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Identification and optimisation of a risk stratified cohort of patients with Type 2 diabetes (T2D) across East Belfast Federation through the delivery of a pharmacist-led virtual and face to face service

This Joint Working project between Boehringer Ingelheim Ltd (BIL) and Federation of Family Practices East Belfast (FFPEB) aimed to explore a new model of care for diabetes primary care reviews by expanding the role of General Practice Pharmacists (GPPs). GPPs’ would be upskilled in the management of patients with T2D, and in the utilisation of virtual reviews. 

This project aimed to support the delivery of safe, high quality, evidence-based, clinically effective, and cost-effective diabetes care in the community and address the backlog of patient reviews. 

The project aimed to:

  • Identify and risk stratify patients for review who have either no relevant phlebotomy records in the previous 12 months or those with phlebotomy but not at their personalised target. 

  • Prevent unscheduled diabetes-related healthcare resource use within the Federation by introducing timely, high value interventions aligned to the Gold Standard 15 Care process.

  • Help provide specialist, dedicated education and training support to existing practice pharmacists to upskill them in diabetes patient management and review. 

  • Enable patients diagnosed with diabetes in the Federation to access healthcare reviews both virtually and face to face.

  • Enable diabetes patients to better manage their disease with appropriate support closer to home.

This pilot started in May 2022 and was completed in May 2024.

Outcome: 

15 GP practices participated in this project, which accommodates approximately 4,000 people living with type 2 diabetes (T2D) and focused on enhanced identification and treatment optimisation in T2D patients to reduce future complications through a pharmacist-led model of care

Delivered:

  • Improved adherence to NICE guidance T2D, NG28 (updated 2022), with a focus on patients with chronic kidney disease (CKD) & cardiovascular disease (CVD).

  • Upskilled diabetes teams to ensure improved holistic management, which will continue beyond the project period. 

  • Used a clinical audit tool to identify, stratify, and optimise T2D patients.

  • Increased identification, coding, and recall of patients with non-diabetic hyperglycaemia (NDH)

Methods

  • Identified patients not meeting their 3 Treatment Targets [3TT] (HbA1c>58 mmol/mol, BP>140/80mmHg, Total cholesterol>5mmol/L) using a clinical search tool.

  • Tailored clinics were created to the specific needs of the practices, focused on optimising patients with CKD & CVD co-morbidities.

  • Provided dedicated specialist education, training, and clinical support to existing GP pharmacists and nurses. This enhanced the level of collaboration and connection across the practices, creating a legacy effect.

Results 

  • The project demonstrated improvement to adherence to NICE NG28 recommendations.

  • 266 additional patients achieved their 3TT, with a total of 978 patients who received treatment optimisation, both starting and stopping treatments.

  • 44% increase in the number of referrals to the Diabetes Prevention Programme.

  • A total of 176 patients saw statin therapy started and/or optimised, and 62 patients saw their BP medications initiated and/or optimised.

Conclusion

This project demonstrated the feasibility and benefits of a pharmacist led T2D service in a primary care setting, such as attainment 3TT in T2D patients. Furthermore, the role promoted the adoption of NICE recommended therapies.

Boehringer Ingelheim Limited is pleased to collaborate with Federation of Family Practices East Belfast, to implement a data-led quality improvement programme supported by the upskill of GPPs, to improve patient outcomes in diabetes.

 

NP-GB-104921    August 2024