Introduction A high dose ICS (HDICS) is defined as daily dose ≥ 1000 micrograms beclometasone dipropionate equivalent and is associated with an increased risk of side effects over their lower dose alternatives, but minimal increase in efficacy. In asthma, HDICS are reserved for severe disease, while in COPD, ICS are beneficial only in those with an FEV1 <50% and frequent exacerbations, but there is evidence for overuse (White P et al. PLoS One 2013 8:e75221). Currently, HDICS (as combination inhalers), comprise 2 of the top 4 highest spend medicines in the NHS (NHSBSA Mar 2015), so the aim of this study was to investigate trends in ICS prescribing across the London Clinical Commissioning Groups (CCGs) and reasons for variation.
Methods The NHS London Procurement Partnership monitors prescribing across London. It has designed a dashboard of primary care prescribing initiatives in collaboration with London CCGs, one of which attempts to support optimised ICS prescribing. The prescribing data for the financial year 2014/15 was compared with 2013/14 for the 32 London CCGs and London as a whole.
Results All but 2 London CCGs increased their total ICS spend between 2014/15 and 2013/14. Altogether, this was an increase of 3% to £67.6 million. In 2014/15, HDICS accounted for 20% of all ICS items prescribed (range 11–27%), or £23.5 million (36%) of total ICS spend (range 23–50%). 7/32 CCGs reduced expenditure on HDICS by >1% compared with 2013/14, with one achieving a 16% reduction. Reduction in HDICS prescribing occurred mostly in CCGs with respiratory integrated care teams.
Conclusion In light of the National Review of Asthma Deaths, the increase in total spend on ICS may be appropriate. However, 20% of all ICS prescribed in London are for HDICS preparations accounting for 36% of the total spend on ICS. With more than two fold variation across CCGs, some HDICS prescribing may be inappropriate and reduction may be associated with the presence of integrated care teams. If all CCGs in London could manage a 10% reduction in inappropriate HDICS prescribing, this could reduce the risk of side effects to patients and save over £2 million per annum.
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