Making it real....

The facts - 2009/10

• Diabetes prevalence 4.1% of population England (2008/9)

• Total spend on diabetes: £649.2 million

• Total number of diabetes items prescribed: 35.5 million

• Net ingredient cost: 7.7% of total cost of prescribing

• 13.2 million Metformin items

• 7.1 million Sulphonylurea items

• Mean number of people with diabetes per pharmacy: 220

• Blood glucose testing strips costs £145.8 million

Reference: NHS Information Centre. Prescription Cost Analysis, England - 2009

The issues

• Diabetes regimen is multidimensional

• More than 95% of diabetes care is managed by the patient

• Many patients do not achieve good glycaemic control

• Risk of complications can be reduced by proper adherence

• Adherence to medication generally better than for lifestyle change; still

estimated to be only around 50%

• Patients often do not adhere to SMBG

• Frustration for healthcare professionals

Cochrane review showed very little effect of nurse led

interventions, home aids, diabetes education and

pharmacy led interventions

The solutions?� Patients to make informed decisions about how they live with their illness

� Patients work towards their own goals

� Roles and responsibilities redefined to match reality of diabetes care

� Patient and HCPs create relationships that promote collaboration and

partnership

� Recognise that patients are experts on their own lives; let go of the

traditional “we know best”

� Use behavioural change techniques providing advice only when patient is

ready to hear and learn more

Once we let go of the issue of non-compliance from our

vision and approach to patients, it disappears as a problem

What should be covered in a type 2

diabetes medicines use review?

• Understand the patient’s view of their treatment and management

• Establish what the patient takes and what they don’t

• Establish what your patient understands about their medicines

• Identify any problems with medicine taking

– Side effects & interactions

– Non-adherence, intentional and unintentional

– Issues with devices

• Identify any broader issues

– Health and wellbeing

– Monitoring of condition

• Support options and offer possible solutions

What should be covered in a type 2

diabetes medicines use review?

What might you uncover?

• Intentional non-adherence

– Denial

– Beliefs – fear,

– Side effects

– Not a priority

– No direct benefit felt

• Unintentional non-adherence

– Complicated regimen

– Confusion

– Cannot swallow, practical difficulties

– Visual impairment

What are the medicine use issues in

type 2 diabetes?

Specific medicine use issues

• Ownership and understanding of their condition and treatment

• Co-morbidities such as hypertension, CVD, neuropathic pain, impaired

renal function

• Use of multiple medicines and multiple dosing regimens

• Use of insulin and associated devices

• Blood glucose control – managing hypos, avoiding hyperglycaemia, linking

treatment to food, exercise and routine

• Self-monitoring of blood glucose

• Importance of lifestyle choices on health outcomes and drug effectiveness

• Overall well-being and mood; anxiety, depression and

poor motivation

• Teenagers and young adults may be more vulnerable

• Social support

It’s not just about medicines

• Varies depending on patient needs and treatment plan

• Local guidance

• Understand any barriers

– Dexterity

– Vision

– Cognitive issues

– Fearful of pain

Health and wellbeing

Case studies

Secondary

Care

Care revolving around the patient

Primary

Care

Checklist

� Prepare

� Understand patient’s current

diabetes management

� Assess medicine use and

management issues

� Support behavioural change

� Offer solutions to support improved adherence and control

(but only after permission)

� Actions as required – you, patient, GP, diabetes nurse

� Remember to signpost

MURs in diabetes - Summary

• Help the patient understand reasons for treatment and benefits of taking (and potential impact if not)

• Recognise different needs of patients who may be taking many other medicines with complex regimes and side effects

• Support patient as part of the local healthcare team; understand local protocols

• Let go of wanting to control

The beauty of empowering others is that your own

power is not diminished in the process

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Additional resources

• Diabetes uk www.diabetes.org.uk

• Diabetes NHS www.diabetes.nhs.uk

• Diabetes travel information www.diabetes-

travel.co.uk

• NHS Choices www.nhs.uk/diabetes

• CPPE www.cppe.ac.uk

• NICE guidance www.nice.org.uk