1. Right Care Deep Dives
NEW Devon CCG
Infectious Diseases

2. Contents 1. Introduction 2. Deep Dive Methodology
Right Care Deep Dives, Unwarranted Variation, Using the Evidence
2. Deep Dive Methodology
Data Extraction and Processing, Analysis and Presentation
3. Deep Dive Findings: Infectious Diseases
The Challenge, Population, Activity/Spend, Outcomes, Opportunities
Who’s Doing Well? What Does This All Mean?

3. Introduction: Right Care Deep Dives
Commissioning for Value packs help identify Programme Areas in which to look
Analytical Deep Dives form part of phase two: ‘What to Change’
Further, specific analytical requests would also support the ‘How to Change’ phase
Commissioning for Value Packs
Deep Dives
Where to look
What to change
How to change

4. Introduction: Unwarranted Variation
Aim to understand what can’t be explained by patient choice or illness of population
A four-stage process
Identify the variation
Understand if it is warranted
What is driving it?
How do we eliminate it?

5. Introduction: Using the Evidence
Using evidence to move from:
“How can I explain this?” to
“What can I do to improve this?”

6. Methodology: Data Extraction and Processing
Downloaded data for NEW Devon and comparator CCGs from a host of national sources:
Programme Budgeting
HSCIC/iView Prescribing
Quality and Outcomes Framework
Public Health Profiles
Many more!
Process this data into formats which allow ease of comparison and further analysis

7. Methodology: Analysis & Presentation
Where NEW Devon CCG is:
In ‘worst’ quintile
Where a related set of indicators show a tendency toward poor performance
Focus on key areas and/or indicators
National median
Median of national upper quintile
Median of ‘most similar 10 CCGs
Median used instead of mean to reduce impact of extreme outliers
Present comparative data against different scenarios
Against national position and benchmarks
Similar CCGs
Provider
Practice
Review data at a range of levels to better understand variation at a macro and micro level

8. Methodology: Analysis & Presentation
Inquiry approach
Exploring data using key lines of enquiry (KLOEs)
Identify ‘golden threads’ present throughout the data
Working with partners to understand local issues
Identify poorly performing area for KLOE using programme budgeting as a base
Review related indicators from other data sources to refine detail
Analyse provider and practice level data to illustrate local variation
Assess scale of opportunity against various scenarios

9. Infectious Diseases Programme

10. Areas for investigation
Septicaemia
Other viral infection
HIV/AIDS
Retrovirus infections
Measles
Rubella
Tuberculosis
Haemophilus influenzae
Mumps
Meningococcal infection
Herpesviral infection
Other infectious diseases

11. The Challenge
• CCG in highest quintile for Outpatient spend and second highest quintile for Day Case and Elective spend • Primary Care Prescribing also shows opportunity • In other areas where spend benchmarks well (Non-elective, A&E) there may still be opportunity to reduce variation or improve value

12. Primary Care Prescribing
Spend in middle quintile nationally
Spend on antibacterial drugs - by far the largest category – is within second lowest quintile
The other four areas are all within the highest quintile for items, and some for spend suggesting potential opportunity
Items
Spend
Opportunity = £70k - £513k

13. Outpatient Opportunity = £1.1M - £1.6M
Outpatients
Outpatient costs in highest national quintile
Significant variation across CCGs which could be down to the availability of specialist clinics
Given high spend there is opportunity, however it would need careful review
Outpatient Opportunity = £1.1M - £1.6M

14. Inpatients (Elective/Day Case)
Elective spend within the second highest national quintile
Some small opportunity has been identified, however there are no obvious areas to focus attention
Highest volume HRGs are: ‘Other Viral Illness with CC’ (39 spells) and ‘Septicaemia with Intermediate CC’ (25 spells)
Reduction scenario
Spend per 100,000 (£000s)
Difference with NEW Devon spend per 100,000 (£000s)
Saving opportunity (£000s)
National median
36.8
-3.1
None
National best quintile median
9.3
24.4
221.5
Similar 10 CCGs median
27.8
6.0
54.1
Elective/Day Case Opportunity = £0k - £222k

15. Inpatients (Non-elective)
Non-elective spend benchmarks well nationally (second lowest quintile) and admission rates are around the middle of the national distribution
There is however, a six-fold variation in standardised non-elective admission rates across NEW Devon CCG practices. Addressing this could deliver some savings.
Non-elective Opportunity = £0k - £472k

16. A&E (1) A&E spend is also low (lowest national quintile).
Volumes in this area are low, and overall attendances show a decrease for the Programme Budgeting category across years
Diagnosis
Infectious disease
404
330
318
Viral infection of unspecified site 10 6 2
Fever of unknown origin 4 1 3
Other septicaemia
Zoster [herpes zoster]
Unspecified parasitic disease
Bacterial infection of unspecified site
Other diseases caused by chlamydiae
Grand Total
422
343
325

17. A&E (2)
It should be noted however that Septicaemia diagnoses, for which inpatient activity is high, are not categorised under 01X Infectious Diseases but under category 03X – Blood Disorders
When this category is broken down further, Septicaemia can be seen to be on the rise
Row Labels
Septicaemia 84
123
199
Haematological conditions 20 30
Other 4 3
Grand Total
108
147
232

18. Outcomes
The percentage of all antibiotic prescription items in primary care that were for key antibiotics:
NEW Devon = 12.3% (fourth worst quintile)
Goal = 10%
National Median = 11% (10 similar CCGs 10.9%)
The percentage of people newly diagnosed with HIV who had a CD4 count test within one month of diagnosis:
NEW Devon = 93.2% (second best quintile)
British HIV Association target is >95%
Median of 10 similar CCGs = 90.3%

19. Outcomes Immunisations with the 5 in 1 vaccine:
At 12 months = 96.4% (second highest quintile)
At 24 months = 98.2% (top quintile)
Booster at 5 years = 92.1% (third national quintile)

20. Overall Infectious Diseases Opportunity: £1.2M - £2.8M
Opportunities
Primary Care Prescribing: £70k - £513k
Elective/Day Case: £0 - £222k
Non-elective: £0 - £472k
Outpatients: £1.1M - £1.6M
Overall Infectious Diseases Opportunity: £1.2M - £2.8M

21. Primary Care Prescribing
Who is doing well?
Primary Care Prescribing
NHS Dorset
NHS Somerset
NHS Southern Derbyshire
Daycase and Elective
NHS Gloucestershire
NHS West Hampshire
Outpatients
NHS Kernow
CCG performance based on age-sex standardised information

22. What does this all mean?
Opportunity in Prescribing in four sub-categories along with potential for quality improvements around antibiotic prescribing  sub-categories are small so intervention would need to be targeted
Outpatient spend benchmarks high when compared to a variable national picture  work to understand whether this is because of service provision or data recording before deciding how to address
Rising Septicaemia attendances at A&E  tackling this could help reduce emergency admission demand

23. Any Questions?