Good Practice Examples
GP Practice pharmacist, London, England
An 18-month pan-London Type 2 diabetes improvement project across an organisation managing 30 GP practices covering a 270000 patient population.
All eight care processes achieved in 92% of patients (cf. London average 54%) and 54% achievement for the 3 treatment targets (cf. London average 41%). Eight care process variation across the GP practices taking part reduced by 52%. Delivered by practice pharmacists and a central pharmacy team supported by GP leadership.
This QI methodology has been replicated at an entire CCG level across Lambeth in 18/19 with significant improvements in diabetes outcomes.
Tarek Radwan and Omar Din
GP Practice pharmacists, Bradford, England
This involved pharmacist led interventions working in primary care including audit, face to face clinics and feedback to practices.
Current results show 547 patients reviewed so far, 34% treatment intensified in line with nice guidance, 2% deprescribed medication, a mean 9% reduction in HbA1c, 18% improvement in cohort with BP target achievement, 5% increase in statin uptake, 12% noncompliance with treatment identified, 8% inappropriate prescribing –impaired renal function, 22% referred for up to date pathology/BP checks and 3% referred into level 2 services.
GP Practice pharmacists, Shropshire, England
In July 2017 72 (24%) of patients with diabetes in Bishops Castle Medical Practice did not have an HbA1c below 65mmol. 14 of these patients were managed in secondary care. A multidisciplinary team comprising practice nurse, GP and pharmacist agreed a strategy to address this.
The team undertook a virtual review of the 72 patients and developed a treatment plan which involved optimising medication and providing lifestyle advice. Following this review the nurse invited the patients in to the surgery to discuss and implement the plan. Patients were also provided with a specific diabetes care plan which the pharmacist developed. The plan was tailored to the individual needs of the patient and generated electronically from EMIS in the surgery.
After 1 year the HbA1c improved in nearly half of the patients. In summary 34 patients had an improvement in HbA1c, 11 patients did not engage, 9 patients HbA1c didn’t improve and 4 were deceased or inactive. Having a clear management plan for patients and using an individualised care plan has helped us to improve our diabetic care.
Community pharmacists, NHS West Midlands
ADEPT Training for Community Pharmacists: Achieving Diabetes Care Excellence through Primary Care Teams.
This initiative by NHS West Midlands was developed in Collaboration with Right Care and Coventry University. There are four face to face tutorials with care planning or with internet access alone. There is a skilled based focus especially based on care planning and medicine optimisation using the Alphabet Strategy for Diabetes Care. Core training material (slides, documents and videos) have created to facilitate and disseminate the programme.
A service based evaluation will be conducted with data collated on changes in National Diabetes Audit scores. A patient satisfaction survey will also be conducted.
- Improvement in process measures: implementation of the Alphabet Strategy for Diabetes Care resulted in a significant (p < 0.05) improvement including lipid measurement, BP, HbA1c, Eye examination and Foot examination
- Improvement in outcome measures: improvements in BP, cholesterol levels, adjusted HbA1c%, and aspirin use were all improved. The rates were comparable to standards achieved in clinical trial setting specifically researching intensive treatment strategies (UKPDS and Steno-2)
- Patient and Health Care Professional Satisfaction: An audit conducted in 27 countries (44 Diabetes service units) showed that 91% of respondent felt that the strategy would have a positive influence on diabetes care and that it would be practical to implement.
Prof Vinod Patel
Community pharmacists, Leicestershire and Rutland
EDEN pharmacy training programme. Following training six pharmacists conducted testing within their pharmacy over a period of eight weeks. A total of 114 tests were conducted over this period. Anonymised data was collated and results were as follows; 74 patients had Hba1C levels tested; HbaA1C Normal result – 34 patients (below 6% ); HBa1c Prediabetes result – 13 patients (6-6.4%), HBa1c Diabetes result - 27 patients (6.5.% or over). 25 patients were referred to GP practice for onward referral
Community pharmacists, Manor Pharmacies in Hertfordshire
Education and counselling by community pharmacists together with the provision of continual blood glucose monitoring (CGM) can result in favourable improvements in diabetes parameters and cardiovascular risk profile of people with Type2 diabetes and Pre-diabetes.
The implications of this study are anticipated to result in the increased involvement of community pharmacists in diabetes management and a reduction in the burden on GPs, secondary care and health budgets. At 12months, significant reductions in HbA1c, blood glucose and systolic blood pressure were found in the intervention group.
The study used the ProLongevity service.
Community pharmacies, Wessex LPN
Pharmacy teams are ideally positioned to help patients and their carers to make positive choices about their health and lifestyle to prevent them developing Type 2 diabetes as well as optimise their use of medicines and signpost to other forms of support. The Wessex Pharmacy Local Professional Network has developed a framework for pharmacy teams to work through to become a Diabetes Focus Pharmacy. The framework is categorised into six elements: The pharmacy team, Prevention and lifestyle, Complications of diabetes, Education programmes, Medicines adherence and Signposting.
Download the framework
Published research Community pharmacist-led interventions and their impact on patients’ medication adherence and other health outcomes: a systematic review (2018) International Journal of Pharmacy Practice, 26 (5), pp. 387-397. Community pharmacist-led interventions have been shown to contribute to improved adherence and better disease control.
Community pharmacists, New Zealand
The influence of pharmacist-led adherence support on glycaemic control in people with type 2 diabetes(2018) International Journal of Clinical Pharmacy, 40 (2), pp. 354-359. MURs may positively influence medication adherence. This improved adherence shows a measurable decline in HbA1c levels.
Community pharmacists, Norway
Risk assessment and HbA1c measurement in Norwegian community pharmacies to identify people with undiagnosed type 2 diabetes –A feasibility study (2018) PLoS ONE, 13 (2), art. no. e0191316. The study showed that pharmacists were able to perform the risk assessment and measurement of HbA1c, and pharmacy customers were willing to participate.
The HbA1c measurements fulfilled the requirements for analytical quality. Therefore, it is feasible to implement this service in community pharmacies in Norway. In a large-scale study the inclusion criteria should be increased to 45 years in accordance with the population the risk test has been validated for.
Community pharmacists, Canada
The Effectiveness of Pharmacist Interventions on Cardiovascular Risk in Adult Patients with Type 2 Diabetes: The Multicentre Randomized Controlled RxEACH Trial (2017) Canadian Journal of Diabetes, 41 (6), pp. 580-586. Community pharmacy-based case finding and intervention program reduced the risk for major CV events by 21% when compared to usual practice. This represents a promising approach to help tackle the major public health problem of diabetes in Canada
Community pharmacists Egypt Pharmacist–patient communication about medication regimen adjustment during Ramadan (2016) International Journal of Pharmacy Practice, 24 (6), pp. 419-427.
Community pharmacy, America
Effects of the lifestyle intervention program GLICEMIA in people at risk for type 2 diabetes: A cluster-randomized controlled trial (2015) Diabetes Care, 38 (5), pp. 937-939. The aim of this study was to assess the efficacy of a 12-month prevention program conducted in 42 community pharmacies in reducing the risk for diabetes. The GLICEMIA program shows the feasibility of a pharmacy-based intervention and leads to a significant modest reduction in diabetes risk score but does not reduce the rate of diabetes progression over one year.
Community pharmacist, Australia
The Pharmacy Diabetes Care Program: assessment of a community pharmacy diabetes service model in Australia, Diabetic Medicine 2007. A pharmacy diabetes service model resulted in significant improvements in clinical and humanistic outcomes. Thus, community pharmacists can contribute significantly to improving care and health outcomes for patients with Type 2 diabetes.
Eastbourne, Hailsham and Seaford & Hasting and Rother CCG Medicines Management team
Young Diabetics Final Report
This project used medicines management (MM) pharmacists to review patients prescribed GLP-1 mimetics within the GP practices to assess prescribing in accordance with NICE guidelines. In total, 850 patient records were reviewed by the MM team. Half were considered suitable for a face to face clinician review, with the aim of stopping the GLP 1 mimetic where appropriate and optimising medicines for diabetes. In 93% (n=396) of patients, recommendations to optimise therapy were implemented generating significant financial savings across both CCGs.
CCG pharmacists, Slough
The key objectives of the project were with regard to the NICE-recommended 9 key care process, to reduce the number of patients with missing or off-target care processes and to optimise the management of T2D as per NICE Guideline NG28.
Analysis conducted after the clinical programme was completed showed that the proportion of patients receiving all of the NICE recommended 9 key care processes increased from 46% at project outset in April 2013 to 58% on completion in April 2014 and the percentage of patients achieving HbA1c, BP and TC targets all increased (65% to 70%, 70% to 76%, 78% to 82%, respectively)
NICE shared learning database
Hospital pharmacists, University Hospital, Southampton
Self-administration of insulin in hospitals. This improves patient satisfaction, ensures patients receive insulin at the appropriate times and doses, and reduce demands on nursing staff as well as reducing insulin wastage. An electronic review process has been developed to assess whether patients are able to self-administer insulin and to ensure that their suitability is continually reviewed.
Hospital pharmacists, Leicester
Hospital Diabetes in-reach service to the vascular surgery ward. In a 12-month cohort of patients with diabetes undergoing elective procedures on a vascular ward it was shown that a diabetes in-reach service resulted in a reduction of length of stay (LOS) of 2 days. Based on an average cost of one day in hospital (£325) this could equate to a cost saving of up to £63,700.
Hospital pharmacists Leicester Hospital Study to demonstrate that undertaking the e-learning module improved pharmacy staff knowledge and to identify if there were certain aspects of insulin prescribing, supply, administration and storage in which staff required further training. There was an improvement of almost 10% in pharmacy staff knowledge after undertaking the safe use of Insulin e-learning module
Hospital pharmacists America Implementing a pharmacist consultation model for multimodal insulin therapy (2017) American Journal of Health-System Pharmacy, 74 (9), pp. e224-e229. The goal of achieving a mean BG concentration of ≤180 mg/dL by day 3 of hyperglycemia management under a pharmacist-managed multimodal insulin protocol was attained in the second and third months after protocol implementation.
Cochrane review: Some services provided by pharmacists can have positive effects on patient health, including improved management of blood pressure and physical function. The pharmacist services did not reduce hospital visits or admissions. Services delivered by pharmacists produced similar effects on patient health compared with services delivered by other healthcare professionals.
Science direct review
Pharmacist-led interventions enhanced outcomes in patients with diabetes (standardized mean difference (SMD) −0.68; 95% CI -0.79, −0.58; p < 0.001). Sub-group analysis by intervention strategy, the type of intervention and outcome measures produced similar results. Further analysis showed that education, printed/digital material, training/group discussion, were more effective than other interventions.
GP Practice pharmacists, Bournemouth
At Westbourne Medical Centre in Bournemouth they have reconfigured their annual QOF reviews of diabetics to utilise the skills of their senior clinical pharmacist, who has diabetes expertise.
Patients are first seen by a practice-based nursing technician to: take bloods; check weight; complete a diabetic foot assessment and discuss lifestyle factors such as smoking, diet, exercise and alcohol intake.
Following receipt of the blood results the practice team then stratify patients according to their key diabetic metabolic targets (HbA1c, blood pressure, cholesterol). About 15% of patients are designated “Green“, meet all three targets, and so are sent their results using the Diabetes UK information prescriptions and invited to make a telephone consultation with the clinical pharmacist only if they have any questions.
45% of patients have results higher than one or more of their metabolic targets, and are designated “Amber”, whilst 30% of patients have results significantly higher than target and so are designated “Red”.
Both Amber and Red patients are then sent their results using the Diabetes UK information prescriptions and invited to make a face to face consultation with the diabetic nurse at the practice.
Using the NHSBSA EPACT2 data the practice then stratifies all patients who are currently being prescribed more than 8 regular medicines. These are designated “Purple” patients and make up 10% of the 825 diabetics at the practice.
As an evolution from conventional practice nurse appointments for specific long term conditions these patients are invited to make a face to face consultation with the clinical pharmacist who also undertakes a concurrent holistic polypharmacy medication review during the 30 minute consultation and also completes any additional QOF reviews such as COPD, asthma.
Community pharmacists, Cornwall
A community pharmacy patient activation model. The project is one of the first in England in which community pharmacists have used the PAM & motivational interviewing to improve patient activation and self-management of T2DM.
During the period of the evaluation on average participants saw a nine point increase in PAM® score and 44% increased their activation level, with a 100% increase for those initially at level 1.
Based on the existing body of evidence around PAM® and applying this to this pilot, it appears that this could have equated with an 18% reduction in hospital admissions for those that participated and the increased levels of activation are likely to have translated into increased self-management including better foot and eye care, better diet and exercise which is likely to have improved the overall health of participants and resulted in lower overall health care resource use.
Community pharmacists, Lloyds Pharmacy, national
Lloyds Pharmacy is part of the NHS Diabetes Prevention Programme (NDPP), which will deliver evidence-based behavioural interventions for people identified as being at high risk of developing Type 2 diabetes.
15,000 tests have been carried out in the 240 Lloyds pharmacies enrolled in the programme, and 840 patients had test results of 48 mmol/mol or above. Patients at high risk are referred to their GP that day for assistance, and 81 patients received a same day referral.
The test is part of the wider NDPP which promotes healthy eating, exercise and lifestyle advice. The team member will discuss any concerns raised regarding lifestyle, to encourage the participant and to reinforce the benefits of the programme.
NDPP can be used to further develop pharmacy input into the prevention programme