Scottish Antimicrobial Prescribing Group Primary Care Prescribing … · 2013. 10. 28. · by NHS board, proportion of items, 2008-09 – 2012-13 19 Table 10: NHS Scotland use of

SAPGScottish Antimicrobial Prescribing Group

Primary Care Prescribing Indicators

Annual Report 2012-13Published October 2013

i

Contents

Executive summary 1

Introduction 2

Data source and definitions 3

Data sources 3

Items 3

Data presentation 4

Items/1000 patients/day 4

Percentage of total antibacterial use 4

Seasonal variation of fluoroquinolone use 4

Interpretation of data 4

Community Health Index (CHI) numbers 4

Total use of antibacterials 5

Antibacterials associated with a higher risk of Clostridium difficile infection 7

Co-amoxiclav 10

Cephalosporins 12

Fluoroquinolones 14

Seasonal variation in use of fluoroquinolones 16

Recommended antibacterials 18

Urinary Tract Infections 21

Nurse Prescribing 26

Dental Prescribing 28

Appendix 1 30

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List of tables

Table 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13 6

Table 2: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2008-09 – 2012-13 8

Table 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, items/100,000/day, 2008-09 – 2012-13 9

Table 4: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13 11

Table 5: NHS Scotland use of cephalosporins in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13 13

Table 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13 15

Table 7: NHS Scotland use of antibacterials in primary care by NHS board, % seasonal variation of fluoroquinolones (Items) 2008-09 – 2012-13 17

Table 8: NHS Scotland use of recommended agents, total items 2012-13 and change from 2011-12 18

Table 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of items, 2008-09 – 2012-13 19

Table 10: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13 20

Table 11: NHS Scotland use of 3 day trimethoprim in primary care by NHS board, proportion of all trimethoprim, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for trimethoprim, Scotland 2010/11-2012/13 88% (NHS board range 83% - 91%) 22

Table 12: NHS Scotland use of 3 day nitrofurantoin in primary care by NHS board, proportion of all nitrofurantoin, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for Nitrofurantoin, Scotland 2010/11-2012/13 91% (NHS board range 88% - 94%) 24

Table 13: NHS Scotland nurse prescribing of antibacterials in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13 26

Table 14: NHS Scotland dental prescribing of antibacterials in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13 28

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List of Figures

Figure 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13 6

Figure 2: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2008-09 – 2012-13 8

Figure 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, items/100,000/day, 2008-09 – 2012-13 9

Figure 4: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13 11

Figure 5: NHS Scotland use of cephalosporins in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13 13

Figure 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13 15

Figure 7: Percentage of GP practices within each NHS board achieving <5% seasonal variation of fluoroquinolones (Items) 2012-13 17

Figure 8: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of total items, 2008-09 – 2012-13 19

Figure 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13 20

Figure 10: NHS Scotland use of 3 day trimethoprim in primary care by NHS board, proportion of all trimethoprim, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for trimethoprim, Scotland 2010/11-2012/13 88% (NHS board range 83% - 91%) 23

Figure 11: NHS Scotland use of 3 day nitrofurantoin in primary care by NHS board, proportion of all nitrofurantoin, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for trimethoprim, Scotland 2010/11-2012/13 91% (NHS board range 88% - 94%) 25

Figure 12: NHS Scotland nurse antibacterial prescribing in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13 27

Figure 13: NHS Scotland dental antibacterial prescribing in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13 29

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Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2012-13 Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2012-13

Executive summary

This is the fifth annual report for the Scottish Antimicrobial Prescribing Group (SAPG). The report contains information on key national primary care antibacterial prescribing indicators. The purpose of this report is to support the work of Antimicrobial Management Teams (AMTs) in NHS boards and SAPG by enabling identification of areas for detailed local analysis and discussion with prescribers to support improvement in the quality of antimicrobial prescribing. This report is published by Information Services Division (ISD) and Health Protection Scotland (HPS), part of the Public Health and Intelligence (PHI) strategic business unit of NHS National Services Scotland (NSS).

The SAPG national prescribing indicators are accessible as standard reports within Prescribing Information System for Scotland (PRISMS). PRISMS is the web based application maintained by Information Services Division (ISD) of NHS National Services Scotland (NSS) giving access to prescribing information on prescriptions dispensed in the community in Scotland. For the first time, this report also includes some patient level analysis using Community Health Index numbers which are held within Prescribing Information System (PIS).

Key findings in 2012-13 include;

• An increase of 3.1% in the total number of prescriptions for antibacterials than in 2011-12. This is equivalent to an increase of 128,369 prescriptions in 2012-13.

• There were 40,933 (9.7%) fewer prescriptions for broad spectrum antibacterials associated with a higher risk of Clostridium difficile infection (CDI) in primary care in Scotland than in 2011-12. This is the fourth successive year in which a reduction has been observed. Reductions have been observed in all NHS boards. In 2012-13 antibacterials associated with a higher risk of CDI accounted for 8.9% of total use of antibacterials and continues the downward trend observed in previous years.

• The use of recommended agents accounted for 81.5% of all antibacterial items across Scotland in 2012-13, continuing the upward trend observed in previous years. This increase was observed in most NHS boards in 2012-13 and suggests increased compliance with local prescribing policies.

• There were 13/14 NHS boards with less than 5% seasonal variation in fluoroquinolone use expressed in terms of items. Until June 2013, seasonal variation in fluoroquinolones was used as a national antimicrobial prescribing indicator to support achievement of the HEAT target for reduction in CDI.

The report illustrates the ongoing impact of initiatives to encourage compliance with evidenced based prescribing guidelines that promote use of recommended agents and restrict the use of broad spectrum antibacterials associated with a higher risk of CDI. The increase in total antibacterial use reinforces the importance of initiatives aimed at reduction in unnecessary use of antibacterials in primary care.

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Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2012-13

Introduction

Welcome to fifth annual report for the Scottish Antimicrobial Prescribing Group (SAPG) published by Information Services Division (ISD) and Health Protection Scotland (HPS), part of the Public Health and Intelligence (PHI) strategic business unit of NHS National Services Scotland (NSS). This report contains information on key national primary care antibacterial prescribing indicators. The purpose of the report is to support the work of NHS board Antimicrobial Management Teams (AMTs) and is intended to enable AMTs to identify areas for detailed local analysis and discussion with prescribers to support improvement in prescribing practice. By highlighting patterns of change in the last twelve months the report is intended to support AMTs to monitor the impact of local and national interventions which aim to enhance the quality of antimicrobial prescribing in a primary care setting.

The national prescribing indicators are accessible as standard reports within Prescribing Information System for Scotland (PRISMS). PRISMS is a web based application maintained by Information Services Division (ISD) of NHS National Services Scotland (NSS) giving access to prescribing information on prescriptions dispensed in the community in Scotland. Further information can be found on the PRISMS website: http://www.prismsweb.scot.nhs.uk/. A full list of the national prescribing indicators available in PRISMS is shown in appendix 1.

This year for the first time, data on antibacterial use by dentist and nurse prescribers is presented to provide AMTs with information on use by a broader range of prescriber types in primary care as part of their approach to antimicrobial stewardship. To further support this, in 2013-14 a series of standard reports in PRISMS will be developed to allow AMTs to monitor antibacterial use by dentist and nurse prescribers at local level.

Community Health Index (CHI) numbers are now captured on most NHS prescriptions dispensed in the community in Scotland. This patient level information is available from the Prescribing Information Scotland (PIS) database which is maintained by ISD. PIS was recently rolled out to NHS boards giving access to more detailed prescribing information than contained within PRISMS. For the first time, information using this CHI level information is presented to enable AMTs to monitor antibacterial use in specific clinical priority areas.

http://www.prismsweb.scot.nhs.uk/

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Data source and definitionsData sourcesData on use of systemic antibacterials comes from a database of all NHS prescriptions written by general practitioners, dentists, nurses and community pharmacists which are dispensed in the community in Scotland. The information is supplied to ISD by Practitioner Services Division (PSD) of NSS who are responsible for the processing and pricing of all prescriptions dispensed in Scotland. This database is known as Prescribing Information Scotland (PIS), includes patient level information. PRISMS is a subset of PIS containing prescribing information but excludes patient level data.

ItemsThe primary measure of antibacterial use in Scotland presented in this report is the number of items. This refers to the number of times an antibacterial appears on prescription.

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Data presentationItems/1000 patients/day This indicator presents use of antibacterials in NHS boards over a given period of time expressed as the number of times an antibacterial has been dispensed. The normal convention to allow comparison between areas with a different population is to present the number of items per 1000 patients per day. In some cases, due to small numbers, indicators are presented as number of items per 100,000 patients per day.

Unless otherwise stated, antibacterial use data excludes dental prescriptions.

Percentage of total antibacterial useThis indicator presents use of selected antibacterials in NHS boards as a percentage of all antibacterial use expressed in items.

Seasonal variation of fluoroquinolone useThis indicator presents the difference in the use of fluoroquinolones in items in the winter (October to March) compared to the preceding summer (April to September). Publications in previous years have reported this measure in terms of defined daily doses (DDD), however, this year the measure is reported in terms of number of items.

Interpretation of dataThe use of antibacterials should normally reflect prescribing policies, guidelines or formularies for each NHS board. When interpreting the graphs it is important to note that the y axis scales vary between graphs and care is needed in interpretation. On each trend graph a line has been included to show data at Scotland level.

Community Health Index (CHI) numbersMeasures which involve the use of CHI numbers are presented quarterly starting from 2010/11 as the CHI capture rates before this point are inconsistent. CHI capture rates may vary by NHS board or by prescription item, when interpreting results consideration should be given to the completeness of CHI and any confounding effect this may have.

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Total use of antibacterials

The development of antimicrobial resistance is a complex evolutionary process. It is accepted that the main driver for the development of resistance is exposure to antimicrobial agents and that resistance is greatest where use is greatest. There is evidence from systematic reviews and randomised controlled trials that antibacterials have limited efficacy in treating a large proportion of respiratory tract infections in adults and children. SAPG has identified reducing unnecessary use of antibacterials as a key aspect of antimicrobial stewardship in Scotland.

In 2012-13 there were 128,369 (3.1%) more prescriptions for systemic antibacterials in primary care in Scotland than in 2011-12, the rate of total antibacterial items dispensed increased by 0.06 items/1000/day (2.9%). There was wide variation in the use of antibacterials (items/1000/day) across NHS boards. NHS Orkney had the lowest use at 1.72 items/1000/day and the highest was in NHS Lanarkshire at 2.50 items/1000/day (table 1, figure 1)

As a result of recent increases in antibacterial use in primary care, SAPG recommended to the Scottish Government that a healthcare associated infection level three quality indicator should be introduced to provide an additional stimulus to reduce unnecessary antibacterial prescribing. This is intended to reduce the pressure for selection of antimicrobial resistance and other forms of ecological damage associated with antibacterial use.

The national quality indicator will use the methodology developed for National Therapeutic Indicators (NTI) developed by the Scottish Government. This approach establishes a best in class level, set at the 25th percentile of all GP practices in Scotland and acknowledges there is variation in the use of antibiotics across practices. To achieve the quality indicator, practices must either achieve an equivalent or lower prescribing rate to that of the Scottish 25th percentile, or achieve an acceptable minimum reduction towards that level. The acceptable minimum level of reduction used in all of the NTI is defined as a reduction in the number of items/1000 patients/day equivalent to one fifth of the national inter-quartile range.

The quality indicator being introduced in 2013-14 is that antibiotic use, expressed in items/1000/day, in at least 50% of practices within each NHS board will be at or below the 25th percentile of Scottish practices or will have made an acceptable move towards that level.

The new measure will be introduced as a level 3 indicator for NHS boards from June 2013 (using January – March 2013 data as the baseline) and will replace the current primary care CDIHEATtargetindicator(seasonalvariationoffluoroquinolones≤5%)whichwasintroducedin 2009.

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Table 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13

Total antibacterials (Items/1000/day) 2008/09 2009/10 2010/11 2011/12 2012/13

NHS AYRSHIRE & ARRAN 2.12 2.08 2.09 2.11 2.24NHS BORDERS 1.85 1.85 1.90 1.93 1.97NHS DUMFRIES & GALLOWAY 2.00 1.91 1.97 2.00 2.10NHS FIFE 2.08 2.07 2.05 2.13 2.15NHS FORTH VALLEY 2.06 2.00 2.01 2.02 2.13NHS GRAMPIAN 1.90 1.89 1.89 1.93 1.96NHS GREATER GLASGOW & CLYDE 2.19 2.13 2.10 2.17 2.24NHS HIGHLAND 1.82 1.84 1.86 1.86 1.91NHS LANARKSHIRE 2.39 2.38 2.39 2.42 2.50NHS LOTHIAN 1.71 1.69 1.72 1.80 1.83NHS ORKNEY 1.69 1.61 1.77 1.75 1.72NHS SHETLAND 1.89 1.87 1.96 1.94 1.97NHS TAYSIDE 2.03 1.96 1.97 1.97 1.98NHS WESTERN ISLES 2.25 2.22 2.23 2.22 2.08SCOTLAND 2.04 2.00 2.01 2.05 2.11

Figure 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13

Financial Year

NHS AYRSHIRE & ARRAN

NHS BORDERS

NHS DUMFRIES & GALLOWAY

NHS FIFENHS FORTH VALLEY

NHS GRAMPIAN

NHS GREATER GLASGOW & CLYDE

NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY

NHS SHETLANDNHS TAYSIDE

NHS WESTERN ISLES

SCOTLAND

1.50

1.60

1.70

1.80

1.90

2.00

2.10

2.20

2.30

2.40

2.50

2008/09 2009/10 2010/11 2011/12 2012/13

Item

s/10

00 P

ts/d

ay

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Antibacterials associated with a higher risk of Clostridium difficile infection

Since its establishment in 2008, a key priority for SAPG has been the reduction in use of broad spectrum antibacterials that increase the risk of CDI. AMTs have developed prescribing policies for first line empirical treatment of infections commonly encountered in primary care based on a national evidence based template. A benefit of this approach is that it restricts the use of high risk antibacterials.

In 2012-13 there were 40,933 (9.7%) fewer prescriptions for antibacterials associated with a higher risk of CDI in the primary care setting in Scotland than in 2011-12. This builds on the reduction observed in the previous years.

In 2012-13 antibacterials associated with a higher risk of CDI accounted for 8.9% of total use of antibacterials and continues the downward trend observed in previous years. In all NHS boards, there has been a reduction in the use of high risk antibacterials as a proportion of overall use (table 2, figure 2).

Table 3 and Figure 3 illustrate the use of antibacterials associated with a higher risk of CDI in primary care by NHS board expressed as items/100,000/day. This shows wide variation across NHS boards. NHS Shetland had the lowest use at 10.55 items/100,000/day and NHS Lothian had the highest at 23.55 items/100,000/day. All NHS boards saw a reduction in use of high risk antibacterials.

Whilst considerable improvements have been made to secure reductions in CDI, there has been a recent slowing of the previous downward trend in national CDI incidence rate. CDI remains a national clinical priority; the continued reduction in 2012-13 in the use of high risk broad spectrum antibacterials is a key finding and shows the ongoing positive impact AMTs and SAPG are having on the quality of antibacterial prescribing in Scotland.

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Table 2: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2008-09 – 2012-13

High risk as % of total items 2008/09 2009/10 2010/11 2011/12 2012/13

NHS AYRSHIRE & ARRAN 24.5% 22.1% 15.3% 9.8% 8.7%NHS BORDERS 19.8% 18.9% 13.6% 11.5% 10.8%NHS DUMFRIES & GALLOWAY 22.6% 16.2% 12.4% 9.6% 8.5%NHS FIFE 18.2% 15.2% 11.6% 10.3% 9.4%NHS FORTH VALLEY 20.8% 17.4% 14.7% 12.1% 9.3%NHS GRAMPIAN 22.9% 18.4% 9.4% 7.2% 6.2%NHS GREATER GLASGOW & CLYDE 19.9% 15.5% 11.3% 10.0% 8.5%NHS HIGHLAND 18.9% 16.8% 13.4% 10.4% 9.0%NHS LANARKSHIRE 20.5% 16.1% 12.5% 10.0% 8.8%NHS LOTHIAN 17.5% 15.7% 14.7% 14.2% 12.8%NHS ORKNEY 22.2% 19.7% 13.7% 7.2% 6.3%NHS SHETLAND 18.5% 15.0% 7.3% 5.9% 5.4%NHS TAYSIDE 18.4% 13.1% 9.5% 6.8% 6.0%NHS WESTERN ISLES 26.2% 22.9% 17.2% 11.7% 10.9%SCOTLAND 20.2% 16.5% 12.3% 10.2% 8.9%

Figure 2: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2008-09 – 2012-13

Financial Year

Perc

enta

ge o

f tot

al (i

tem

s)


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

2008/09 2009/10 2010/11 2011/12 2012/13

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Table 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, items/100,000/day, 2008-09 – 2012-13

High risk antibacterials (Items/100,000/day) 2008/09 2009/10 2010/11 2011/12 2012/13


Figure 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, items/100,000/day, 2008-09 – 2012-13

Financial Year


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Item

s/10

0,00

0 Pt

s/da

y

0.1

10.1

20.1

30.1

40.1

50.1

60.1

2008/09 2009/10 2010/11 2011/12 2012/13

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Co-amoxiclav

In 2012-13, co-amoxiclav accounted for 37.5% of use of antibacterial items associated with a higher risk of CDI. However, there were 9,148 (6%) fewer prescriptions for co-amoxiclav dispensed in primary care in Scotland than in 2011-12. This builds on the reduction observed in previous years.

There was wide variation in the use of co-amoxiclav across NHS boards. NHS Shetland had the lowest use at 2.02 items/100,000/day and NHS Lothian the highest at 10.21 items/100,000/day. The trend toward lower use of co-amoxiclav was observed in most NHS boards (table 4, figure 4).

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Table 4: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13

Co-amoxiclav (items/100,000/day) 2008/09 2009/10 2010/11 2011/12 2012/13


Figure 4: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13

Financial Year


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Item

s/10

0,00

0 Pt

s/da

y

0

4

8

12

16

20

24

2008/09 2009/10 2010/11 2011/12 2012/13

12


Cephalosporins

In 2012-13 cephalosporins accounted for 27.3% of use of antibacterial items associated with a higher risk of CDI. Cefalexin accounted for 89.4% of all cephalosporin items in 2012-13.

In 2012-13 there were 20,129 (16.2%) fewer prescriptions for cephalosporins dispensed in primary care in Scotland than in 2011-12. This builds on the reduction observed in previous years.

Table 5 and Figure 5 illustrate the use of cephalosporins in primary care by NHS board expressed as items/100,000/day. This shows wide variation in the use of cephalosporins across NHS boards. NHS Grampian had the lowest use at 2.19 items/100,000/day and NHS Western Isles the highest at 10.56 items/100,000/day. The trend towards lower use of cephalosporins was observed in most NHS boards.

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Table 5: NHS Scotland use of cephalosporins in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13

Cephalosporins (Items/100,000/day) 2008/09 2009/10 2010/11 2011/12 2012/13


Figure 5: NHS Scotland use of cephalosporins in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13

Financial Year


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Item

s/10

0,00

0 Pt

s/da

y

0

5

10

15

20

25

30

35

2008/09 2009/10 2010/11 2011/12 2012/13

14


Fluoroquinolones

In 2012-13 fluoroquinolones accounted for 33.9% of use of antibacterial items associated with a higher risk of CDI. Ciprofloxacin, the most commonly prescribed fluoroquinolone accounted for 89.2% of all fluoroquinolone items in 2012-13.

In 2012-13 there were 11,757 (8.3%) fewer prescriptions for fluoroquinolones dispensed in primary care in Scotland than in 2011-12. This builds on the reduction observed in previous years.

Table 6 and Figure 6 illustrate the use of fluoroquinolones in primary care by NHS board expressed as items/100,000/day. It shows variation between NHS boards. NHS Tayside had the lowest use at 3.51 items/100,000/day. NHS Fife had the highest at 8.58 items/100,000/day.

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Table 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13

Fluoroquinolone (Items/100,000/day) 2008/09 2009/10 2010/11 2011/12 2012/13


Figure 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/100,000/day, 2008-09 – 2012-13

Financial Year


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Item

s/10

0,00

0 Pt

s/da

y

2

4

6

8

10

12

14

16

18

2008/09 2009/10 2010/11 2011/12 2012/13

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Seasonal variation in use of fluoroquinolones

Seasonal variation is defined as the difference in use during the winter (October to March) relative to use in the preceding summer (April to September). In the winter more respiratory tract infections are seen but many are caused by viruses which are self-limiting and do not require treatment with an antibacterial. Excess use of fluoroquinolones in the winter suggests inappropriate use for respiratory infections.

Until June 2013, seasonal variation in fluoroquinolones was used as a national antimicrobial prescribing indicator to support achievement of the HEAT target for reduction in CDI. A target was set which required no more than 5% seasonal variation in the use of fluoroquinolones.

From June 2013, SAPG has agreed that the seasonal variation of fluoroquinolones target should be replaced by a new level three quality indicator on total antibacterial use but advised AMTs to continue to monitor seasonal variation of fluoroquinolones use and to focus interventions at those practices with seasonal variation above 5%.

Table 7 illustrates the percentage seasonal variation of fluoroquinolone use (in items) by NHS board in primary care. In 2012-13, 13 NHS boards were below the target. A negative seasonal variation means there was lower use in the winter compared to the preceding summer.

NHS Ayrshire and Arran saw an 8.7% seasonal variation in 2012-13. There was a decrease in total use of fluoroquinolones in NHS Ayrshire and Arran compared with 2011-12. However, this reduction was only seen in the summer, with a small increase in the winter which has resulted in an increase in seasonal variation.

Figure 7 illustrates the proportion of GP practices within each NHS board with less than 5% seasonal variation of fluoroquinolones in 2012-13. This illustrates variation between NHS boards. NHS Ayrshire & Arran had the lowest use proportion of GP practices with less than 5% seasonal variation at 47%. NHS Orkney had the highest at 93%

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Table 7: NHS Scotland use of antibacterials in primary care by NHS board, % seasonal variation of fluoroquinolones (Items) 2008-09 – 2012-13

Fluoroquinolones(% seasonal variation)

2008/09 2009/10 2010/11 2011/12 2012/13

NHS AYRSHIRE & ARRAN 11.3 12.0 -20.3 -8.4 8.7NHS BORDERS 11.6 7.1 -2.4 -3.8 -1.3NHS DUMFRIES & GALLOWAY 2.8 -6.6 2.8 -13.6 -7.7NHS FIFE 7.0 -6.8 -5.5 0.3 -5.6NHS FORTH VALLEY 17.9 -11.7 -5.5 6.9 -15.3NHS GRAMPIAN 5.2 -22.3 -7.7 -3.2 4.9NHS GREATER GLASGOW & CLYDE 9.3 0.6 3.5 6.2 -13.3NHS HIGHLAND -1.7 -5.4 -10.7 -4.7 3.0NHS LANARKSHIRE 6.9 6.0 -0.2 -5.0 -0.4NHS LOTHIAN 6.3 -0.9 2.0 1.9 -2.1NHS ORKNEY -2.1 21.9 -36.3 -11.8 -17.9NHS SHETLAND 16.8 -2.1 -47.1 20.5 -12.8NHS TAYSIDE 0.0 -25.3 -6.5 -2.7 1.2NHS WESTERN ISLES 19.4 15.0 -17.0 6.9 2.9

Figure 7: Percentage of GP practices within each NHS board achieving <5% seasonal variation of fluoroquinolones (Items) 2012-13

0%

20%

40%

60%

80%

100%

NHS Ayrs

hire

& Arra

n

NHS Bord

ers

NHS Dum

fries

& Gall

oway

NHS Fife

NHS Forth

Vall

ey

NHS Gram

pian

NHS Grea

ter G

lasgo

w

& Clyd

e

NHS High

land

NHS Lana

rkshir

e

NHS Lothi

an

NHS Orkn

ey

NHS She

tland

NHS Tays

ide

NHS Wes

tern I

sles

Per

cent

age

of G

P P

ract

ices

Scotland

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Recommended antibacterialsThis indicator presents the use of antibacterials recommended, in the national evidence based guidance template supported by SAPG, as first line empirical treatment in commonly encountered infections in primary care. It includes a group of narrow spectrum antibacterials; amoxicillin, clarithromycin, doxycycline, erythromycin, flucloxacillin, nitrofurantoin, phenoxymethylpenicillin and trimethoprim.

In 2012-13 there were 155,612 (4.7%) more prescriptions for recommended antibacterials in primary care in Scotland than in 2011-12 and builds upon the increases observed in previous years. Most notably in 2012-13 there have been large increases in use of doxycycline, nitrofurantoin and clarithromycin (Table 8).

Table 8: NHS Scotland use of recommended agents, total items 2012-13 and change from 2011-12

Number of items 2012/13 % Change from 2011/12

Amoxicillin 1,251,047 2.4%

Clarithromycin 311,658 13.6%

Doxycycline 252,066 21.9%

Erythromycin 220,021 -4.7%

Flucloxacillin 457,403 -0.2%

Nitrofurantoin 233,199 17.3%

Phenoxymethylpenicillin 269,550 1.0%

Trimethoprim 482,933 4.0%

All Recommended Agents 3,477,877 4.7%

Figure 8 and table 9 illustrate the number of recommended antibacterial items as a proportion of total antibacterial use in primary care by NHS board. The use of recommended agents accounted for 81.5% of all antibacterial items across Scotland in 2012-13, slightly higher than the proportion observed in 2011-12. This increase in the proportion of recommended agents was observed in all NHS boards in 2012-13 except NHS Tayside where the proportion remained the same as that of 2011-12.

Figure 9 and table 10 illustrate the use of recommended antibacterials in primary care by NHS board expressed as items/1000/day. It shows there is variation in the use of these antibacterials across the NHS boards. NHS Orkney had the lowest use at 1.42 items/1000/day and the highest was in NHS Lanarkshire at 2.04 items/1000/day. The pattern of increased use is observed in all but two NHS boards.

The continued increase in the use of first line recommended agents in line with national guidance is a key finding and suggests increased compliance with local prescribing policies.

19


Table 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of items, 2008-09 – 2012-13

Recommended items (% of all items) 2008/09 2009/10 2010/11 2011/12 2012/13

NHS AYRSHIRE & ARRAN 67.4% 69.4% 75.8% 81.0% 82.0%NHS BORDERS 71.4% 72.1% 77.5% 79.1% 79.7%NHS DUMFRIES & GALLOWAY 68.2% 74.5% 78.8% 81.1% 82.9%NHS FIFE 73.2% 75.9% 79.5% 80.8% 81.5%NHS FORTH VALLEY 71.1% 74.1% 77.0% 79.2% 82.0%NHS GRAMPIAN 69.5% 73.6% 81.8% 83.5% 84.3%NHS GREATER GLASGOW & CLYDE 70.7% 74.7% 78.6% 79.8% 81.2%NHS HIGHLAND 71.9% 74.0% 77.7% 80.5% 81.8%NHS LANARKSHIRE 70.1% 74.3% 77.8% 80.0% 81.5%NHS LOTHIAN 73.8% 75.4% 76.5% 76.9% 78.2%NHS ORKNEY 67.4% 69.5% 75.7% 82.1% 82.9%NHS SHETLAND 72.1% 74.8% 81.9% 83.4% 84.8%NHS TAYSIDE 73.9% 78.6% 82.3% 84.2% 84.2%NHS WESTERN ISLES 65.7% 68.5% 73.9% 78.9% 79.8%SCOTLAND 71.1% 74.4% 78.5% 80.3% 81.5%

Figure 8: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of total items, 2008-09 – 2012-13


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Perc

enta

ge o

f tot

al (i

tem

s)

60.0%

64.0%

68.0%

72.0%

76.0%

80.0%

84.0%

88.0%

2008/09 2009/10 2010/11 2011/12 2012/13Financial Year

20


Table 10: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13

Recommended agents (Items/1000/day) 2008/09 2009/10 2010/11 2011/12 2012/13


Figure 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2008-09 – 2012-13


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Item

s/10

00 P

ts/D

ay

Financial Year

1

1.2

1.4

1.6

1.8

2

2.2

2008/09 2009/10 2010/11 2011/12 2012/13

21


Urinary Tract Infections

Urinary Tract Infections (UTI) are a common reason for consultation with a GP and after respiratory infections are the second most common indication for empirical antibacterial use in primary care. National guidelines state that non-pregnant women of all ages with signs and symptoms of acute lower UTI should be treated empirically with trimethoprim or nitrofurantoin for three days.

The number of items with a three day duration as a proportion of total items of trimethoprim and nitrofurantoin may be a useful measure of prescribing quality in UTI in adult females.

The following measures are based on items dispensed to females aged 16 years or over. For trimethoprim, a three day course was assumed if six (200mg) tablets were dispensed. For nitrofurantoin, a three day course was assumed if 12 (50mg) tablets were dispensed. All items assumed to be for prophylaxis were excluded from the analysis.

CHI capture rates may vary by NHS board or by prescription item, when interpreting results consideration should be given to the completeness of CHI and any confounding effect this may have.

Table 11 and figure 10 illustrate the use of three day trimethoprim in NHS boards as a proportion of all trimethoprim items dispensed for adult females.

The use of three day duration trimethoprim as a proportion of all trimethoprim use has increased since the start of 2010-11 with the exception of the most recent quarter which saw a small decrease. There is wide variation between boards. NHS Greater Glasgow & Clyde had the highest proportional use at 65.4%, while NHS Orkney had the lowest at 37.8% in the most recent quarter. Only NHS Orkney has not increased the proportional use of three day trimethoprim since the start of 2010-11.

In Q4 2012-13, in 11 NHS boards, items for three day duration accounted for more than 50% of total trimethoprim use in adult females compared to two NHS boards at the start of data availability.

Table 12 and figure 11 highlight the use of three day nitrofurantoin as a proportion of all nitrofurantoin items dispensed for adult females. Use of three day nitrofurantoin as a proportion of all nitrofurantoin scripts has generally increased steadily since Q1 2010-11 but is lower than that observed for trimethoprim. There is wide variation between boards. NHS Forth Valley had the highest proportional use at 44.8% while NHS Orkney had the lowest at 6.2%.

22

Scottish A

ntimicrobial P

rescribing Group - P

rimary C

are Prescribing Indicators - A

nnual Report 2012-13

Table 11: NHS Scotland use of 3 day trimethoprim in primary care by NHS board, proportion of all trimethoprim, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for trimethoprim, Scotland 2010/11-2012/13 88% (NHS board range 83% - 91%)

2010/11 2011/12 2012/13

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

NHS AYRSHIRE & ARRAN 28.2% 33.6% 39.6% 43.5% 45.7% 47.7% 50.2% 51.7% 50.8% 52.1% 55.4% 52.9%

NHS BORDERS 33.4% 31.5% 30.9% 35.9% 36.7% 47.4% 54.7% 55.6% 58.0% 60.8% 59.7% 62.3%

NHS DUMFRIES & GALLOWAY 35.9% 37.4% 43.9% 50.3% 51.1% 54.6% 55.9% 53.4% 55.2% 54.2% 53.5% 52.0%

NHS FIFE 27.7% 27.7% 30.0% 30.7% 35.2% 38.9% 44.1% 46.8% 50.0% 51.9% 51.1% 53.7%

NHS FORTH VALLEY 20.4% 21.7% 30.0% 35.7% 41.7% 53.8% 58.6% 58.5% 58.1% 59.7% 61.1% 61.8%

NHS GRAMPIAN 48.4% 50.8% 51.8% 50.8% 52.7% 53.2% 53.5% 53.6% 54.2% 55.2% 57.3% 56.0%


39.5% 41.5% 44.7% 47.5% 51.8% 56.0% 58.7% 61.9% 62.1% 64.9% 66.0% 65.4%

NHS HIGHLAND 31.3% 35.6% 39.0% 40.6% 42.8% 43.3% 42.6% 44.5% 46.1% 46.7% 46.4% 44.1%

NHS LANARKSHIRE 34.3% 37.3% 40.5% 41.6% 42.5% 44.7% 49.2% 50.3% 51.7% 54.7% 54.2% 53.5%

NHS LOTHIAN 47.2% 49.1% 47.4% 47.9% 47.9% 49.7% 50.8% 53.1% 54.2% 58.0% 57.1% 57.4%

NHS ORKNEY 42.2% 47.7% 38.2% 31.8% 32.4% 34.3% 34.0% 37.5% 40.1% 38.3% 32.9% 37.8%

NHS SHETLAND 53.2% 59.6% 60.3% 56.5% 57.4% 61.0% 59.5% 72.0% 68.1% 68.0% 64.0% 62.3%

NHS TAYSIDE 52.9% 54.0% 55.3% 56.3% 55.5% 58.2% 60.0% 61.9% 59.8% 62.1% 62.2% 61.9%

NHS WESTERN ISLES 22.9% 23.2% 29.9% 28.4% 30.3% 31.8% 29.0% 27.0% 46.2% 43.9% 48.1% 41.2%

SCOTLAND 38.9% 41.2% 43.6% 45.4% 47.6% 50.8% 53.2% 55.0% 55.6% 57.9% 58.5% 58.2%


22

23


Figure 10: NHS Scotland use of 3 day trimethoprim in primary care by NHS board, proportion of all trimethoprim, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for trimethoprim, Scotland 2010/11-2012/13 88% (NHS board range 83% - 91%)


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Year

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42010/11 2011/12 2012/13

% o

f tri

met

hopr

im s

crip

ts

for

3 da

y co

urse

24

Scottish A

ntimicrobial P

rescribing Group - P

rimary C

are Prescribing Indicators - A

nnual Report 2012-13

Table 12: NHS Scotland use of 3 day nitrofurantoin in primary care by NHS board, proportion of all nitrofurantoin, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for Nitrofurantoin, Scotland 2010/11-2012/13 91% (NHS board range 88% - 94%)

2010/11 2011/12 2012/13

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

NHS AYRSHIRE & ARRAN 15.6% 13.2% 22.2% 24.8% 25.0% 26.4% 28.8% 27.8% 31.4% 30.8% 31.1% 32.5%

NHS BORDERS 19.3% 12.5% 14.7% 24.8% 22.0% 31.8% 32.7% 36.3% 39.8% 45.2% 41.9% 43.7%

NHS DUMFRIES & GALLOWAY 11.9% 10.7% 15.9% 27.0% 28.2% 32.0% 28.0% 30.7% 27.8% 28.7% 29.3% 30.6%

NHS FIFE 13.4% 12.8% 13.5% 10.6% 17.8% 23.3% 27.0% 30.4% 30.8% 33.0% 29.1% 32.8%

NHS FORTH VALLEY 11.8% 13.2% 12.5% 12.1% 11.6% 16.2% 17.0% 19.7% 29.5% 44.9% 46.4% 44.8%

NHS GRAMPIAN 15.7% 15.1% 16.3% 16.9% 16.8% 16.7% 15.8% 18.1% 17.5% 18.5% 18.0% 18.6%


13.1% 15.2% 15.6% 17.4% 16.4% 16.8% 20.8% 24.4% 24.0% 25.3% 24.5% 27.6%

NHS HIGHLAND 10.0% 13.2% 11.7% 13.7% 14.1% 13.0% 9.5% 9.9% 12.4% 12.0% 11.1% 15.7%

NHS LANARKSHIRE 15.7% 19.8% 22.8% 24.6% 23.6% 23.2% 22.2% 25.0% 27.1% 26.2% 24.9% 23.7%

NHS LOTHIAN 7.7% 7.7% 6.3% 8.8% 8.8% 11.5% 10.8% 12.7% 13.3% 12.6% 13.4% 14.5%

NHS ORKNEY 0.0% 8.8% 12.9% 8.3% 9.4% 6.5% 8.2% 6.9% 9.6% 6.9% 11.0% 6.2%

NHS SHETLAND 20.8% 29.3% 24.7% 18.0% 16.5% 29.9% 32.1% 20.5% 34.0% 29.9% 30.2% 23.5%

NHS TAYSIDE 19.2% 21.8% 21.4% 24.2% 23.8% 26.6% 25.0% 25.6% 26.8% 28.4% 25.6% 30.2%

NHS WESTERN ISLES 6.5% 6.1% 5.6% 5.0% 1.6% 5.1% 5.0% 7.6% 8.1% 17.7% 21.8% 41.5%

SCOTLAND 13.6% 14.7% 15.9% 17.7% 17.8% 19.4% 20.0% 22.3% 23.3% 25.1% 24.3% 26.2%


24

25


Figure 11: NHS Scotland use of 3 day nitrofurantoin in primary care by NHS board, proportion of all nitrofurantoin, 2010-11 Q1 – 2012-13 Q4. CHI capture rates for nitrofurantoin, Scotland 2010/11-2012/13 91% (NHS board range 88% - 94%)


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Year

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42010/11 2011/12 2012/13

% o

f nitr

ofur

anto

in s

crip

ts

for 3

day

cou

rse

26


Nurse Prescribing

In 2006, changes in prescribing legislation were introduced which allowed appropriately qualified nurse prescribers to prescribe any licensed medicine for any medical condition which they are competent to treat.

There has been a steady increase in the number of antibacterials being prescribed by nurses in Scotland. In 2012-13, there were 169,563 antibacterial items, written by nurse prescribers, dispensed which accounted for 4.0% of all antibacterials dispensed.

There was wide variation in nurse prescribing rates across NHS boards which may reflect differences in the number of nurse prescribers and the configuration of service delivery within primary care. Most NHS boards saw an increase in nurse prescribing rates in 2012-13 compared with 2011-12 (table 13, figure 12).

Table 13: NHS Scotland nurse prescribing of antibacterials in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13

Nurse antibacterial use (Items/100,000/day) 2008/09 2009/10 2010/11 2011/12 2012/13


27


Figure 12: NHS Scotland nurse antibacterial prescribing in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Financial year

0

2

4

6

8

10

12

14

16

18

20

2008/09 2009/10 2010/11 2011/12 2012/13

Item

s/10

0,00

0 Pt

s/D

ays

28


Dental Prescribing

Dental practitioners in Scotland can prescribe on NHS prescriptions from a limited set of medicines which include a range of 14 antibacterials.

There has been a steady increase in the number of antibacterials being prescribed by dentists in Scotland. In 2012-13, there were 411,417 items written by dentists dispensed in Scotland which accounted for 8.8% of all antibacterials dispensed in Scotland.

There was wide variation in dental prescribing across NHS boards. The extent to which this reflects access to NHS dental services is unknown. There was an increase in dental prescribing in most NHS boards in 2012-13 (table 14, figure 13).

Table 14: NHS Scotland dental prescribing of antibacterials in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13

Dental antibacterial use (Items/100,000/day) 2008/09 2009/10 2010/11 2011/12 2012/13


29


Figure 13: NHS Scotland dental antibacterial prescribing in Scotland by NHS board, Items/100,000/day, 2008-09 – 2012-13


NHS BORDERS



NHS GRAMPIAN


NHS HIGHLAND

NHS LANARKSHIRE

NHS LOTHIAN

NHS ORKNEY


NHS WESTERN ISLES

SCOTLAND

Financial year

Item

s/10

0,00

0 Pt

s/D

ays

6

8

10

12

14

16

18

20

22

24

26

2008/09 2009/10 2010/11 2011/12 2012/13

30


Appendix 1

List of all measures in

PRISMS (available at

NHS board, CHP and GP

practice levels) DD

D/1

00

0/d

ay

Item

s/10

00/

da

y

DD

D/I

tem

Pro

po

rtio

n o

f

tota

l (I

tem

s)

Pro

po

rtio

n o

f

tota

l (D

DD

s)

Sea

son

al

Va

ria

tio

n (

Item

s)

Sea

son

al

Va

ria

tio

n (

DD

Ds)

Seasonal variation of fluoroquinolone use x x

Total antibacterial use x x x x x x xRecommended antibacterials – total use x x x x

Antibacterials associated with a higher risk of Clostridium difficile infection – total use

x x x x

Total penicillin use x x xAmoxicillin use x x xFlucloxacillin use x x xPhenoxymethylpenicillin use x x xCo-amoxiclav use x x xTotal tetracycline use x x xDoxycycline use x x xTotal macrolide use x x xTrimethoprim use x x xCo-trimoxazole use x x xTotal fluoroquinolone use x x xCiprofloxacin use x x xNitrofurantoin use x x xClindamycin use x x x


Documents

Scottish Antimicrobial Prescribing Group Primary Care Prescribing … · 2013. 10. 28. · by NHS board, proportion of items, 2008-09 – 2012-13 19 Table 10: NHS Scotland use of