Identification and optimisation of a risk stratified cohort of patients with type 2 diabetes through the delivery of a enhanced pharmacist-led service
Authors: Mcbrien S 
Published: October 2024

Abstract

Introduction
Cardio-renal metabolic (CRM) diseases are each associated with significant morbidity and mortality, and due to their shared pathology, the benefit of managing these diseases holistically is becoming increasingly evident. The East Belfast Federation practices have sought to review patients living with type 2 diabetes (T2D), prioritising those not meeting their 3 Treatment Targets (3TT, HbA1c, blood pressure [BP] and cholesterol) to optimise treatment through a pharmacist-led model of care.

Aims and Objectives
1. Improve adherence to latest update of NICE T2D [NG28, 2022], with a focus on patients with Cardiovascular Disease (CVD) & Chronic Kidney Disease (CKD).
2. Upskill diabetes teams, to create a legacy effect and ensure improved holistic management will continue beyond the project period.
3. Use a clinical audit tool to identify, stratify and optimise T2D patients not meeting their 3TTs.
4. Improve identification, coding and recall of patients with non-diabetic hyperglycaemia (NDH) as per QOF Indicator NDH001NI [QOF 2022/23].
5. Enhanced focus on review of sulphonylureas (SU) in relation to frailty and risk of hypoglycaemia [Strain, 2021].

Method
Patients not meeting their 3TTs (HbA1c&gt;58 mmol/mol, BP&gt;140/80mmHg, total cholesterol&gt;5mmol/L) were identified from October 2022 to July 2023. Primary care based clinics created which we tailored to the specific needs of the practices with a focus on optimising patients with CVD & CKD co-morbidities. Dedicated specialist education and clinical support was provided to existing diabetes teams in CRM patient management. Additional searches were created and patients identified to review patients experiencing NDH and on a SU.

Results
At 9 months from baseline, there was a statistically significant improvement of 8.9% in patients achieving all 3TTs (n=373, P=0.013). This was accompanied by an increase in the number of patients optimised for CV risk reduction, with a 39% and 42% increase in patient receiving sodium glucose co-transporter-2 (SGLT2) inhibitors (n=542) and Glucagon-like peptide-1 receptor agonists (GLP1RA) (n=190), respectively. A 5.5% (n=28) reduction in the number of patients on a SU was observed, as well as a 44% (n=76) increase in the number of referrals into the Diabetes Prevention Programme (DPP). 151 statins and 51 BP medications were started/optimised.

Discussion and Conclusion
The project further exemplifies the feasibility of a pharmacist-led T2D service in a primary care setting. In addition to improvement in established T2D markers, the role promoted collaboration and facilitated best-practice sharing across multiple diabetes teams. This approach allows for more co-ordinated care for patients who may otherwise be referred to multiple specialists, which often results in fragmented care. Future work should focus on promoting CRM protection as early as possible to reduce disease progression and improve outcomes.Number of patients on antidiabetic meds% attainment of 3TT