Supporting the management of type 2 diabetes with pharmacist-led reviews and implementing NICE recommended nine key care processes

Type 2 diabetes (T2D) is a complex condition to manage. When T2D is not well managed, it is associated with considerable morbidity and serious complications, including heart disease, stroke, diabetic retinopathy, kidney disease and amputation—over time leading to disability and premature mortality. Since 1996, the number of people diagnosed with diabetes in the UK has increased from 1.4 million to 2.9 million, and by 2025, it is estimated that there will be 5 million people with diabetes in the UK.

In response to this the National Institute for Health and Clinical Excellence (NICE) released guidance that that each patient with diabetes should receive each of the nine NICE recommended care processes annually.

These care processes are:

• Glycated haemoglobin (HbA1c) measurement, with a suggested target of 59 mmol/mol.
• Blood pressure (BP) measurement, with a suggested target of 140/80 mm Hg.
• Cholesterol level measurement, with a suggested target for total cholesterol (TC) of 5 mmol/L.
• Retinal screening.
• Foot checks.
• Urinary albumin testing.
• Serum creatinine testing.
• Weight check.
• Smoking status check.

Taking into consideration the quality of current T2D management and projections of a substantial increase in T2D prevalence nationally, NHS Slough CCG identified the improved management of T2D as a key strategic priority.

To achieve this, Slough CCG partnered with Interface Clinical Services to improve the proportion of patients receiving the NICE recommended nine key care processes and proportion of patients whose glycated haemoglobin (HbA1c), blood pressure (BP) or total cholesterol (TC) readings achieved target following the intervention period. In addition to this the project aimed to provide patients with access to better education around their condition including dietary and life style advice (NG28

Prior to project commencement, the prevalence of (diagnosed) T2D in NHS Slough CCG was higher than the national average and increasing. According to the National Diabetes Audit 2012/2013, which was published during the project year, only a minority (40.0%) of T2D patients in NHS Slough CCG achieved all treatment targets recommended by NICE.

With too few patients achieving all treatment targets, this highlighted that improvement was key to delivering better patient care and improving efficiencies within the CCG. Baseline assessments were carried out by analysing practice performance data in relation to diabetes and specifically the nine key care processes from the financial year prior to project initiation. These findings were discussed with key personnel within each GP practice and tailored strategies were developed to increase the percentage of patients achieving targets.

 During the project, pharmacists reviewed 5,910 patients identified with T2D in Slough CCG and worked with general practice teams to schedule any of the nine key care processes that the patients were lacking, to optimise medication and to make other interventions such as providing structured education as per NICE guidelines.

Of these patients, the pharmacist team identified 3,211 patients missing at least 1 of the care processes and a plan was agreed with each practice to ensure that these were completed wherever possible. Within the UK, there is currently a policy drive to use clinical pharmacists more effectively in primary care.

Based on this and with a need to deliver improvements in patient outcomes, each pharmacist became part of the general practice team at each site for the duration of the programme.

Slough CCG commissioned support from Interface Clinical Services. To ensure a high level of continuity within the work delivered throughout the project and to engage all stakeholders, each of the 13 GP practices participating in the programme was assigned an experienced clinical pharmacist who worked with the practice throughout the year that the project took place.

The project and associated NICE Guidance was then implemented in 3 key phases: The first phase of the project involved data collection, analysis and work-stream prioritisation. A total of 2984 of the 5910 patients were found by the pharmacist team to be at risk of poor T2D control as defined by their latest HbA1c, BP or TC readings being over the NICE recommended target.

Key activities at phase I of the project included:

• Identification of patients who were missing any of the nine key care processes.
• Referral of patients to receive any missing or outdated care processes.
• Identification of patients for further review where HbA1c, BP and TC targets not achieved.
• Educational sessions for practice personnel in optimising T2D management and control. Recommendations made included but were not limited to drug initiations, dose changes, drug discontinuations, interventions regarding adherence to and persistence with treatment, lifestyle and diet advice, and referring to specialist care where complications were identified.
• During phase III of the programme, each practice received a follow-up visit from the pharmacist at 6 and 12 months post initial review in order to evaluate the impact of interventions made during phases I and II. The aim of these visits was to assess the extent to which agreed recommendations had been actioned and to implement any outstanding activities.
• The second phase of the programme was designed to optimise treatment for those patients identified in phase I as having failed to achieve their HbA1c, BP and TC targets.

While a clinical programme such as this carries associated financial costs, it is widely accepted that the financial costs of managing poorly controlled T2D patients (and the associated complications) far exceed the costs of managing well-controlled T2D patients.

The key objectives of the project were

1. With regard to the NICE-recommended 9 key care process, to reduce the number of patients with missing or off-target care processes.
2. To optimise the management of T2D as per NICE Guideline NG28.

Analysis conducted after the clinical programme was completed showed that the proportion of patients receiving all of the NICE recommended 9 key care processes increased from 46% at project outset in April 2013 to 58% on completion in April 2014 and the percentage of patients achieving HbA1c, BP and TC targets all increased (65% to 70%, 70% to 76%, 78% to 82%, respectively).

QOF data for Slough CCG showed the percentage of diabetic patients achieving target HbA1c, BP and TC readings increased from April 2013 to April 2014. This means that practices benefited in terms of additional resource, efficiencies and increased QOF income, whilst patients benefited from improved care and the opportunity to attend clinics.

Outcomes highlight that the project increased the number of key care processes administered and improved diabetic control during the year of programme delivery. By implementing and/or acting on the results of a higher proportion of the key care processes, Slough CCG were able to improve T2D control and therefore reduce the additional risk of complications and mortality associated with T2D. This, in turn, will help to control the costs of diabetes, given that complications account for over two-thirds of the estimated costs of diabetes to the NHS.

The improvements made abated during the year after project completion, suggesting that this project should be ongoing rather than fixed term to achieve longer term results.

• The key learnings from this project were that pharmacist-led reviews supported by a multidisciplinary team increased the number of key care processes administered and improved diabetic control during the year of programme delivery.
• The project worked well as it combined the strategic drive and project facilitation skills of Slough CCG, the general practice teams’ knowledge of their patients and the clinical and information technology skills of an experienced pharmacist team and is a positive example of the ways in which multidisciplinary teams can work pro-actively to implement NICE guidance.
• Whist the outcomes of the project were positive, the improvements diminished in the year following project completion, suggesting that such programmes should be ongoing rather than fixed term. This would be a key learning point for other organisations to consider when implementing a similar programme.
• A paper regarding this project has been published on BMJ Open should further information be required: http://bmjopen.bmj.com/content/7/3/e013451