Figures suggested that patients with diabetes in the Medway Clinical Commissioning Group area were 88.6% more likely to have a heart attack and 85.7% more likely to have a stroke than the general population. Also, targets for blood pressure and cholesterol were below the NHS England average. These findings prompted a service re-evaluation. Glycaemic support is inadequate to manage macrovascular complications, but a multifactorial management approach can reduce cardiovascular mortality by about 50%. A pharmacist prescriber ran a pilot service for eight months, using a cardiometabolic approach to review glycaemic control, blood pressure and chronic kidney disease in five practices.
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Audits of the diabetes register were conducted through the software EMIS. All patients with either an HbA1c of ≥ 58 mmol/mol, blood pressure of ≥ 140/80 mmHg or total serum cholesterol of ≥5 mmol/l were identified. This list of patients was provided to the practices so they could arrange the initial appointments (appointment one). A total of 698 patients were identified and 2,094 appointments were offered to practices, equating to three per patient identified in the initial audit. The initial appointments were offered to patients who had agreed to participate in the service. Any patients who had had no HbA1c, cholesterol, creatinine, or UACR measurement taken in the previous three months, had these tests requested again before the initial baseline review. The service began in mid-April 2019 to allow the first practices at least four weeks to arrange these clinics. If interventions were made, the patients were seen again between two and four weeks later (appointment two) and then again for a followup appointment at three months (appointment three). Patients were given the option of having appointments two and three conducted virtually or via instant messenger. Each patient received a feedback questionnaire to complete in their own time and hand back to reception. All consultations were complete by December 2019.
By December 2019, a total of 507 patients had been reviewed, with the provision of 1,003 patient consultations and delivery of 974 accepted service interventions. This service brought a range of benefits including: meeting the primary KPI and ensuring that all practices utilising the service were above the NDA Medway CCG and NHS England averages for T2DM patients meeting all three treatment targets as of December 2019; facilitating the measurement of the eight key care processes at each practice, with a notable increase in Urine Albumin measurements; ensuring that patients received essential CVD risk reduction measures and actively screened diabetes patients for arrhythmias and heart failure; reducing referrals to the community specialist diabetes team and providing a seamless service to patients for injectable and insulin therapy, facilitating fluid and safe patient management; taking a targeted approach to patient follow-up, ensuring patient safety, optimising therapy and discontinuing ineffective medicines, thereby eliminating clinical inertia and reducing waste and medicines costs; facilitating the NHS long-term plan by enabling patients to achieve recommended diabetes treatment targets and reducing variation between practices, as well as helping to meet the CVD milestone of preventing up to 150,000 heart attacks and stroke cases over the next 10 years through prevention of two coronary heart disease events, one stroke or three overall CVD events over the next five years.
Sustainability and Spread
The service has gained funding for a further 600 patient reviews for 2020/2021 from The Paula Carr Diabetes Charitable Trust with stakeholders of additional practices and Medway Hospital Foundation Trust. This service evaluation has been submitted as a business case to Kent and Medway CCG. As a result of COVID-19, all long-term condition pathway considerations have ceased for the time being. It is hoped that, in due course, it will be considered for broader roll-out across Medway CCG, with a five-pharmacist team to deliver specific and targeted diabetes care to patients at those practice in most need. The service is operationally efficient, with all service interventions actioned immediately. All consultations are entered directly to the EMIS practice system without delay to ensure that all clinical governance requirements are met when compared with awaiting correspondence for GPs to action from the external diabetes service, which can cause delays in patients receiving their medications. This service would be delivered directly from general practices and remotely, thereby saving premises costs and expensive information technology installations. Since pharmacists would travel between practices, the costs could be shared appropriately. As this evaluation has shown, a targeted approach can yield cost savings and deliver measurable clinical outcomes. It facilitates the NHS long-term plan in enabling patients to achieve the recommended diabetes treatment targets, reducing variation between practices and having the potential to reduce CVD events. This service is feasible, cost-effective and can be implemented in a short period of time. There is no shortage of trained pharmacist prescribers. The impact and benefits of this service are considerable and should be considered for implementation across Kent and Medway.
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