Commissioning view of immunoglobulin

Malcolm QualieHead of Health Policy

East Midland Specialised Commissioning Group

Immunoglobulin prescribing approval process

Aims of the National Immunoglobulin Database

Initial aims [in 2007]• To allow more accurate assessment of immunoglobulin use for forecasting and tendering• To provide an accurate picture of prescribing by indication and a

tracking mechanism of individual batches of immunoglobulin for safety purposes

These aims developed further [in 2008]• With the publication of the Model Commissioning Policy by the NSCG, there is now an explicit desire to link immunoglobulin use to payment

at the PCT or SHA level through the records contained in the database

Current position going into 2012.....

Updated guidelines Commissioning perspective

“Increased clarity regarding patient selection criteria and the need for prescribers to report clinical outcome after treatment are strongly supported”

Selection criteria and outcomes

“Effective Immunoglobulin Assessment Panels (IAPs) are important to monitor adherence to these new selection criteria in routine clinical practice”

Effective IAPs

Database Information Service

East Midlands Specialised Commissioning Group

Bespoke immunoglobulin prescribing reports

East Midlands Specialised Commissioning Group has incorporated a requirement for National Immunoglobulin Database entry as a condition for payment.

Bespoke immunoglobulin prescribing reports are generated from the commissioners’ portal on the database, which document the total volume and cost of each product prescribed per Trust. These data are used to calculate the ‘spend’ entered onto the database. Payments arewithheld from the Trust if the spend and the actual volume used do not correlate.

“The update specifies the outcome(s) measures, but not the degree in improvement ofoutcome(s) required to constitute treatment success”

Commissioners will work with expert clinicians to refine these outcomes to provide defined ‘treatment success’ measures where possible.

Efficacy monitoring

“For most diseases the treatment duration is short term (<3 months). The treatment episode endsat 3 months; treatment re-initiation will be regarded as a new treatment episode, based on a new IAP decision”

Stopping criteria

Patients with ongoing ITP beyond 12 months (chronic ITP) should not normally be treated with long-term immunoglobulin as there are alternative approaches. To reflect this, immunoglobulin in chronic ITP is now a Grey indication

Modulating use in large volume indications

“For patients on long-termimmunomodulatory doses, attempts should be made to reduce the dose, by increasing the dosing interval or by using reduced dose, or both, and, for patients with a high BMI, adjusted-body-weight dosing is used”

Modulating use in large volume indications

The future of the National Immunoglobulin Database and commissioning of immunogobulin

Enhanced commissioner reporting tools will facilitate:• monitoring of prescribing patterns• identification of individual cases which do not meet the selection criteria• tracking of cases that do not have (appropriate) outcome measures.

There will be automated email alerts and automatic stopping rules through database locking to prevent inappropriate unsanctioned use. This will make it possible to link payment for immunoglobulin to appropriate prescribing as recorded in the National Immunoglobulin Database.

Enhanced database functionality

Supporting SCG transition & delivery

‘Minimum Take’ specialised services 2012/12

Although the new arrangements for specialised services will not come into place in full until April 2013, the NHS Transitional Oversight Group (TOG) for specialised services has agreed to a stepped implementation with a nationally consistent approach to commissioning for many of the services from April 2012 (‘minimum take services).

SCGs will commission a consistent sub-set of the Specialised Services National Definitions Set (‘Minimum Take’ services) from April 2012, with the remainder being commissioned from April 2013.

Specialised Services National Definition Set

Supporting SCG transition & delivery

National Immunoglobulin Database – linking prescribing with payment

Timeline of mandated requirements from commissioners

1st April 20121. ‘New treatment episode’ at 3 months to be recorded in

short term cases if immunoglobulin is to be continued

1st April 20132. Annual review for long-term users3. Outcome measures reported

Developing a quality dashboard for immunoglobulin

What is a Quality Dashboard?

A graphic array of information that demonstrates an organisation’s performance in a number of designated areas of quality

It is meant to be visual, constructed in a way that it is intuitively meaningful to a variety of readers

The minimum amount of space is used to demonstrate the information

The focus remains on the outcome rather than the process delivering change

Why is a dashboard useful?

A dashboard in a car is visualised whilst driving. Changes in measurement parameters can lead to immediate corrective action. The aim for a quality dashboard is that it becomes part of the day-to-day work of service provision. The frontline staff delivering care should be able to freely see the dashboard to see the quality benefits of service change.

The dashboard is a strong tool to facilitate discussion between commissioners, the organisation, and the clinical team to focus on interventions that make a measurable change to care quality.

The focus is on the delivery of improvement from the established baseline. This is opposed to the identification of ‘failure’ to meet a fixed critical threshold.

Define measures

Measures should be meaningful to the clinical staff in the service and patients experiencing the care

The outcomes can be compared with nationally established benchmarks but this is not a requirement

Outcomes may include critical national initiatives Measure variables that relate to the delivery of the improved outcome Variables can include publicly reported data; progress on local

initiatives; patient satisfaction; patient complaints and potential litigation; significant incidents; workforce issues, such as retention; and peer review summaries

A good number of variables for each clinical system is 10 to 20. Each variable should have a meaningful corresponding number, trend, percentage or a ranking against providers of comparable size as a way to measure progress

Run Chart

• The most common form of data presentation will be a run chart of the parameter score plotted over time. As 7 data points are required to demonstrate a change more frequent data points are preferred.

Statistical Process Control

• An SPC chart is the preferred method to demonstrate a data parameter allowing a focus on not only modifying a median position but on the reduction of variability

Waiting Times for Consecutive Patients Requiring Radical Radiotherapy

0

20

40

60

80

100

120

1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 113 120 127 134 141 148 155 162 169 176 183 190 197 204 211 218

Consecutive Patients

Days

Waiting Time Average UCL LCL

Mean:34.8631 days

UCL:68.71

Draft immunoglobulin measuresMeasure Measurement definition Numerator Denominator

1

80% of patients confirm that they have been supported in self management as appropriate to their indivdual situation.

Patients confirming that they have been supported in self management as appropriate to their indivdual situation.

Number of patients confirming that they have been supported in self management as appropriate to their indivdual situation.

Total number of patients under treatment with immunoglobulin at the provider.

2

Of patients registered, there has been a letter sent to the GP in last 12 months for 90% of patients receiving immunoglobulin for long term conditions

At least annual communication with GPs about the care of patients on long term immunoglobulin treatment who are registered with a GP

Number of patients on long term immunoglobulin treatment about whom a letter has been sent to the GP in the last 12 months

Number of patients who are on long term immunoglobulin treatment

3

Patients on immunoglobulin for PID who are deemed suitable for homecare should be offerred this choice

Number of patients receiving immunoglobulin for PID who have been offerred treatment via homecare

Number of patients receiving immunoglobulin for PID who are deemed suitable for homecare that have been offerred treatment via homecare

Number of patients receiving immunoglobulin for PID

4

Patients on immunoglobulin for PID who are receiving treatment at home should have been trained by an accredited home therapy centre

Number of patients receiving immunoglobulin for PID who are receiving treatment at home who have received training from an accredited home therapy centre

Number of patients receiving immunoglobulin for PID who are receiving treatment at home who have received training from an accredited home therapy centre

Number of patients receiving immunoglobulin for PID who are receiving treatment at home

Draft immunoglobulin measuresMeasure Measurement definition Numerator Denominator

5100% of patients receiving immunoglobulin are entered on the national database

Proportion of patients receiving immunoglobulin who are entered on the national database

Number of patients receiving immunoglobulin entered on the national data base

Number of patients receiving immunoglobulin

6

100% of patients receiving immunoglobulin for grey/black indications entered on the national database have their outcomes reported

Number of patients who are receiving immunoglobulin for a grey/black indication who have outcomes entered on the national database

Number of patients who are receiving immunoglobulin for a grey/black indication who have outcomes entered on the national database during the quarter who require outcomes to be reported

Number of patients who are receiving immunoglobulin for a grey/black indication who require outcomes to be reported during the quarter

7

Patients who are receiving immunglobulin for a long term condition must have an annual review

Number of patients who are on immunoglobulin for a long term condition who receive an annual review

For those patients due a review in the quarter the number of patients who are on immunoglobulin for a long term condition who receive an annual review that is documented on the national database

For those patients due a review in the quarter the number of patients who are on immunoglobulin for a long term condition who are registered on the national database

8

Patients who receive immunoglobulin should have any adverse events documented on the national database

Number of adverse events documented on the national database

Number of adverse events documented on the national database

Number of doses of immunoglobulin documented on the national database

Draft immunoglobulin measuresOptions Measure Measurement definition Numerator Denominator

9

100% of patients receiving immunoglobulin for designated short term conditions must be re-registered on the national database if retreatment is required

Number of patients receiving immunoglobulin for designated short term conditions who are re-registered on the national database

Number of patients receiving immunoglobulin for designated short term conditions who are re-registered on the database

Number of patients receiving immunoglobulin for designated short term conditions who require retreatment

10

Patients receiving immunoglobulin for designated short term conditions should have their outcomes reported on the national database

Number of patients receiving immunoglobulin for designated short term conditions who have outcomes reported on the national database

Number of patients receiving immunoglobulin for designated short term conditions whose outcomes are documented on the national database during the quarter when outcomes should be documented

Number of patients receiving immunoglobulin for designated short term conditions whose outcomes are due to be documented during the quarter

11

Patients who are receiving immunoglobulin for a long term condition should have their dose and/or dosing frequency reviewed on an at least annual basis

Number of patients who are receiving immunoglobulin for a long term condition who have documented evidence of dose reduction and/or increased dosing interval

Number of patients who are receiving immunoglobulin for a long term condition who have documented evidence of a dose reduction and/or increased dosing interval

Number of patients who are receiving immunoglobulin for a long term condition

12

100% of patients receiving immunoglobulin for designated grey and grey unlisted indications should have been reviewed and approved by a multidisciplanary panel before commencing on immunoglobulin therapy

Patients receiving immunoglobulin for designated grey and grey unlisted indications who have been reviewed and approved by a multidisciplanary panel before commencing on immunoglobulin therapy

Patients receiving immunoglobulin for designated grey and grey unlisted indications who have been reviewed and approved by a multidisciplanary panel that is documented on the national database before immunoglobulin therapy is commenced

Patients receiving immunoglobulin for designated grey and grey unlisted indications who have been registered on the national database

Draft immunoglobulin measuresOptions Measure Measurement definition Numerator Denominator

13

100% of patients receiving immunoglobulin for designated grey and grey unlisted indications have had their panel recommendation confirmed for funding by the relevant commissioner before commencing on immunoglobulin therapy

Number of patients receiving immunoglobulin for designated grey and grey unlisted indications who have had their panel recommendation confirmed for funding by the relevant commissioner before commencing on immunoglobulin therapy

Number of patients receiving immunoglobulin for designated grey and grey unlisted indications who have documented evidence that the panel recommendation has received confirmation for funding by the relevent commissioner before commencing on immunoglobulin therapy

Number of patients receiving immunoglobulin for designated grey and grey unlisted indications

14

Patients on long term therapy for PID should have trough immunoglobulin levels measured on a quarterly basis

Number of patients who are on long term immunoglobulin therapy for PID who have quarterly trough immunoglobulin levels measured

Number of patients who are on long term immunoglobulin therapy for PID who have quarterly trough immunoglobulin levels documented

Number of patients who are on long term immunoglobulin therapy for PID

15

Patients on long term immunoglobulin therapy for a neurological condition should have objective improvement measured on an annual basis

Number of patients on long term immunoglobulin therapy for a neurological condition who have objective measures of improvement documented

Number of patients on long term immunoglobulin therapy for a neurological condition who have objective measures of improvement documented

Number of patients on long term immunoglobulin therapy for a neurological condition

10 minutes to comment on draft measures

How to contact MDSAS about the IVIG Database

0161 277 7917

support@mdsas.com

MDSAS IVIG Support

Rob.Hollingsworth@MDSAS.com0161 277 7917

Thank you for listening and have a great Christmas!

In need of IT Services? Contact us - support@mdsas.com or visit our website www.mdsas.com