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 existing between GP practices. This project was undertaken by the Medicines Management (MM) Team to support primary care diabetes teams to work with patients to optimise prescribing through implementation of NICE NG28 guidelines for Type 2 diabetes.
Aims and objectives
To review all patients prescribed GLP-1 mimetics within our GP practices to assess prescribing in accordance with NICE guidelines. The main objectives were to identify suboptimal prescribing, rationalise therapy, and improve quality of life for patients, whilst ensuring good value from the prescribing budget.
Reasons for implementing your project
Diabetes prescribing, and in particular glucagon-like peptide 1 mimetics was identified through benchmarking against other CCGs as a therapeutic area where there was potential to improve quality and reduce costs. Our CCGs were higher (EHS 33% and HR 25%) than the national average for prescribing of GLP-1 mimetics with significant variation in prescribing costs between GP practices.
We identified that medicines optimisation through implementation of NICE guidance for diabetes (focusing primarily on GLP-1) will improve quality, reduce prescribing costs and variation between GP practices.
The project was included as a key part of our GP prescribing support scheme (PSS) which provides financial incentive for engagement. All key stakeholders were consulted during the project development.
How did you implement the project
The project was included as a key part of our GP prescribing support scheme (PSS) which provides financial incentive for engagement.
Opportunities to educate clinicians on diabetes medicines optimisation and share details of our project were utilised during GP engagement events. Inspirational speakers delivered key note sessions at our annual GP education event. Details of the project were shared with all key stakeholders through communications such as newsletters.
Training was provided for medicines management (NMM) pharmacists undertaking reviews prior to project implementation. Key resources included searches and an EMIS template which were developed to standardise data collection.
Practices were required to meet with their MM Pharmacist to discuss patient level diabetes medication reviews and agree an action plan to improve prescribing in line with NICE guidelines.
The focus of these reviews was diabetes medication optimisation to include blood pressure and cholesterol management; however, other medication issues identified were highlighted and discussed making the reviews more holistic. Action plans were agreed to ensure key messages became embedded into normal practice. An audit was then carried out to ensure the agreed actions 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.
The project was not without challenges; in some practices it was possible to observe difference in behaviour between individual GPs, appearing to reflect the individual clinician’s attitudes, beliefs and engagement with the project. Other barriers such as capacity and capability were also identified.
Forty four practices (all but two practices in both CCGs) undertook the project and agreed an action plan with their MM Pharmacist.
In total, 850 patient records were reviewed by the MM team. Half were considered suitable for a face to face clinician review, with the aim of stopping the GLP-1 mimetic where appropriate and optimising medicines for diabetes.
In 93% (n=396) of patients, recommendations to optimise therapy were implemented generating significant financial savings of £290k across both CCGs.
Prescribing shows the positive impact of the project - our CCGs demonstrate reduced growth of GLP-1 mimetic prescribing compared to national.
There was a clear focus on improving quality of prescribing which clinicians valued. Feedback on the project was very positive; clinicians enjoyed the holistic discussions and the presentation of patient cases using the EMIS template which made it clear where NICE recommended HbA1c and weight reductions had not been achieved.
We identified cases of diabetic polypharmacy where patients were receiving more than three blood glucose lowering therapies suggesting clinical inertia towards insulin. This also suggests therapy had been added to rather than reviewing current therapies and stopping if no sufficient reduction in HbA1c.
Cases were identified where medication should have been stopped owing to poor renal function. We also identified numerous cases of patients receiving both GLP-1 mimetics and DPP-4 inhibitors suggesting a lack of awareness of mechanisms of action as both these agents work on the same pathway. These messages were highlighted to clinicians during the project.
Key learning points
There was an apparent lack of awareness of NICE guidance in relation to both initiation and monitoring of these agents which we underestimated. Many clinicians were unaware of the initiation criteria and the 6 month targets to continue requiring both a reduction in HbA1c and weight to continue. Education was required before the patients could even be discussed. In most cases, measurements were not recorded as recommended by NICE. This made data collection and analysis of whether therapy should be continued time consuming for the pharmacists carrying out these reviews. We underestimated the amount of time these reviews could take which put pressure on meeting our deadlines.
Additionally, we noted that GLP-1 mimetics were frequently added to patients’ repeat prescription record in quantities not aligned to the dose, resulting in inadvertent over ordering. We used this opportunity to develop local guidance and resources to support our clinicians.
We continue to share the legacy messages of this project encouraging clinicians to refer to our formulary GLP-1 mimetic initiation flowchart and GLP-1 mimetic patient contract when initiating these agents documenting the targets for continuation at 6 months and prescribing appropriate quantity of devices.
We are working collaboratively with clinicians and managers to integrate effective medicines optimisation including insulin initiation into local service redesign for diabetes. Working with our stakeholders and forming good relationships was key to the successes of this project