Enhancing Diabetes Care in Primary Care Setting

1. IMPROVING DIABETES MANAGEMENT IN PRIMARY CARE Jonathan Dartnell, Yeqin Zuo, Lynn Weekes, RoshmeenAzam NPS: Better choices ► Better health International Conference for Improving Use of Medicines 14-18 November 2011, Antalya, Turkey

2. ABSTRACT • Problem: Diabetes has been an Australian national health priority. Metformin is a cost-effective first-line therapy for type 2 diabetes; however, uptake has not been optimal. • Objectives: To demonstrate the impact of a national program to improve management of diabetes in primary care • Design: NPS: Better Choices, Better Health implemented 3 national programs to improve management of type 2 diabetes: 2001–03 (#1), 2005–06 (#2), and 2007–08 (#3). Key messages focused on encouraging lifestyle interventions, management of risk factors, and first-line use of metformin. Programs were evaluated to measure changes in knowledge and prescribing practice. Computer simulation modelling, based on risk reductions achieved through use of metformin in overweight patients in the UKPDS study, was used to evaluate the likely impact of increased use of metformin on progression of diabetes and its complications. • Setting: Primary care • Study population: General practitioners (GPs) and their patients • Intervention: For each program, NPS deployed a range of activities to deliver key program messages. NPS facilitators based in local areas conducted face-to-face visits with practitioners and small group case study discussions. Clinical audits with feedback were available to help clinicians reflect on their practice. Information resources on the management of diabetes were distributed to support good decisions by health professionals and consumers. • Outcome measures: Prescribing rate change, knowledge of health professionals • Results: The numbers of GPs who participated were 6,704 (#1); 6,965 (#2); and 8,746 (#3)—approximately a third of the Australian GP population. Between 2001 and 2007, the mean prescribing rate increased from <20 to >25 metformin prescriptions per 1,000 consultations per month on the national Pharmaceutical Benefits Scheme. Time-series analysis did not confirm a statistically significant increase associated with NPS active program interventions. A random sample of 2,000 GPs was surveyed before and after the implementation of program #2. The proportion of respondents who selected metformin correctly in the management of a hypothetical patient was significantly higher in the post-survey (42% vs. 55%). Based on the survey and clinical audit results of program #2, it was estimated 3,000 additional patients were prescribed metformin. Computer simulation modelling projected that the additional use would result in 231 myocardial infarctions prevented, 370 premature deaths averted, and 1,719 life years saved. • Conclusions: National use of metformin has increased substantially and is likely to have major benefits for patients. Although the impact of NPS programs was not able to be demonstrated using available nationally aggregated data, audit and survey data demonstrated an impact. NPS experience should be of benefit to other countries to promote better diabetes care. • Funding source: NPS is funded by Australian Government Department of Health

3. NPS: BETTER CHOICES, BETTER HEALTH • Established in 1998 • Funded by the Australian Government • Independent, not-for-profit organisation • Membership based • Work in partnership • consumers • health professionals • government • industry

4. INTRODUCTION • Diabetes has been an Australian national health priority. • Several new oral antidiabetic drugs and insulins have become available in recent years. • There are established guidelines1 in Australia for the management of type 2 diabetes. • Metformin is an established cost-effective oral antidiabetic drug and recommended as first-line therapy. • Metformin uptake has not been optimal. • This study was undertaken to demonstrate the impact of a national program to improve management of diabetes in primary care. 1. RACGP and Diabetes Australia. Diabetes management in General Practice. 2009/10. Diabetes Australia

5. DESIGN AND SETTING • National programs to improve management of type 2 diabetes were implemented in primary care: • 2001–03 (#1) • 2005–06 (#2) • 2007–08 (#3). • Evaluation included general practitioner (primary care doctors) knowledge and prescribing practice. • Computer simulation modelling, based on risk reductions achieved through use of metformin in overweight patients in the UKPDS study, was used to evaluate the likely impact of increased use of metformin on progression of diabetes and its complications.

6. KEY MESSAGES • Key messages focused on encouraging lifestyle interventions, management of risk factors, and first-line use of metformin, for example: • Encourage intensive lifestyle change to slow progression of diabetes and prevent complications. • Use metformin as initial drug therapy unless contra-indicated. • Manage all cardiovascular risk factors. • Consider glitazones only when a combination of metformin and a sulfonylurea is not suitable or fails to maintain glycaemic control. • Consider insulin early when blood glucose control fails with maximal oral therapy.

7. INTERVENTIONS • For each program, NPS deployed a range of activities to deliver key program messages: • Academic detailing: NPS facilitators based in local areas conducted face-to-face visits with practitioners and small group case study discussions. • Clinical audits with feedback were available to help clinicians reflect on their practice. • Information resources on the management of diabetes were distributed to support good decisions by health professionals and consumers.

8. ACADEMIC DETAILING (educational outreach) • Face-to-face, one-to-one visits with GPs • Trained facilitators, usually pharmacists • Targeted and general messages • Good evidence that is effective at changing practice

9. CLINICAL SELF AUDITS • Completed by general practitioners and pharmacists. • Self-audits of records (paper or electronic). • Assesses practice in comparison with evidence-based guidelines (using indicators of quality prescribing). • Feedback is given on their practice in comparison with their peers.

10. DRUG AND THERAPEUTIC INFORMATION RESOURCES • NPS News • program key messages • Prescribing Practice Review • prescribing feedback • NPS RADAR • New drug updates • Australian Prescriber • reviews and updates http://www.nps.org.au/health_professionals/publications

11. RESULTS: prescribing rates • Approximately one-third of all Australian GPs participated: • 2001-03: 6,704 (#1) • 2005-06: 6,965 (#2) • 2007-08: 8,746 (#3) • Between 2001 and 2007, the mean prescribing rate increased from <20 to >25 metformin prescriptions per 1,000 consultations per month on the national Pharmaceutical Benefits Scheme. • Time-series analysis did not confirm a statistically significant increase associated with NPS active program interventions.

12. RESULTS: prescribing rates Changes in the mean prescribing rate per 1000 consultations per month for antidiabetics on the PBS (July 1996 to December 2006)

13. RESULTS: computer simulation modelling • A random sample of 2,000 GPs was surveyed before and after the implementation of program #2. • The proportion of respondents who selected metformin correctly in the management of a hypothetical patient was significantly higher in the post-survey (42% vs. 55%). • Based on the survey and clinical audit results of program #2, it was estimated 3,000 additional patients were prescribed metformin. • Computer simulation modelling projected that the additional use would result in 231 myocardial infarctions prevented, 370 premature deaths averted, and 1,719 life years saved.

14. CONCLUSIONS • National use of metformin has increased substantially and is likely to have major benefits for patients. • Although the impact of NPS programs was not able to be demonstrated using available nationally aggregated data, audit and survey data demonstrated an impact. • Subsequent analyses of patient level data from the PBS have demonstrated increasing use of metformin as first-line therapy between 2004 and 2008. • NPS experience should be of benefit to other countries to promote better diabetes care.