IMPROVING DIABETES MANAGEMENT IN PRIMARY CARE Jonathan Dartnell, Yeqin Zuo, Lynn Weekes, Roshmeen Azam NPS: Better choices ► Better health International Conference for Improving Use of Medicines 14-18 November 2011, Antalya, Turkey Please make this a banner 1.3m long and about 12 cm deep

ABSTRACT The following slides should be 19.05cm x25.4 cm.? Problem: Diabetes has been an Australian national health priority. Metformin is a cost-effective first-line therapy for type 2 diabetes; however, uptake has not been optimal. Objectives: To demonstrate the impact of a national program to improve management of diabetes in primary care Design: NPS: Better Choices, Better Health implemented 3 national programs to improve management of type 2 diabetes: 2001–03 (#1), 2005–06 (#2), and 2007–08 (#3). Key messages focused on encouraging lifestyle interventions, management of risk factors, and first-line use of metformin. Programs were evaluated to measure changes in knowledge and prescribing practice. Computer simulation modelling, based on risk reductions achieved through use of metformin in overweight patients in the UKPDS study, was used to evaluate the likely impact of increased use of metformin on progression of diabetes and its complications. Setting: Primary care Study population: General practitioners (GPs) and their patients Intervention: For each program, NPS deployed a range of activities to deliver key program messages. NPS facilitators based in local areas conducted face-to-face visits with practitioners and small group case study discussions. Clinical audits with feedback were available to help clinicians reflect on their practice. Information resources on the management of diabetes were distributed to support good decisions by health professionals and consumers. Outcome measures: Prescribing rate change, knowledge of health professionals Results: The numbers of GPs who participated were 6,704 (#1); 6,965 (#2); and 8,746 (#3)—approximately a third of the Australian GP population. Between 2001 and 2007, the mean prescribing rate increased from <20 to >25 metformin prescriptions per 1,000 consultations per month on the national Pharmaceutical Benefits Scheme. Time-series analysis did not confirm a statistically significant increase associated with NPS active program interventions. A random sample of 2,000 GPs was surveyed before and after the implementation of program #2. The proportion of respondents who selected metformin correctly in the management of a hypothetical patient was significantly higher in the post-survey (42% vs. 55%). Based on the survey and clinical audit results of program #2, it was estimated 3,000 additional patients were prescribed metformin. Computer simulation modelling projected that the additional use would result in 231 myocardial infarctions prevented, 370 premature deaths averted, and 1,719 life years saved. Conclusions: National use of metformin has increased substantially and is likely to have major benefits for patients. Although the impact of NPS programs was not able to be demonstrated using available nationally aggregated data, audit and survey data demonstrated an impact. NPS experience should be of benefit to other countries to promote better diabetes care. Funding source: NPS is funded by Australian Government Department of Health The following slides should be 19.05cm x25.4 cm.?

NPS: BETTER CHOICES, BETTER HEALTH Established in 1998 Funded by the Australian Government Independent, not-for-profit organisation Membership based Work in partnership consumers health professionals government industry If image resolution poor, perhaps enlarge on separate page 3

INTRODUCTION Diabetes has been an Australian national health priority. Several new oral antidiabetic drugs and insulins have become available in recent years. There are established guidelines1 in Australia for the management of type 2 diabetes. Metformin is an established cost-effective oral antidiabetic drug and recommended as first-line therapy. Metformin uptake has not been optimal. This study was undertaken to demonstrate the impact of a national program to improve management of diabetes in primary care. 1. RACGP and Diabetes Australia. Diabetes management in General Practice. 2009/10. Diabetes Australia

DESIGN AND SETTING National programs to improve management of type 2 diabetes were implemented in primary care: 2001–03 (#1) 2005–06 (#2) 2007–08 (#3). Evaluation included general practitioner (primary care doctors) knowledge and prescribing practice. Computer simulation modelling, based on risk reductions achieved through use of metformin in overweight patients in the UKPDS study, was used to evaluate the likely impact of increased use of metformin on progression of diabetes and its complications.

KEY MESSAGES Key messages focused on encouraging lifestyle interventions, management of risk factors, and first-line use of metformin, for example: Encourage intensive lifestyle change to slow progression of diabetes and prevent complications. Use metformin as initial drug therapy unless contra-indicated. Manage all cardiovascular risk factors. Consider glitazones only when a combination of metformin and a sulfonylurea is not suitable or fails to maintain glycaemic control. Consider insulin early when blood glucose control fails with maximal oral therapy.

INTERVENTIONS For each program, NPS deployed a range of activities to deliver key program messages: Academic detailing: NPS facilitators based in local areas conducted face-to-face visits with practitioners and small group case study discussions. Clinical audits with feedback were available to help clinicians reflect on their practice. Information resources on the management of diabetes were distributed to support good decisions by health professionals and consumers.

ACADEMIC DETAILING (educational outreach) Face-to-face, one- to-one visits with GPs Trained facilitators, usually pharmacists Targeted and general messages Good evidence that is effective at changing practice Face-to-face, one-to-one visits with GPs Trained facilitators, usually pharmacists Good evidence that is effective at changing practice Academic detailing is NPS’s strength Academic detailing, modelled on the drug detailing Expensive

CLINICAL SELF AUDITS Completed by general practitioners and pharmacists. Self-audits of records (paper or electronic). Assesses practice in comparison with evidence- based guidelines (using indicators of quality prescribing). Feedback is given on their practice in comparison with their peers. To focus on example of interactive self learning… Fairly good evidence that it is effective Other notes: Potential for data extraction from prescribing software

DRUG AND THERAPEUTIC INFORMATION RESOURCES NPS News program key messages Prescribing Practice Review prescribing feedback NPS RADAR New drug updates Australian Prescriber reviews and updates We produce a range of drug and therapeutic information resources – available freely from our website Australian Prescriber Well read and regarded Drug and therapeutics journal NPS Radar periodical that provides critiques of new drugs as they become available on the PBS Medicines Update consumer version NPS News provides specific advice on guidance to GPs and pharmacist on therapeutic management of targeted topics Prescribing Practice Review does a similar thing but also provides GPs with feedback on their prescribing habits http://www.nps.org.au/health_professionals/publications

RESULTS: prescribing rates Approximately one-third of all Australian GPs participated: 2001-03: 6,704 (#1) 2005-06: 6,965 (#2) 2007-08: 8,746 (#3) Between 2001 and 2007, the mean prescribing rate increased from <20 to >25 metformin prescriptions per 1,000 consultations per month on the national Pharmaceutical Benefits Scheme. Time-series analysis did not confirm a statistically significant increase associated with NPS active program interventions.

RESULTS: prescribing rates Changes in the mean prescribing rate per 1000 consultations per month for antidiabetics on the PBS (July 1996 to December 2006) For each of the 3 antidiabetic drugs - namely metformin, glitazones and sulfolnylureas -the mean rate of prescribing per GP per 1000 consultations per month for the period July 1996 to June 2007 was modelled in terms of its association with the proportionate cumulative levels of GP participation (i.e. participating GPs as a proportion of the total no. of GPs in the PBS dataset for each month) in the active components of the diabetes intervention programs (see Figure 1; note different scales for each measure). Figure 1: Changes in the mean prescribing rate per 1000 consultations per month for antidiabetics on the PBS (July 1996 to December 2006)

RESULTS: computer simulation modelling A random sample of 2,000 GPs was surveyed before and after the implementation of program #2. The proportion of respondents who selected metformin correctly in the management of a hypothetical patient was significantly higher in the post-survey (42% vs. 55%). Based on the survey and clinical audit results of program #2, it was estimated 3,000 additional patients were prescribed metformin. Computer simulation modelling projected that the additional use would result in 231 myocardial infarctions prevented, 370 premature deaths averted, and 1,719 life years saved.

CONCLUSIONS National use of metformin has increased substantially and is likely to have major benefits for patients. Although the impact of NPS programs was not able to be demonstrated using available nationally aggregated data, audit and survey data demonstrated an impact. Subsequent analyses of patient level data from the PBS have demonstrated increasing use of metformin as first- line therapy between 2004 and 2008. NPS experience should be of benefit to other countries to promote better diabetes care.