Medicine Optimisation Guidance
CFF MO metric area 1
Reducing the overall prescribing of antibacterial prescription items per STAR PU (Specific Therapeutic Patient Unit) –This takes into account the demographics of patients receiving a therapy).
Why are we focussing on this?
Work to develop and deliver this Quality Premium target directly responds to the ambitions set by Government following the O’Neill Review on Antimicrobial Resistance (May, 2016). These ambitions include a:
• 50% reduction of Gram Negative Bloodstream Infections (GNBSIs) by 2020.
• 50% reduction of the number of inappropriate antibiotic prescriptions by 2020.
It also enables work to support the UK 5 Year AMR Strategy (2013-2018), which states that there are few public health issues of greater importance than antimicrobial resistance (AMR) in terms of impact on society. Infections are increasingly developing that cannot be treated and the rapid spread of multi-drug resistant bacteria means that we could be close to reaching a point where it is not possible to prevent or treat everyday infections or diseases. Achieving the QP target at CCG level will generate a quality payment to the organisation.
What is the achievement threshold?
<=0.965 items per antibacterial STAR-PU. Practice baseline data for illustration will be provided. (Jan to Dec 2017)
What do practices need to do?
Ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content of, and have access to:
- The latest version of Herts Guidance for the Management of Infection in Primary Care available here (this is also available as a smartphone app).
- Suite of other resources in relation to treating infections including tackling antimicrobial resistance, restricted antibiotics, UTIs in care homes, tips for self-care here
If prescribing rate is already at the threshold at baseline this should be maintained or further improved where possible. For practices above the threshold, clinicians should review their approach to the management of infection. Learning resources can be found in the TARGET Antibiotic Toolkit available here:
How will patients be identified?
Most cases will be acute presentations, requiring a prescribing decision at point of care. Practices can also search their clinical system for patients who have long term prophylactic prescriptions for antibacterials and review whether continued prescribing is appropriate.
How will payment be achieved?
10p per registered patient – If the achievement threshold is reached for the twelve month period ending March 31st 2019. Practices will be paid 50% upfront and the final 50% will be paid upon achievement.
Prescribing will be monitored by PMOT using epact/epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice.
CFF MO metric area 2
Reducing prescribing of trimethoprim to patients >= 70 years
Why are we focussing on this?
NHSE reports that the age group with the highest rates of E. coli bacteraemia in England have been observed amongst the elderly (75 years and over). PHE data for E coli blood stream infections stated that 50% cases related to the urogenital tract, and in these 72% occurred in patients >65years, and 64% of patients had reported at least one UTI in the previous 12 months. A significant proportion of the rise in cases may be due to patients being prescribed inappropriate antibiotics, resulting in relapsing infections. However, there remains a difficult balance between the clinical management of UTIs and the empiric prescribing of broad-spectrum antimicrobials due to increasing resistance to narrow spectrum antibiotics which limits available treatment options. This indicator works to increase the appropriate use of nitrofurantoin as 1st line choice for the empirical management of UTI in primary care settings, and support a reduction in inappropriate prescribing of trimethoprim which is reported to have a significantly higher rate of non-susceptibility in ‘at risk’ groups. Achieving the QP target at CCG level will generate a quality payment to the organisation, but it is accepted that prescribing nitrofurantoin in place of trimethoprim will create a cost-pressure.
What is the achievement threshold?
>=35% reduction in number of prescription items for trimethoprim from baseline (June 2015-May 2016 as defined by NHSE QP). Practice latest data for illustration will be provided (Jan to Dec 2017).
What do practices need to do?
Unless contra-indicated or susceptibility testing shows resistance, nitrofurantoin should be the first-line antimicrobial agent used in managing urinary tract infections. They should ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content and have access to:
- Herts Guidance for the Management of Infection in Primary Care available here (also available as a smartphone app). Included is updated guidance on the management of UTIs.
- Suite of other resources in relation to treating infections including UTIs in care homes, tips for self-care here
If prescribing rate is already at the threshold at baseline this should be maintained or further improved where possible. For practices above the threshold, clinicians should review their approach to the management of infection.
How will patients be identified?
Most cases will be acute presentations, requiring a prescribing decision at point of care. Practices can also search their clinical system for patients who have long term prophylactic prescriptions for trimethoprim and review whether continued prescribing is appropriate.
How will payment be achieved?
10p per registered patient – If the achievement threshold is reached for the twelve month period ending March 31st 2019. Practices will be paid 50% upfront and the final 50% will be paid upon achievement.
Prescribing will be monitored by PMOT using epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice.
CFF MO metric area 3
Ensure appropriate prescribing of broad spectrum antibiotics in primary care.
Why are we focussing on this?
The purpose is to maintain an improvement in appropriate antibiotic prescribing in primary care, in particular broad spectrum antibiotics. Evidence suggests that antimicrobial resistance (AMR) is driven by over-using antibiotics and prescribing them inappropriately. Reducing the inappropriate use of antibiotics will delay the development of antimicrobial resistance that leads to patient harm from infections that are harder and more costly to treat. Reducing inappropriate antibiotic use will also protect patients from healthcare acquired infections such as Clostridium difficile infections.Broad spectrum antibiotics, such as co-amoxiclav, cephalosporins and quinolones, should be prescribed in line with prescribing guidelines and local microbiology advice. This indicator has been part of the CCG Improvement Assessment Framework for CCGs in 2017-18.
What is the achievement threshold?
<=10% of total antibacterial items prescribed to be for cephalosporin, quinolone or co-amoxiclav antibacterials. Practice latest data for illustration will be provided (Jan to Dec 2017).
What do practices need to do?
Ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content of, and have access to:
- The latest version of Herts Guidance for the Management of Infection in Primary Care available here (this is also available as a smartphone app).
- Suite of other resources in relation to treating infections including tackling antimicrobial resistance, restricted antibiotics, UTIs in care homes, tips for self-care here
Practices should respond to requests for root cause analysis of community- acquired c. diff cases and share learning gained with all prescribers.
If prescribing rate is already at the threshold at baseline this should be maintained or further improved where possible. For practices above the threshold, clinicians should review their approach to the management of infection. Learning resources can be found in the TARGET Antibiotic Toolkit available here:
How will patients be identified?
Most cases will be acute presentations, requiring a prescribing decision at point of care. Practices can also search their clinical system for patients who have long term prophylactic prescriptions for cephalosporins, quinolones or co-amoxiclav and review whether continued prescribing is appropriate.
How will payment be achieved?
5p per registered patient – If the achievement threshold is reached for the twelve month period ending March 31st 2019. This payment is lower because it has been used as a KPI in recent years. Practices will be paid 50% upfront and the final 50% will be paid upon achievement.
Prescribing will be monitored by PMOT using epact/ epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice.
CFF MO metric area 4
These relate to items which should not be routinely prescribed in primary care
Why are we focussing on this?
This element relates to the recently published guidance from NHSE on what CCGs should consider in respect of the de-prescribing of drugs deemed to have low clinical value. There are 18 in total on the list but some will require additional services in order to de-prescribe and provide suitable alternatives in some cases. There are 7 where no routine exceptions to prescribing have been identified by NHSE and PCMMG agreed these could be the focus of de-prescribing initially. Not all practices would have to do work on all of these drugs in order to achieve the target, and payment is regarded as recognition of good clinical practice and for not initiating new prescriptions. Those achieving in-year would receive the payment in recognition of the additional workload generated by the implementation of the guidance.The 7 areas covered are:
Co-proxamol
Omega –3 fatty acid compounds
Rubefacients (excluding topical NSAIDs)
Lutein and Antioxidants
Herbal medicines
Glucosamine & Chondroitin
Homeopathy
The estimated annual spend on these is in excess of £212K across the CCG.
What is the achievement threshold?
By the end of Q3 2018-19 there should be zero prescribing in each of the seven NHSE categories of low-value medicines.
Practice latest data for illustration will be provided (Oct to Dec 2017). Where a practice with usage of these medicines in Q4 can demonstrate that a patient has joined their list on or after January 1st 2018 and was already prescribed one of these medicines at that point then this will be ignored on the understanding that a review of the prescribing is taking place as soon as possible.
What do practices need to do?
Ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content of, and have access to:
Specifically, no new prescriptions for these 7 drugs/categories should be initiated. Patients already using any of the listed drugs need to have them de-prescribed. With the exception of co-proxamol, patients can purchase the medicines over the counter if they wish to continue with them. However, it is recognised that alternative options may need to be prescribed for chronic use, e.g. topical non-steroidal anti-inflammatory agent (if appropriate) in place of a rubefacient, alternative analgesic in place of co-proxamol or advice given e.g. dietary advice in place of omega-3 compounds and lutein antioxidants.
How will patients be identified?
Practices can search their clinical system to identify patients with a repeat template for prescriptions for drugs in the seven categories. Because of the delay in receiving prescription data from NHSBSA practices are advised to run searches for all 7 categories on a monthly basis so that any new prescribing can be identified promptly after any initial de-prescribing initiatives have taken place.
How will payment be achieved?
5p per registered patient for de-prescribing/ maintaining zero prescribing of co-proxamol
5p per registered patient for de-prescribing/maintaining zero prescribing of omega-3 compounds
5p per registered patient for de-prescribing/maintaining zero prescribing of rubefacients (excluding topical NSAIDs), lutein and antioxidants, herbal medicines, glucosamine & chondroitin, homeopathic products. Practices will be paid 50% upfront and the final 50% will be paid upon achievement.
Prescribing will be monitored by PMOT using epact/ epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice unless they wish to appeal usage for new patients in Q4.
It should be noted that data on prescribing runs two months behind, thus prescribing in March 2019 will not be scrutinised until May 2019.
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