This project was undertaken to support primary care diabetes teams to work with patients to optimise prescribing through implementation of type 2 guidelines for diabetes particularly focusing on assessing prescribing of GLP-1 mimetic's in accordance with NICE guidance.
The main objectives were to identify suboptimal prescribing, rationalise therapy, generate financial efficiencies and improve quality of life for patients.
Through benchmarking data, we identified that our spend on diabetes prescribing, in particular glucagon like peptide 1 (GLP-1) mimetics within our CCGs was significantly higher than expected based on national prescribing patterns with significant variation between GP practices.
The project was included as a key part of our GP prescribing support scheme which provides financial incentives for engagement. Opportunities to educate clinicians on diabetes medicines optimisation and share details of our project were utilised during GP engagement events and inspirational speakers including Partha Kar delivered key note sessions at our annual GP education event.
Training was provided for pharmacists undertaking the reviews prior to project implementation. Key resources to include searches and an EMIS template were developed to standardise data collection. Pharmacists arranged MDT meetings with key clinicians at the GP practices to discuss the patients identified and agree medicines optimisation changes. The focus of these reviews was diabetes medication optimisation to include BP and cholesterol management, however, where other medication was identified as requiring review; this was flagged making the reviews more holistic. Action plans were agreed to ensure key messages became embedded into normal practice. An audit was carried out in Q3 to ensure the agreed action had been implemented.
In addition, a formulary update and development of key resources in collaboration with primary and secondary care colleagues ran parallel to the patient centred reviews.
Patient:
As a result of these pharmacist led reviews, patients had their diabetic medication optimised enabling better outcomes and quality of life. Numerous cases of diabetic polypharmacy were identified where patients were receiving more than three blood glucose lowering agents increasing the risk of drug interactions, adverse drug reactions, impaired adherence to medication and reduced quality of life. Cases where medication should have been stopped owing to poor renal function were identified. There were also numerous cases in which patients were receiving both GLP-1 mimetics and DPP-4 inhibitors suggesting a lack of awareness of mechanism of actions as both these agents work on the same pathway meaning that they should not be prescribed together.
Healthcare professionals:
Increased awareness of NICE guidance and updated knowledge on medications optimisation in type 2 diabetes. Resources to aid reviews and guide on treatment decisions.
The wider NHS:
Financial savings from optimisation of medication, improved medication compliance and reduction of medication associated admissions and complications.
In total, 850 patient records were reviewed by pharmacists. Half were considered suitable for a face to face clinician review with the aim of stopping the GLP 1 mimetic where appropriate and optimising diabetes medication.
In 93% (n=396) of patients, recommendations to optimise therapy were implemented generating financial savings of £290k across both CCGs.
Overall, the key messages of the project were well received. There was a clear focus in improving quality of prescribing which clinicians valued. Clinicians, in particular nurses commented that they enjoyed the opportunity for MDT discussions and had increased their knowledge on medicines as a result.
There was an apparent lack of awareness of NICE guidance in relation to both the initiation and monitoring of these agents which we realised very early on into the project. We used this opportunity to develop local guidance as part of the formulary review which we continue to share during diabetes education sessions.
We have presented the new resources within the diabetes section of our new formulary chapter at numerous stakeholder events where attendees have included primary and secondary care clinicians including junior doctors, GPs, consultants, nurses and pharmacists from hospital and community settings. We continue to share the legacy message of the project encouraging clinicians to refer to these resources. We have also embedded content into the GP locally commissioned diabetes service EMIS template around GLP 1 mimetic initiation and monitoring.
As we ran the diabetes formulary update parallel to the reviews, we were able to utilise new relationships and time with secondary care colleagues to discuss some of the challenges encountered and obtain specialist advice on complex patient cases. We are now working collaboratively with clinicians and mangers to integrate effective medicines optimisation including insulin initiation into local service redesign project for diabetes. The diabetes service redesign project provides an opportunity for further education on diabetes medication optimisation and to implement local pathways and formulary choices. As a result of our involvement, there is now funding for a pharmacist to be part of the diabetes integrated service redesign team.
In addition we have used the launch of our new formulary to encourage clinicians to view the new diabetes chapter.
Our project for next year builds continues to build on this work of optimising diabetes treatment where MM pharmacists will undertake polypharmacy reviews in frail elderly patients with type 2 diabetes.
