Step 3a. Develop aims – consider particular patient groups

Your aim to improve prescribing in T2DM in line with guidance, should be specific (e.g. all patients or limited to particular groups); timebound (e.g. in next quarter, at next medication review); aligned (e.g. to guidance and local formulary choices), numeric (e.g. target percentage change).

Suggested actions - developing aims, project planning

• Those with T2DM often have other co-morbidities.
• Supporting particular at risk groups can help prioritise reviews, target resources and reduce adverse outcomes.

Frailty

There is greater risk of over-treatment with subsequent risk of hypoglycaemia, falls and hospitalisation.

Less stringent HbA1c targets can reduce this risk, reduce medication and polypharmacy and improve medicine adherence.

• National therapeutic indicator for Endocrine and falls (sulfonylureas older people %)
• Frailty section in Diabetes guidance
• Rockwood Clinical Frailty Scale

Co-morbidities

Those with established atherosclerotic cardiovascular disease, heart failure and/or renal disease would benefit from SGLT-2i or GLP-1RA regardless of HbA1c.

• Diabetes Quality Prescribing Guide: ASCVD, heart failure and renal disease
• National therapeutic indicators data visualisation - Public Health Scotland ASCVD not treated with SGLT-2i/GLP-1RA
• NICE guideline (NG203) - Chronic kidney disease: assessment and management

Use Scottish Therapeutic Utility (STU) to identify (groups of) individuals in GP practices  

• Information and download instructions for practices
• STU installation

Under-treated and over-treated

• HbA1c >58mmol/mol. Generally require additional treatment. Ensure that guidance is followed, as it may be more appropriate to substitute a more effective treatment than add an additional agent.
• HbA1c <48mmol/mol. Increased risk of hypoglycaemia (especially if frail), therefore reduction of treatment may be appropriate, either stopping treatment or dose reduction.

Polypharmacy

• National therapeutic indicators
• Sections in guidance Diabetes Quality Prescribing Guide and Polypharmacy Guidance 2018.

Focus on disadvantaged groups

This may include minority ethnic groups, those with English as an additional language, low literacy, mental health conditions., people living in adversity, poor housing etc.

How are they supported – leaflets in additional languages, community outreach work?

Mental health

• Depression and anxiety patient health questionnaire (PHQ-9)
• Scottish Government publication: Improving the physical health and well being of those experiencing mental illness
• Prime scholars article: Cultural barriers impeding ethnic minority groups from accessing effective diabetes care services

Patient identification

• Use the National Therapeutic Indicators (NTIs) to identify variation between boards, clusters or practices.
• Individuals within each group can be identified using the Scottish Therapeutics Utility (STU) in general practice