An audit of a general practices compliance with national recommendations for the avoidance of complications for type 2 diabetic patients

Introduction

Each week, diabetes leads to more than 700 strokes, almost 600 heart attacks and more than 2000 instances of heart failure, in addition to being the single most common cause of chronic kidney disease in the UK.1 The NHS spends 10% of its annual budget on diabetes with 80% of that treating the complications of diabetes.2 Pharmacists have a crucial role to optimise the medication of diabetic patients and prevent future problems.

Aim

To assess a general practices (GP) compliance with national recommendations and the Quality and Outcomes Framework for the avoidance of complications for Type 2 Diabetes Mellitus (T2DM) patients.

Methods

This single-centre, retrospective audit was conducted at a GP in the London Borough of Southwark. Six standards were measured focusing on the prevention of the complications of diabetes. Each standard incorporated an exclusion and inclusion criteria. Standard 1 and 2 reviewed the appropriate management of nephropathy and hypertension respectively. Standard 3 and 4 relate to statin use for primary and secondary prevention. The final standards assess how many patients have documented QRISK2 scores and initiated on a Sodium-Glucose Co-Transporter 2 (SGLT2) inhibitor as per the new NICE guidelines.3 Ethical approval was not deemed necessary for this clinical audit in agreement with the Hurley Group and King’s College Hospital NHS Foundation Trust guidelines.

Results

Half (50%, n=153/304) of all included T2DM patients at the practice have a blood pressure reading defined as hypertensive. Out of all diabetic patients, 25 of them had clinical proteinuria, micro-albuminuria, or a diagnosis of nephropathy. Of these 25 patients, 19 (76%) were prescribed an angiotensin-converting enzyme inhibitor or angiotensin-receptor blockers. A small portion (7%, n=28/374) of the diagnosed T2DM patients have a documented QRISK2 score. Subsequently, only 32 diabetic patients (9%, n=32/374) are prescribed an SGLT2 inhibitor. For standards 3 and 4, there were 122 patients (73%) who were prescribed a statin for primary prevention and 89 patients (87%) who were prescribed a statin for secondary prevention.

Discussion/Conclusion

The microvascular and macrovascular complications of diabetes are well documented. The incidence of these complications can be reduced by pharmacological management. Although none of the standards were met, the results are similar to other practices across the country. However, in comparison to the local average, the audited GP underperformed with no standards being better than the average of GPs in the area. Sub-analysis emphasises the disparities in health between various racial and ethnic groups. The results of the two largest demographic groups audited, Caucasian and Caribbean patients, show that the former is more likely to meet the standards. These findings indicate that the processes of the practice require change to meet the needs of our diabetic patients. In particular, work is required to understand the disparities in care for our patients categorised as ethnic minorities. The recommendations fall under 5 main categories – feedback, learn, templates, analyse, and review.

References

1. NHS Digital. National Diabetes Audit, 2017-18 Report 2a: Complications and Mortality. [online]. England and Wales 2019. [Accessed 10/10/22] Available from: https://files.digital.nhs.uk/91/084B1D/National%20Diabetes%20Audit%2C%202017-18%2C%20Report%202a.pdf

2. The British Diabetic Association. Diabetes Statistics. [online]. London. Diabetes UK. [Accessed 10/10/22] Available from: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics

3. National Institute for Health and Care Excellence. Type 2 diabetes in adults: Management. [online]. London. 2022. [Accessed 10/10/22] Available from: https://www.nice.org.uk/guidance/ng28/