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.
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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