENTIA

  
Pre-guidance (£)
Post guidance (£)
Mean
8.77
16.06
Range
38.78
89.22
Minimum
0.9
2.24
Maximum
39.68
91.46


  Although therefore there has been a notable increase in the amount spend per patient, the variation between Health Authorities has if anything increased rather than decreased following the guidance.

  Further analysis indicated that the greatest increases in use of the three medicines occurred in those Health Authorities who were already using the most (see figure 1).

Figure 1:

RELATIONSHIP BETWEEN SPEND PRE AND POST GUIDANCE (RETAIL PHARMACY ONLY)


  From this, it would appear that NICE guidance has not made a significant difference to Health Authority spending. Rather, it would appear that those Health Authorities who were persuaded to use the drugs continued to do so, increasing at the same rate (despite starting from a higher base) as those Health Authorities that had used the drugs less often in the past.

Analysis of the effect of memory clinics

  The results of this analysis are surprising. It appears that those Health Authorities with a memory clinic actually spend less per patient with dementia on the three drugs. This is surprising because the guidance indicated that patients should be assessed at a specialist centre before prescribing. It was felt that the existence of memory clinics would accelerate the assessment process and thus lead to a greater uptake of the drug (table 2).

Table 2

SPEND PER PATIENT WITH DEMENTIA IN HEALTH AUTHORITIES

WITH AND WITHOUT MEMORY CLINICS


  
Pre guidance (£)
Post guidance (£)
Increase

Memory clinic HA
8.3
14.5
75 per cent
No clinic HA
8.51
16.0
88 per cent

5.  DISCUSSION POINTS

    —  Absence of hospital information

  This analysis is based upon the purchases made by retail pharmacists. No information was used showing the spend by hospitals. It is difficult to assess the significance of these data. However it should be noted that community purchases represent the bulk of the prescribing of these drugs at a national level (72 per cent). It should also be noted that for the absence of hospital data to make a significant difference, there would have to be significant variation in the amount of hospital prescribing per patient by Health Authority.

    —  Estimates of prevalence

  These are calculated using an average figure for prevalence. There will be Health Authorities that fall above and below that average. It may be, therefore, that some Health Authorities' spend per patient has been over or under-estimated. The year on year comparison however tends to negate the effect of such bias. From this it is clear that Health Authorities spending patterns tended to remain similar pre and post guidance.

    —  Memory clinics

  It is possible that those Health Authorities with memory clinics distribute medicines to patients differently to those that do not have memory clinics. Given that many of these clinics are based in hospital may mean that a greater proportion of prescriptions are dispensed by hospital pharmacies than in other areas. This is felt to be unlikely to have affected the results significantly however. It is felt that even if the first prescription were dispensed in the hospital, if memory clinics increased the uptake of these drugs there would nevertheless be sufficient increase in the community for their effect to be detected.

6.  CONCLUSIONS

  There has been a significant increase in the amount of the three drugs purchased by community pharmacies in the period post publication of the NICE guidance. The guidance does not seem however to reduced the variation between Health Authorities, nor does it appear to have changed the pattern of prescribing in Health Authorities significantly. Those Health Authorities who were higher prescribers have remained so.


 
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Prepared 8 July 2002