Support for Regional Medical Directors Challenging Variation Innovation Scorecard October 2015

A key aim of NHS England is to increase uptake and reduce variation in the utility of new innovative treatments. In the first three years of the Innovation strategy we have seen promising signs of improved growth rates, but this still needs to improve; To do this, we need to harness the influence of Regional Medical Directors and National Clinical Directors, to challenge CCGs and Trusts where uptake is variable and unexplained. Data analyzed in these slides are from the October 2015 Innovation Scorecard published by the Health and Social Care Information 2015 Innovation Scorecard published by the Health and Social Care Information This guide has been designed to help identify areas of variation of utility of innovative medicines, and ask the right questions where variation occurs. The hyperlinks work when showing as a slideshow. Introduction How to use this guide Background to the medicine, including NICE’s view on its role in treatment Top and bottom usage CCGs or Area Teams for particular drug, with trend over last 4 quarters. Graph showing range of variation across country, from highest to lowest utility by CCG or Area Team Link to online heat map to look at data interactively Heat map, with CCGs or Area Teams split into 5 quintiles of activity. 2 (Medicines are measured in DDD(defined daily dosage) or mg where these are not available.)

Canagliflozin – Primary care Background This is one option for treatment of type 2 diabetes recommended in NICE TA (TA315) published in July 2011 for use in combination with insulin with or without other antidiabetic drugs for people with type 2 diabetes.TA315 Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority); CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. mgs per 100,000 Resident population Q4 2014/15 Key lines of enquiry Significant variation in uptake can be seen on the maps below, with some areas having no access. Have the area teams identified local barriers to the use of this treatment in both primary care and secondary care ? Lowest CCGs RegionTrend North Tyneside CCG0N. Newbury and District CCG0S. South Norfolk0M. Highest CCGs Heywood, Middleton and Rochdale CCG1,025,222N ↑ Oldham CCG933,607N ↑ South Eastern Hampshire CCG828,037S ↑ Click here to see interactive heat map online

Dapagliflozin – Primary care Click here to see interactive heat map online Background This is one option for the treatment of type 2 diabetes recommended in NICE TA (TA288) published in October 2010, Dapagliflozin should be given with other drugs as a treatment for some people with type 2 diabetes.TA288 Key lines of enquiry Significant variation in uptake can be seen on the maps below. Is it being considered as a treatment option? 4 DDDs per 100,000 Resident population Q4 2014/2015 RegionTrend North Tyneside CCG48N ↑ Brighton and Hove CCG322S ↑ Great Yarmouth and Waveney CCG334M ↑ Highest CCGs South Eastern Hampshire CCG19,564S ↑ North East Hampshire and Farnham CCG 18,676S ↑ Medway CCG18,340S ↑ Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA) CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Denosumab 60mgs – Primary care Background This is one option for treatment recommended by NICE TA (TA204) published in October 2010, for preventing bone fractures in some postmenopausal women with osteoporosis. Denosumab was a priority work-stream for the NICE Implementation Collaborative in its first year. For more information click hereTA204click here Key lines of enquiry Some areas do not appear to have access to this treatment. Have the area teams identified local barriers to the use of this treatment in both primary care and secondary care? Click here to see interactive heat map online 5 DDDs per 100,000 Resident population Q4 2014/15 RegionTrend Windsor, Ascot and Maidenhead CCG0S. Lewisham CCG0L. Ipswich & East Suffolk CCG0M. Highest CCGs Somerset CCG16,388S ↑ Southampton CCG14,567S ↑ Oxfordshire CCG12,738S ↑ Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ;CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Dronedarone Hydrochloride – Primary care Background This is one treatment option recommended by NICE TA (TA197) published in August 2010, for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation.TA197 Key lines of enquiry Some areas do not appear to have access to this treatment. Have the area teams identified any local barriers to the use of this treatment in both primary care and secondary care ? Click here to see interactive heat map online 6 DDDs per 100,000 Resident population Q4 2014/15 RegionTrend Swindon CCG0S ↓ Halton CCG0N. Tower Hamlets CCG0L. Highest CCGs Hastings and Rother CCG7,525S ↔ Eastbourne, Hailsham and Seaford CCG4,213S ↔ South Eastern Hampshire CCG2,344S ↔ Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Exenatide - Primary care Background This is one option of treatment recommended by NICE TA (TA248) published in February 2012 in combination with other oral drugs, for people with type 2 diabetes.TA248 Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in both primary care and secondary care? Click here to see interactive heat map online 7 DDDs per 100,000 Resident population Q4 2014/15 RegionTrend Nottingham West CCG0M. Tower Hamlets CCG10L ↓ Camden CCG37L ↑ Highest CCGs Wirral CCG10,930N ↑ South Kent Coast CCG7,367S ↔ Wyre Forest CCG7,134M ↔ Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Ivabradine – Primary care Background This is one treatment option recommended by NICE TA: (TA267) published in November 2012, as a treatment for some people with chronic heart failure after standard treatment.TA267 Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have the area teams identified local barriers to the use of this treatment in both primary care and secondary care ? Click here to see interactive heat map online 8 DDDs per 100,000 Resident population Q4 2014/15 RegionTrend Crawley CCG475S ↔ East Surrey CCG738S ↑ Chiltern CCG772S ↑ Highest CCGs Bradford City CCG18,635N ↔ Bolton CCG17,045N ↔ Bradford Districts CCG16,457N ↔ Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Liraglutide – Primary care Background This is one treatment option recommended by NICE TA (TA203) published in October 2010 for people with type 2 diabetes mellitus.TA203 Click here to see interactive heat map online 9 DDDs per 100,000 Resident population Q4 2014/15 RegionTrend Corby CCG958M ↓ Bath and North East Somerset CCG983S ↔ Great Yarmouth and Waveney CCG1,453M ↔ Highest CCGs Wolverhampton CCG28,598M ↔ Halton CCG17,111N ↔ Trafford CCG16,839N ↔ Key lines of enquiry Some areas do not appear to have access to this treatment. Have the area teams identified local barriers to the use of this treatment in both primary care and secondary care ? Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA) CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Nalmefene – Primary care Background Nalmefene is recommended as a treatment option for alcohol dependence by NICE (TA325) since November It is the topic of a NICE Implementation Collaborative work stream and further details can be found hereTA325here Lowest CCGs RegionTrend North East Hampshire and Farnham CCG0S ↓ South Lincolnshire CCG0M ↓ Gateshead CCG0N. Highest CCGs South Manchester CCG173N ↑ Hammersmith and Fulham CCG172L ↑ Oldham CCG169N ↑ DDDs per 100,000 Resident population Q4 2014/15 Click here to see interactive heat map online Key lines of enquiry Some areas do not appear to have access to this treatment. Have the area teams identified local barriers to the use of this treatment in both primary care and secondary care Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) : CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Novel Oral Anti-Coagulants (NOACs) – Primary care Background This group of treatments are recommended as a treatment option for the prevention of stroke in Atrial Fibrillation and the treatment and secondary prevention of Deep Vein Thrombosis and/or Pulmonary Embolism. (TA249, TA256, TA275, TA327) in several technology appraisals up to December It has been a topic in a NICE Implementation Collaborative for use in Atrial Fibrillation and a consensus statement on its use has been produced by Royal Colleges. Find out more hereTA249 TA256 TA275 TA327Find out more here Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have the area teams identified any local barriers to the use of this treatment in both primary care and secondary care ? Lowest CCGs RegionTrend Newham CCG4,552L ↑ Tower Hamlets CCG5,739L ↑ Haringey CCG6,855L ↑ Highest CCGs Somerset CCG127,447S ↑ South Gloucestershire CCG111,264S ↑ Dudley CCG103,845M ↑ DDDs per 100,000 Resident population Q4 2014/15 Click here to see interactive heat map online Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Ticagrelor – Primary care Background This is a treatment option recommended by NICE TA (TA236) published in October 2011, combined with low- dose aspirin for up to a year for some people with acute coronary syndromes.TA236 Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have the area teams identified any local barriers to the use of this treatment in both primary care and secondary care ? Click here to see interactive heat map online 12 DDDs per 100,000 Resident population Q4 2014/15 Lowest CCGs RegionTrend Nottingham West CCG126M ↑ Guildford and Waverley CCG206S ↓ Nottingham North and East CCG209M ↓ Highest CCGs Barnsley CCG14,440N ↔ Lincolnshire East CCG14,005M ↑ Leeds South and East CCG11,850N ↔ Sources: Innovation Scorecard, Prescribing and Medicines Team, HSCIC using data from ePACT (NHS Business Services Authority) ; CCG Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Afatinib – Secondary care Background This is one option of treatment recommended by NICE TA (TA310) published in April 2014 for locally advanced or metastatic non- small-cell lung cancer.TA310 mgs per 100,000 Resident population Q4 2014/15 Click here to see interactive heat map online Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in secondary care ? Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved Lowest Area TeamsTrend Merseyside 0. Leicestershire and Lincolnshire 0. Arden, Herefordshire and Worcestershire 0. Highest Area Teams Cumbria, Northumberland, Tyne and Wear1,518 ↑ Thames Valley1,372 ↑ Devon, Cornwall and Isles of Scilly1,168 ↑

Boceprevir – Secondary care Background This is one treatment option recommended by NICE TA (TA253) published in April 2012, with peginterferon alfa and ribavirin as treatment for genotype 1 chronic hepatitis C in adults with the earlier stages of liver disease.TA253 Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in secondary care ? Click here to see interactive heat map online 14 DDDs per 100,000 population by Area Teams Q4 2014/15 Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) ; Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved Trend Shropshire and Staffordshire 0↓ Birmingham and the Black Country 0↓ Essex 0. Highest Area Teams Greater Manchester37 ↓ Bristol, North Somerset, Somerset and South Gloucestershire 33 ↓ East Anglia33 ↓

Dabrafenib – Secondary care Background This is one option of treatment recommended by NICE TA (TA321) published in October 2014 as a treatment for unresectable or metastatic BRAF V600 mutation-positive melanoma.TA321 mgs per 100,000 population by Area Teams Q4 2014/15 Lowest Area TeamsTrend Merseyside 0. Hertfordshire and the South Midlands 0↓ Arden, Herefordshire and Worcestershire 0. Highest Area Teams East Anglia13,624 ↑ Bristol, North Somerset, Somerset and South Gloucestershire 12,943 ↑ London10,891 ↑ Click here to see interactive heat map online Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in secondary care ? Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved

Enzalutamide – Secondary care Background This is one option of treatment recommended by NICE TA (TA316) published in July 2014, for people with relapsed prostate cancer.TA316 Key lines of enquiry Some areas do not appear to have access to this treatment. Have the area teams identified local barriers to the use of this treatment in both primary care and secondary care? Is this treatment option being considered? DDDs per 100,000 Resident population Q4 2014/15 Click here to see interactive heat map online Lowest Area TeamsTrend Merseyside 0. Hertfordshire and the South Midlands 77↑ Shropshire and Staffordshire 101↑ Highest Area Teams Devon, Cornwall and Isles of Scilly604 ↑ Cheshire, Warrington and Wirral547 ↓ Bath, Gloucestershire, Swindon and Wiltshire470 ↑ Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS Business Services Authority), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved

Erythropoietin analogues - Secondary care (epoetin alpha, epoetin beta, epoetin zeta, darbepoetin alpha) Background This group of treatments are recommended as treatment options by NICE TAs (TA142,TA323) published up to November 2014 as stimulating agents for treating anaemia in people with cancer have chemotherapy.TA142TA323 DDDs per 100,000 Resident population Q4 2014/15 Click here to see interactive heat map online Key lines of enquiry Have the area teams identified local barriers to the use of this treatment in both primary care and secondary care? Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA), Hospital Pharmacy Audit Index (HPAI) (IMS Health) Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved Lowest Area TeamsTrend Bath, Gloucestershire, Swindon and Wiltshire 2,891↔ Lancashire 2,918↔ Durham, Darlington and Tees 3,097↓ Highest Area Teams Birmingham and the Black Country10,305 ↑ London9,583 ↓ Bristol, North Somerset, Somerset and South Gloucestershire 9,065 ↔

Golimumab – Secondary care Background This is one option of treatment recommended by NICE TAs (TA220,TA225,TA233,TA329) published up to February 2015 for active and progressive psoriatic arthritis; sever ankylosing spondylitis(adults); rheumatoid arthritis that has responded inadequately to other disease-modifying anti-rheumatic drugs and active ulcerative colitis (moderate to severe) after failure of conventional therapy.TA220TA225TA233TA329 Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in secondary care? Lowest Area TeamsTrend Derbyshire and Nottinghamshire 114↑ Lancashire 156↓ Shropshire and Staffordshire 194↓ Highest Area Teams South Yorkshire and Bassetlaw1,985 ↑ Devon, Cornwall and Isles of Scilly1,893 ↑ Durham, Darlington and Tees1,826 ↑ DDDs per 100,000 population by Area Teams Q4 2014/15 Click here to see interactive heat map online Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA), Hospital Pharmacy Audit Index (HPAI) (IMS Health) ; Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved

Imatinib – Secondary care Background This is a treatment option recommended by NICE TA (TA241 and TA326) published up to November 2014, for the treatment of Philadelphia- chromosome- positive chronic myeloid leukemia and gastrointestinal stromal tumours.TA241TA326 Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in secondary care ? Click here to see interactive heat map online 19 Mgs per 100,000 population by Area Teams Q4 2014/15 Trend Essex 145,621↔ Lancashire 177,450↑ Surrey and Sussex 185,781↔ Highest Area Teams Merseyside401,327 ↔ Cumbria, Northumberland, Tyne and Wear369,259 ↔ East Anglia354,617 ↔ Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA), Hospital Pharmacy Audit Index (HPAI) (IMS Health) ; Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved

Nilotinib – Secondary care Background This is an option of treatment recommended by NICE TA (TA251) published in April 2012, for people with chronic myeloid leukaemia.TA251 Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in secondary care ? Click here to see interactive heat map online 20 Mgs per 100,000 population by Area Teams Q4 2014/15 Trend Cheshire, Warrington and Wirral 31,892↑ Leicestershire and Lincolnshire 53,851↔ Lancashire 58,522↔ Highest Area Teams Merseyside177,765 ↓ Birmingham and the Black Country136,030 ↑ Devon, Cornwall and Isles of Scilly135,184 ↔ Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA), Hospital Pharmacy Audit Index (HPAI) (IMS Health) ; Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved

Novel Oral Anti-Coagulants (NOACs) – Secondary care Background This group of treatments are recommended as a treatment option for the prevention of stroke in Atrial Fibrillation, the treatment and secondary prevention of Deep Vein Thrombosis and/or Pulmonary Embolism, (TA249, TA256, TA275, TA327), and prevention of Venous Thromboembolism in several technology appraisals up to December It has been a topic in a NICE Implementation Collaborative for use in Atrial Fibrillation and a consensus statement on its use has been produced by Royal Colleges. Find out more hereTA249 TA256 TA275 TA327Find out more here Key lines of enquiry Significant variation in uptake can be seen on the maps below. Have the area teams identified any local barriers to the use of these treatments in secondary care? Click here to see interactive heat map online 21 DDDs per 100,000 population by Area Teams Q4 2014/15 Trend Lancashire 21,992↑ London 24,618↑ East Anglia 24,922↑ Highest Area Teams Bristol, North Somerset, Somerset and South Gloucestershire 119,571 ↑ Bath, Gloucestershire, Swindon and Wiltshire77,819 ↑ Kent and Medway69,195 ↑ Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA), Hospital Pharmacy Audit Index (HPAI) (IMS Health) ; Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved

Telaprevir – Secondary care Background This is an option of treatment recommended by NICE TA (TA252) published in April 2012, with Peginterferon alfa and ribavirin for genotype 1 chronic hepatitis C in adults with the earlier stages of liver disease.TA252 Key lines of enquiry Have the area teams identified any local barriers to the use of this treatment in secondary care ? Click here to see interactive heat map online 22 DDDs per 100,000 population by Area Teams Q4 2014/15 Trend Lancashire 0↓ Shropshire and Staffordshire 0↓ Birmingham and the Black Country 0↓ Highest Area Teams East Anglia44 ↓ West Yorkshire19 ↓ Surrey and Sussex17 ↓ Sources: Innovation Scorecard, HSCIC using data from ePACT (NHS BSA), Hospital Pharmacy Audit Index (HPAI) (IMS Health) ; Area Team Resident population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved

Debrisoft monofilament debridement pad (MTG17) Medical Technology Click here to see interactive heat map online Background NICE developed medical technology guidance (MTG17) in March 2014 on the Debrisoft monofilament debridement pad for use in acute or chronic wounds.MTG17 Key lines of enquiry Have the area teams identified any local barriers to the use of this medical technology ? 23 Sources: Innovation Scorecard, HSCIC using data from HES, NHS Supply Chain and ePACT (NHS BSA), Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved Lowest Area TeamsTrend Thames Valley 18.97↓ East Anglia 56.72↔ London 63.33↑ Highest Area Teams Birmingham and the Black Country ↑ Devon, Cornwall and Isles of Scilly ↑ Shropshire and Staffordshire ↑ Pads per 100k resident population, by Area Teams Q4 2014/15

TAVI (Transcatheter Aortic Valve Implantation) Medical Technology Click here to see interactive heat map online Key lines of enquiry Have the area teams identified any local barriers to the use of this medical technology ? 24 Procedures per 100,000 Resident Population, by Area team Q4 2014/15 Lowest Area TeamsTrend Cheshire, Warrington and Wirral 0.16↓ Bristol, North Somerset, Somerset and South Gloucestershire 0.28↓ South Yorkshire and Bassetlaw 0.34↑ Highest Area Teams Surrey and Sussex1.43 ↔ Birmingham and the Black Country1.22 ↑ Cumbria, Northumberland, Tyne and Wear 1.09 ↑ Sources: Innovation Scorecard, HSCIC using data from Hospital Episode Statistics (HES) ; Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved. Background NICE has issued full guidance (IPG421) in March 2012 on Transcatheter aortic valve implantation for aortic stenosis. This document replaces previous guidance IPG 266.(IPG421)

Vertebral Fractures - Vertebroplasty and Kyphoplasty Medical Technology Click here to see interactive heat map online Background This is treatment option recommended by NICE TA (TA279) in April 2013, for people with spinal compression fractures caused by osteoporosis.TA279 Key lines of enquiry Have the area teams identified any local barriers to the use of this medical technology ? 25 Procedures per 100,000 Resident Population, by Area team Q4 2014/15 Lowest Area TeamsTrend Kent and Medway 0.06↑ Bath, Gloucestershire, Swindon and Wiltshire 0.07↑ Bristol, North Somerset, Somerset and South Gloucestershire 0.07↓ Highest Area Teams North Yorkshire and Humber1.14 ↑ Durham, Darlington and Tees1.02 ↑ Cumbria, Northumberland, Tyne and Wear0.93 ↑ Sources: Innovation Scorecard, HSCIC using data from Hospital Episode Statistics (HES) ; Resident Population: ONS Note: data have not been adjusted for demography & disease prevalence Re-used with the permission of the HSCIC. All rights reserved.

Ratio of colonoscopy procedures to flexible sigmoidoscopy procedures by CCG, 2012/13. Background Flexible sigmoidoscopy is the preferred procedure in some clinical situations because sedation is not required, and it is quicker and carries less risk than colonoscopy. Further detail of the evidence base is available in the Atlas of Variation.Further detail of the evidence base is available in the Atlas of Variation Key Lines of enquiry Have the area teams identified any local barriers to the use of this technology? Lowest CCGs Region Guildford and Waverley CCG0S North Durham CCG1N North East Essex CCG1M Highest CCGs East Lancashire CCG10N Dorset CCG9S Eastbourne, Hailsham and Seaford CCG4S Source: HES HSCIC, taken from Endoscopy CCG.xlsx. Note: Excludes all cases where age, sex, IMD or CCG is missing or not relevant.

Rate of computed tomography (CT) colonoscopy procedures per population by CCG 27 Key lines of enquiry Have the area teams identified any local barriers to the use of this technology? Background Computed tomography (CT) colonoscopy is a relatively new radiological technique designed to image the colon and is minimally invasive with no need for sedation, although a laxative bowel preparation is sometimes still required. Whilst it is used to investigate patients with symptoms suggestive of colorectal cancer, and has been found to be as effective as optical colonoscopy in the diagnosis of colorectal cancer, it is less useful for the diagnosis of IBD because biopsy material is invariably required to support or refute the diagnosis. Further detail of the evidence base is available in the Atlas of Variation.Further detail of the evidence base is available in the Atlas of Variation. Lowest CCGs RegionTrend Newcastle North and East CCG0N. Brighton and Hove CCG0S ↓ Leicester City CCG 0M. Highest CCGs Fareham and Gosport CCG108S ↓ Portsmouth CCG103S ↔ South Eastern Hampshire CCG89S ↓ Procedures per 10,000 population, by CCG 2013/ /15 Source: DID, taken from Colonoscopy Barium Enema Standardised Rates.xlsx. Note: Excludes all cases where age, sex, IMD or CCG is missing or not relevant.

Rate of dual-energy X-ray absorptiometry (DEXA) activity per weighted population by CCG 28 Background Dual-energy X-ray absorptiometry (DEXA) is a type of X-ray used to measure the density of bones, is more sensitive than a normal X-ray and is also safer in that it delivers a much lower dose of radiation. Following a suspected fragility fracture, investigation of bone density, for instance using DEXA, is advised such that osteoporosis treatment can be initiated to help prevent a subsequent fracture and the consequent considerable morbidity. Further detail of the evidence base is available in the Atlas of VariationFurther detail of the evidence base is available in the Atlas of Variation. Key lines of enquiry Have the area teams identified any local barriers to the use of this technology ? Lowest CCGs RegionTrend Isle of Wight CCG90S ↓ Eastbourne, Hailsham and Seaford CCG173S ↑ Hastings and Rother CCG193S ↑ Highest CCGs North, East, West Devon CCG19,568S ↑ Sheffield CCG14,420N ↓ Dorset CCG12,222S ↑ Sources: Numerator from the Monthly Diagnostics Waiting times and Activity return (DM01). Note: Denominator taken from CCG-weighted-populations NHS England.