This document analyzes prescribing data from 2013 to 2016 to understand trends in osteoporosis treatment in England. Key findings include: 1) Alendronic acid accounts for 88% of osteoporosis prescriptions while denosumab use has increased slightly; 2) The overall cost per patient year has changed little; 3) The national rate of patients on osteoporosis treatment has declined 11.2% over 44 months. Some CCGs have bucked this trend with Fracture Liaison Services. Crude models suggest FLS could increase the rate of patients on treatment by 26 people per month in a typical CCG population of 300,000.

1. What can prescribing data
tell us about FLS?
Findings from a new analysis’
3 March 2017

2. 2
Source data
Prescribing data for all CCGs in England is freely
available in easily downloadable files:
https://openprescribing.net/
CCG registered population data is available from:
http://content.digital.nhs.uk/catalogue/

3. 3
This analysis (1)
Looked at a range of data for 44 months, from Apr
2013 to Nov 2016. Available data include:
•All major medicines prescribed for osteoporosis
•Cost
•Number of items
•Quantity per item
•Month of prescription
•CCG
Note: the data are for medicines prescribed in primary
care only

4. 4
This analysis (2)
Using these data we were able to estimate the
number of patients on treatment for each month.
Population data were added to create rates of patients
on treatments for the population aged 50 and over for
each CCG. This is the denominator in every chart in
this presentation
This analysis has yielded a number of findings

5. 5
‘Chemicals’ included
Alendronic Acid
Denosumab
Ibandronic Acid
Risedronate
Alendronic Acid plus
Colecalciferol
Zolendronic Acid
Other Bisphosphonate

6. 6
Treatments have changed little
Table shows % of patients on treatment by chemical
Chemical 2013 2014 2015 2016
Alendronic Acid 88.2% 88.2% 88.2% 88.0%
Denosumab 0.1% 0.2% 0.4% 0.5%
Ibandronic Acid 2.7% 2.5% 2.4% 2.3%
Risedronate 8.7% 8.8% 8.8% 9.0%
Alendronic Acid plus Colecalciferol 0.22% 0.20% 0.17% 0.14%
Zolendronic Acid 0.002% 0.002% 0.002% 0.002%
Other Bisphosphonate 0.01% 0.01% 0.01% 0.01%
Grand Total 100% 100% 100% 100%

7. 7
Denosumab has made inroads in primary
care prescribing/administration

8. 8
Cost per patient year of treatment has
changed little
Table shows average cost per patient year of treatment
Chemical 2013 2014 2015 2016
Alendronic Acid £13.80 £14.64 £15.15 £12.84
Denosumab £187.24 £196.21 £194.91 £192.65
Ibandronic Acid £149.90 £75.39 £55.14 £43.49
Risedronate £29.38 £27.31 £26.88 £23.80
Alendronic Acid plus Colecalciferol £326.97 £321.53 £316.16 £319.20
Zolendronic Acid £189.31 £192.51 £190.81 £170.95
Other Bisphosphonate £366.20 £337.59 £307.96 £339.42
Grand Total £22.33 £23.19 £25.83 £25.84

9. 9
National trend
Notes

10. 10
National trend including confidence
intervals
Notes

11. 11
44 months of decline in rate of PoT
This is equivalent to a decline of around 11.2%. Possible reasons:
Being stopped after 3/5years due to the concerns of the longer term complications
(atypical fractures including in the ear and osteonecrosis of the jaw)
• NICE’s recommendation of discussing stopping after 3 years and NOGGs recommendation
slightly different, as NOGG suggest that patients who go on this ‘drug holiday’ should be
reviewed for fracture risk after 2 years if no fracture in that time (fracture before 2 years =
automatic review) – this is something that is not represented in the NICE pathway for
secondary prevention of Osteoporosis.
• GP’s only have to keep a list of patients who ARE on bisphosphonates. How are GP
surgeries keeping track of all the people they might be stopping for a drug holiday to
review in 2 years? Are people stopped and just not been reviewed again?
Poor adherence to treatment due to:
• Patients perceive that the longer term complications of treatment carry a greater risk that
the complications of another fracture if they didn’t take the bisphosphonates (MHRA
warning etc)
• Administration issues – patients cease to take medication or GPs stopping it as per the
MHRA recommendation that states ‘alendronate, oral ibandronate and risedronate should
be used with caution in patients with active or recent upper gastrointestinal problems’.

12. 12
Bucking the trend – some examples

13. 13
Portsmouth
Notes

14. 14
Oxford
Notes

15. 15
CCG – north of England
Notes

16. 16
Decommissioning?
Notes

17. 17
Will FLS make a difference?
All data from FLS Benefits Calculator and FLS Pathway and Costing Tool
Typical CCG population 300,000
Number of people 50 and over 106,456
FLS cases 1,212
Numbers onto treatment (year) 781
Numbers on treatment at 12 months follow up 625
FLS additional numbers on treatment (year) 312.5
FLS additional numbers on treatment (month) 26.0

18. 18
Will FLS make a difference?
Hypothetical example of a FLS covering 300,000 population typical for England

19. 19
When does the difference show?
Hypothetical example of a FLS covering 300,000 population typical for England

20. 20
Summary (1)
Prescribing data are readily available thanks to
https://openprescribing.net/. These are refreshed
monthly
Population data are readily available and allow us to
create rates of patients on treatment for the target
population
The Charity has this data for every CCG in England

21. 21
Summary (2)
There is a long term and steady decline in rates of
patients on treatment
There are distinctive patterns for CCGs with FLS
services in many cases
Crude models suggest that rate of patients on
treatment per 1000 population 50 and over is useful
measure of effectiveness at a service level

22. 22
Caution
Data is for prescribing in primary care only and does
not tell the whole story
There are large underlying variations in ‘historical’
rates for which we have no explanation
Effective services depend on effective primary care