Intensive treatment with insulin and sulfonylureas in older people with low HbA1c (<53mmol/mol) can increase the risk of hypoglycaemia, morbidity and mortality. Older people are less likely to benefit from the long-term protective effects of good glycaemic control and are at risk of inappropriate polypharmacy owing to co-morbidities.
Severe hypoglycaemia is the second most common cause of hospital admission for drug-related adverse events. Owing to concerns around the use of hypoglycaemic agents for type 2 diabetes mellitus (T2DM) treatment, latest guidance from the National Institute for Health and Care Excellence (NICE) recommends individualising approaches for older people at high risk of hypoglycaemia, with shared decision making and relaxed HbA1c targets.
NHS Eastbourne, Hailsham and Seaford Clinical Commissioning Group (CCG), and NHS Hastings and Rother CCG, undertook a project across GP practices in summer 2018 to support primary care diabetes teams work with patients to review prescribing. This focused on developing guidance to implement the NICE’s recommendation to adopt an individualised approach to diabetes care that considers the need for relaxed individualised HbA1c targets for older people with frailty, balanced with the drive for tight glycaemic targets and prevention of harm.
The project was included in a CCG prescribing support scheme that incentivises GP practices to invest time in reducing unwarranted variation in diabetes prescribing. CCG pharmacists reviewed more than 400 patients with frailty across 43 GP practices who were identified by undertaking searches on their prescribing systems. Practices were then required to meet with a senior CCG pharmacist to discuss the patient-level diabetes medication reviews and agree action plans to individualise diabetes care. Meetings were held with GPs and, in most cases, practice nurses and pharmacists attended. Training was provided by the Effective Diabetes Education group for the pharmacists undertaking reviews.
Pharmacist-led reviews resulted in 55% (n=238) of patients having a blood-glucose-lowering agent stopped and, in 45% (n=198) of patients, a medication was changed (for example, the blood-glucose-lowering agent was continued, but at a lower dose). Some 541 medication optimisation recommendations not relating to blood glucose management were also made.
Around 20% of recommendations were related to renal function decline, where therapies should have been reduced/stopped in line with the manufacturer’s recommendations. In addition, 60% (n=204) of patients reviewed had an HbA1c ≤48mmol/mol, of which 19% (n=66) were ≤42mmol/mol; all were receiving blood-glucose-lowering therapies. Where HbA1c was deemed unreliable (for example, in severe chronic kidney disease) these readings were excluded.
Throughout the project, medicines management pharmacists delivered several education and training sessions to clinicians working in community, primary and secondary settings. Around 200 clinicians attended these events; 93% of attendees rated the session as good/excellent and reported that their practice would change as a result.
The project generated total financial savings of £75,000, which does not include savings by practices that continued to review patients beyond the requirements for the scheme, nor the financial benefits of preventing a hospital admission for hypoglycaemia.
During the initial stages of the project development, some diabetes leads did not feel overtreatment of T2DM in older people was a problem as individualising targets was part of their routine practice. However, case presentation of severely frail patients with low HbA1c treated with insulin and/or sulfonylureas justified the development of the project.
At practice level, practice managers and some GP colleagues challenged the possible negative effect of this project on Quality and Outcomes Framework (QOF) targets. In these cases, an individualised approach to diabetes care had not been adopted, therapy had remained unchanged or escalated to meet QOF targets for patients with frailty and comorbidities. Many of the HbA1c levels identified were very low, which was concerning. This also indicated that a significant increase in HbA1c would be required to affect QOF. Towards the end of the project, proposed changes to QOF regarding frailty were released, which supported the project.
Frailty scores recorded on clinical systems did not always accurately represent the patient, but reviewing individual patient notes and multidisciplinary team discussions, allowed frailty scores to be determined before individualising targets.
Challenges identified included health professionals’ capacity and capability to undertake medication review within practices. Some nurse colleagues undertaking annual reviews reported a lack of support in making therapy changes. Differences in behaviour were observed between clinicians across practices, reflecting individual attitudes and beliefs, so practice action plans had to be flexible to capture individual prescribing practice. For example, some practices focused on building personalised targets into face-to-face annual reviews with patients. Other practices focused on improving the use of IT, implementing quarterly searches to identify patients with too tightly controlled HbA1c.
As a result of undertaking holistic reviews, therapy was rationalised to improve patient safety, and decrease polypharmacy and inappropriate prescribing. This also financially benefited the health economy and prescribing budget. Improved local formulary guidance on setting HbA1c targets is available online. Overall, feedback on the project was positive and well received, with the focus on improving quality of prescribing valued by clinicians. The outcomes continue to be shared and improvements in diabetes medicines optimisation through encouragement of an individualised approach to diabetes care continue.
Hannah Syed, medicines management adviser and practice pharmacist, NHS Eastbourne, Hailsham and Seaford CCG and NHS Hastings and Rother CCG