1. Antibiotics National Prescribing Indicators
Kate Jenkins
Senior Pharmacist
Welsh Analytical prescribing Support Unit
I am a pharmacist working within the Welsh Analytical Prescribing Support Unit, which is part of the All Wales Therapeutics and Toxicology Centre.
The All Wales Therapeutics and Toxicology Centre or AWTTC is responsible for providing a variety of prescribing and medicines management services to NHS Wales, mainly around advice on new medicines, and education and communication on prescribing and therapeutic initiatives. The groups supports All Wales Medicines Strategy Group and the All Wales Prescribing Advisory Group.
The Welsh Analytical Prescribing Unit or WAPSU is the analytical arm of this organisation and we provide AWMSG and NHS Wales with robust data and analysis, supporting information and tools to analyse prescribing.

2. “Antibiotic prescriptions soar as doctors ignore superbug warning”
The Times, Friday October
“Antibiotics wrongly prescribed by many GPs, survey finds”
The Guardian, Tuesday 19 August 2014
Before moving on to discuss the National Prescribing Indicators and present some prescribing data, I would like to remind ourselves why antibiotic prescribing is the focus of so much attention.
Antibiotics regularly make the headlines, just two of many examples are on the slide.
They are also regularly the centre of new features.
Most articles state how antibiotics are being used excessively and the potential issues that arise from this.

3. In 2013-2014 Wales prescribed 20% more antibiotics than England
Items per 1,000 patients
All the data included in my presentation relates to primary care prescribing by GPs on standard WP10 prescriptions.
The data is obtained from CASPA systems in Wales. CASPA is an electronic system for measuring prescribing trends in primary care in Wales. The data originates from what is actually dispensed on WP10 prescriptions. Therefore it would not be able to identify prescriptions that have been written but not dispensed, nor would it be able to tell us what has been dispensed but not actually taken. To get this level of detail would need to undertake audit.
The English data was obtained by accessing a similar system running in England called EPACT
Our colleagues in Scotland kindly supplied the Scottish data.
We also have to assume that all the systems in Wales, England and Scotland record the data in the same way.
This graph shows the total number of antibiotic prescriptions dispensed per 1,000 patient population for the financial year
England 659/1,00 patients
Scotland 691/1,000 patients
Wales 800/1,000 patients

4. Variation in antibiotic prescribing exists
Items per 1,000 patients
This graph also plots the number of antibiotic prescriptions dispensed per 1,000 patients, for the financial year
The mid blue colour each line is on of the 211 CCGs in England, whilst the dark blue/black lines are each of the 14 Scottish health boards and the red lines are each of the 7 health boards in Wales.
Using patients as a denominator is quite crude, as it doesn’t account for the age and sex of the population, demographic differences, differences in disease prevalence, difference in prescribing arrangements etc.
The happy and sad faces also quite crude as we are suggesting that lower is better, however, there could be a health board at the left happy face end whose prescribing is inappropriately low.

5. Prescribing indicators are tools which can be used to compare the way different prescribers and organisations use a particular medicine or group of medicines.
In October 2003, AWMSG agreed that National Prescribing Indicators (NPIs) were useful tools to promote rational prescribing across NHS Wales.
So what are Prescribing Indicators – they are tools which can be used to compare the way different prescribers and organisations use a particular medicine or group of medicines
A good prescribing indicator should be:
Evidence-based, clear, easily understood and allow health boards, practices and prescribers to compare current practice against an agreed standard of quality
Ideally they should be validated by a group of experts and recommend the direction prescribing should move, even if it is not possible to specify an exact value that represents “good practice”
They should be standardised to allow comparison between health boards or practices serving different size populations. Weighting may also be able to consider the age and demographics of a population.
Prior to 2003 each local health board developed their own prescribing indicators, however in 2003 the All Wales Medicines Strategy Group agreed that National Prescribing Indicators were useful tools which could be used to promote rational prescribing across NHS Wales.
AWMSG also recommended that National Prescribing Indicators should address efficiency as well as quality and ideally targets should be set, which should be challenging but achievable.
In practical terms a target threshold is generally set at the 25th percentile of all practices, and the target is to maintain prescribing in that top quartile or move towards that target threshold.

6. Developing NPIs Meeting of the AWPAG task and finish sub-group
July
2014
Meeting of the AWPAG task and finish sub-group
Review NPIs
Propose deletions, additions and amendments to the NPIs
September 2014
AWPAG discuss the proposed NPIs for
October - November 2014
NPI document sent out for consultation
December 2014
Endorsed by AWMSG
The National Prescribing Indicators are developed by a task and finish sub-group of the All Wales Prescribing Advisory Group
The group comprises a chief pharmacist, hospital, primary care and medicines information pharmacists, GPs and hospital doctors, a data analyst; representation from all HBs in Wales
The group review the current National Prescribing Indicators, in light of prescribing data, QIPP indicators in England and new evidence
The proposed National Prescribing Indicators are then developed
These are reviewed and discussed by AWPAG
The document then undergoes a period of consultation ensuring representatives from each speciality have opportunity to comment – consultation phase closes tomorrow
Endorsed by AWMSG – this has to be completed by the end of December to allow health board medicines management teams to consider how they will use the indicators with in their Clinical effectiveness and prescribing programmes.

7. There are 4 antibiotic NPIs:
Total antibacterial items per 1,000 STAR-PUs
Cephalosporins as a percentage of total antibacterial items
Co-amoxiclav as a percentage of total antibacterial items
Quinolones as a percentage of total antibacterial items
In the current National Prescribing Indicators there are four which focus on antibiotic prescribing:
One which looks at total antibacterial prescribing, whilst the remaining 3 focus on the prescribing of individual or specific groups of antibacterials.
The aim of all four NPIs is to reduce inappropriate antibiotic prescribing.
On the following slides I will go into each National Prescribing Indicator in a little more detail and show you some examples of the way we present prescribing data.

8. Total antibacterial items per 1,000 STAR-PUs
Measures the number of prescriptions
Weighted by population
STAR-PU: Specific therapeutic group age–sex related prescribing units (STAR-PUs) are designed to measure prescribing weighted for age and sex of patients. There are differences in the age and sex of patients for whom medicines in specific therapeutic groups are usually prescribed. To make such comparisons, STAR-PUs have been developed based on costs of prescribing items within therapeutic groups.
No target threshold is set of this NPI
Target is to reduce total antibacterial prescribing
This measure looks at overall antibiotic prescribing in primary care
And measures the total number of prescriptions dispensed for antibiotics in primary care
And is weighted meaning that health boards, localities, clusters, and practices of different sizes can be compared
In this instance it is weighted by STAR-PUs
STAR-PUs have been developed in England following analysis of prescribing in different age groups and between genders. They have been developed for different groups of medicines, so the STAR-PUs used in this analysis are specific for antibiotic prescribing.
No target threshold is set for this indicator as seasonal variation means a threshold set on a summer quarter would not be relevant to a winter quarter and vice versa, however the overall target is to reduce total antibacterial prescribing when comparing quarterly or yearly data.

9. Antibacterial prescribing is showing a slight reduction in prescribing?
This 4 year trend in total antibacterial prescribing shows some slight reduction in the winter peaks over the last four years, whilst summer prescribing appears fairly stable.
We need to wait for this years data to see whether the reducing trend continues

10. Variation exists between health boards
The next three graphs use data the quarter January – March 2014 and in each case looks at total antibacterial prescribing weighted by STAR-PUs
In this graph each column represents one health board.
Each practice is represented as a blue dot (lots of the dots overlap). Within each HB the central horizontal line is the health board median value, the upper and lower horizontal lines show the range of the middle 50% of practices, whilst the graph also show the full extremes of prescribing.

11. Variation exists between localities
Again using data for the period January – March 2014
Each of the 22 old local health boards/localities are coloured according to their total weighted prescribing. The areas coloured darkest turquoise show where prescribing is highest, whilst the pale yellow areas show where prescribing is lowest.
This does not consider differences in deprivation, disease prevalence or other factors which may influence prescribing.

12. Variation exists between practices
Again using data for the period January – March 2014
All practices in Wales are plotted on the graph (pale grey dots), from the lowest prescribers to the highest prescribers, the blue crosses represent practices from one specific health board.
These plots are can be produced for each health board, and can identify individual practices.

13. Three of the NPIs focus on particular antibiotics or groups of antibiotics
Cephalosporins as a percentage of total antibacterial items
Co-amoxiclav as a percentage of total antibacterial items
Quinolones as a percentage of total antibacterial items
The other 3 National prescribing Indicators all focus on the prescribing of specific antibiotic or group of antibiotics
In each case the number of items for the specific antibiotic or group of antibiotics is presented as a percentage of total antibacterial items.
This means that for these three National Prescribing Indicators the information needs to be looked at in the context of other data.
For example a practice may appear to have very low percentage use of cephalosporins, but because overall antibacterial use is high, although the percentage is low, the actual number of prescriptions issued is still high.
Therefore when looking at this data, total prescription numbers need to be considered.
Additionally as we are looking at specific antibiotics, it is also necessary to consider local resistance patterns and disease prevalence, as this may affect antibiotic choice in certain areas.
Target thresholds have been set for these NPIs, but again they are subject to seasonal variation because the calculation is using total antibiotics as the denominator.

14. Reduction in specific antibiotic prescribing
This 4 year trend shows that prescribing for each of these three antibiotic groups is reducing in Wales

15. This figure uses data for the period April – June 2014 and shows the variation in the cumulative percentage use of the three groups of antibiotics (cephalosprins, co-amoxiclav and quinolones) for the 22 localities in Wales.

16. For all three of the antibiotic groups included in the national prescribing indicators I am now going to present the prescribing data. The graphical representations are similar for each of the antibiotics/groups of antibiotics, so I am not going to provide lengthy explanations as I will get bored of repeating myself and I am sure you will get bored of hearing me repeat myself.
I do think it is important to re-iterate though that in all cases the data does not account for differences in demographics, disease prevalence, deprivation, resistance patterns and other factors which may account for variations in prescribing. The data provides a tool therefore to identify areas where closer scrutiny of the data may be useful.
The next three graphs all show prescribing of cephalosporins as a percentage of all antibiotics in slightly different ways.
This is the prescribing trend by health board, all moving a downward direction.

17. This is a pictorial representation of prescribing for the period April –June 2014 by locality, the bluer and larger the writing the higher the proportion of cephalosporin prescribing

18. We are starting to present data by the 64 local cluster groups which have been developed in Wales
This graph presents the proportion of cephalosporin prescribing for each of 64 cluster groups and compares prescribing for the period April – June 2014, the shapes in grey with the same period the previous year the shapes in green.
The graph identifies where changes in prescribing have been seen.

19. The next three graphs all show prescribing of co-amoxiclav as a percentage of all antibiotics in slightly different ways
This is prescribing trend by health board.

20. This is a pictorial representation of prescribing for the period April –June 2014 by locality, the bluer and larger the circle the higher the proportion of co-amoxiclav prescribing, the smaller and paler yellow the circle the lower the prescribing.

21. This graph presents the proportion of co-amoxiclav prescribing for each of 64 cluster groups and compares prescribing for the period April – June 2014, the shapes in grey with the same period the previous year the shapes in green.
The graph identifies where changes in prescribing have been seen.

22. And finally the next three graphs all show prescribing of quinolones as a percentage of all antibiotics
This is prescribing trend by health board

23. This is a treeview representation of prescribing for the period April –June 2014 by locality, the bluer and larger the box the higher the proportion of quinolone prescribing, the smaller and paler yellow the box the lower the prescribing.

24. This graph presents the proportion of quinolone prescribing for each of 64 cluster groups and compares prescribing for the period April – June 2014, the shapes in grey with the same period the previous year the shapes in green.
The graph identifies where changes in prescribing have been seen.

25. Future developments
As previously mentioned the NPIs are out for consultation, and it is proposed that all 4 National Prescribing Indicators are retained for the next year, however, the group propose to change the measure for each of the individual antibiotics or groups of antibiotics to items/1,000 patients looking for a continued year on year reduction. This is to simplify monitoring and hopefully make it more understandable to the lay person who doesn’t look at prescribing data on a regular basis.
To date National Prescribing Indicators have included prescribing measures specific to primary care. AWPAG are keen to develop prescribing measures within the National Prescribing Indicators which focus on secondary care prescribing, in specific areas including antibiotics. This is difficult to achieve as prescribing data is reported in a different way through a different system.
AWPAG and AWMSG are keen to present more of the data at cluster level to allow evolving cluster groups to have data specific to their group. There is also work in progress to develop cluster group comparators. This will identify similar cluster groups based on deprivation, disease prevalence and other relevant factors, which in turn will provide more accurate benchmarking with other clusters of a similar demographic profile.
To really make the most of the prescribing data it is necessary to link it with other relevant data, such as resistance data, deprivation data, chronic disease prevalence and hospital admissions rather than being looked at in isolation.

26. Materials available to support the reduction in antibiotic prescribing
And finally a plug for some of the resources which have been developed by AWTTC, WAPSU and AWPAG over the last couple of years.
Over the summer a report specifically focusing on the antibiotic NPIs was produced. There is a specific one available for each HB, through the medicines management teams.

27. A summary document has been produced to support the National Prescribing Indicators. Within the antibiotic section there are links to resources available in Wales to support appropriate antibiotic prescribing.

28. AWPAG has developed a National Audit focusing on antibiotic prescribing.
The document contains several stand alone audits which can be used to review prescribing in a particular practice.
Links to all of these documents can be found on the AWMSG website.

29. Thank you