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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR6

Pharmaceutical care needs in the primary care management of type 2 diabetes mellitus

By E. Douglas, S. Hudson, M. Bennie, D. McGhee*, A. Dowers* and C. McShane*

Introduction Patients with type 2 diabetes represent over 80 per cent of the diabetic population and recent clinical outcome studies have made diabetics a target for primary care initiatives to improve the quality of care. Diabetes is now the subject of specific guidelines for community pharmacists1 which highlight measures for including community pharmacists in the primary care diabetic team. In order to improve clinical outcomes in type 2 diabetics, care should address the management of blood glucose2 and blood pressure control3 in addition to individualised cardiovascular risk assessment.4 To develop a pharmaceutical care model for diabetes that integrates with the team effort requires both an examination of patient needs and an understanding of the implications for pharmaceutical care.

Method The primary care medical records of 106 patients managed as type 2 diabetics were studied over a 12-month period ending March, 1998, representing 85 per cent of the known diabetics in the practice population of 8,800 (four general medical practitioners). The level of recording was ascertained for diabetes monitoring over a 12-month period by the GP practice (nurse-led clinic) and/or hospital diabetes clinic. A total of 52 patients (49 per cent) with type 2 diabetes were managed exclusively by the GP practice. The documented care of all patients was evaluated against current guidelines.

Focal points

  • Care of diabetics by pharmacists is a priority for the profession
  • Documented clinical data is incomplete
  • Traditional approaches to identifying patients in need of pharmaceutical care may not be valid
  • There remains scope to improve patient care in type 2 diabetics

Results The study group comprised 61 (58 per cent) males; 55 (52 per cent) greater than or equal to 65 years and 30 (29 per cent) were diagnosed for >10 years. A diagnosis of peripheral neuropathy, diabetic nephropathy and retinopathy was made in 13 (12 per cent), two (2 per cent) and 22 (21 per cent) patients, respectively. There were 56 (52 per cent) patients prescribed medication with hypertension as an indication. The mode of diabetic treatment for 101 (95 per cent) patients remained unchanged during the year. Treatment was by diet alone (27 per cent), oral antidiabetic agents (57 per cent) or insulin (11 per cent).
Completeness of clinical data recorded was: blood pressure 87 per cent; glycaemic control (HbA1c) 72 per cent; total cholesterol 59 per cent; HDL cholesterol 42 per cent; obesity 70 per cent; and renal function 70 per cent. Table 1 identifies the evidence for targeting improvements in care. Unsatisfactory glycaemic control (HbA1c >8 per cent) affected 42 per cent of patients in whom it was recorded and was associated with age <64 years (odds ratio 3.9, 95 per cent CI 1.5, 10.1). Unsatisfactory blood pressure control affected 64 per cent of patients. There was no statistical evidence to indicate that polypharmacy or treatment in a secondary care diabetic clinic might identify patients either with poor diabetic control or with less than optimal blood pressure control. There were 57 (54 per cent) patients with complete records of total cholesterol, glycaemic control and blood pressure control and 14 (25 per cent) patients had unsatisfactory control of all three indicators of care. Total cholesterol was available in 28 of 50 (56 per cent) candidates for coronary heart disease (CHD) risk assessment. In those requiring secondary prevention, only 22 out of 37 (59 per cent) were prescribed aspirin.

Table 1

Discussion The development of professional guidelines to enable pharmacists to develop their practice in the care of patients with type 2 diabetes is based on firm evidence that specific treatment goals are associated with improved outcomes. Aspirin was under-utilised and CHD prevention was hindered by the lack of cholesterol measurement. There are no practice-based studies to inform the operational definition of the pharmacist's contribution to the team effort in the care of type 2 diabetics. The delivery of a pharmaceutical service to these patients requires information on the population at risk of poor outcomes and methods for targeting patients and their needs. Improvements in primary care multidisciplinary services to diabetic patients are dependent on the development of shared databases and implementation of protocols designed to address individual patients' pharmaceutical care needs.

Department of pharmaceutical sciences, University of Strathclyde; *Townhead Health Centre, Glasgow

References

1. Royal Pharmaceutical Society. Guidelines for community pharmacists on the care of patients with diabetes. Diabetes task force. London: The Society; 1999.
2. UK prospective diabetes study group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complication in patients with type 2 diabetes. UKPDS 33. Lancet 1998;352:837-53.
3. UK prospective diabetes study group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS 38. BMJ 1998;317:703-13.
4. Ramsay LE, Williams B, Johnston GD, MacGregor GA, Poston L, Potter L et al. Guidelines for management of hypertension. Report of the third working party of the British Hypertension Society. J Hum Hyperten 1999;13:569-92.