This site is intended for health professionals only

Prescribing decision support for diabetes in primary care

Stephen R Chapman
BSc PhD MRPharm FRSM CertHEconRes
Professor of Prescribing Studies
Head of School of Pharmacy
Keele University
Staffordshire

In the March issue of Nursing in Practice (Can PbC restore nurses' confidence? NiP 2007;33:4), Marilyn Eveleigh laid out the challenge for community and practice nurses as practice-based commissioning (PbC) starts to bite. As she points out, the Quality and Outcomes Framework (QOF) drives the general practice agenda and many nurses will already have helped their practices meet QOF targets for diabetes through case screening and audits. This undoubtedly moves diabetes care on a step, through increased screening, earlier awareness and management of the condition. But what happens when we get to the next stage and engage in prescribing or prescription recommendations? The challenges are increasing, particularly in relation to type 2 diabetes patients who form the majority of those treated.
Good prescribing requires a strong grasp of the evidence base for medicines, the ability to balance both cost and benefit, and a recognition of the tension between the needs of the individual and the practice population as a whole.(2) However, a comparatively short training programme in prescribing - no matter how thorough - is never going to be sufficient to make nurses totally comfortable with such complexities, and further professional support is inevitably going to be required.(3)
The shift from secondary care clinics will inevitably lead to more treatment being initiated in primary care. This, coupled with the emergence of new generations of antidiabetic drugs - such as glitazones, DPP IV inhibitors and GLP-1 analogues - will expand the number of treatment options available in primary care and could lead nurses into a labyrinth of clinical trials and reviews, etc, from which they would never emerge, particularly in the environment of a busy clinic.
Being overwhelmed by a morass of clinical evidence is not unique to nurses; it is a challenge to all prescribers. While sound guidance exists from organisations such as the National Institute for Health and Clinical Excellence (NICE) and the Association of British Clinical Diabetologists, the issue remains - how quickly can you recall all that guidance and apply it to the patient in front of you?(4-6)
Back in 2000, Dr Dougal Jeffries wrote a letter to the British Medical Journal saying: "I read all the relevant papers (some of them twice) and the accompanying editorial, yet came away feeling that I was floundering around in a muddy present rather than striding out into a brave new evidence-based future …".(7) He concluded with a request for a simple tool to help him apply that evidence to the individual, "I want a simple chart or computer program that will allow me to assess and reduce the risk … I also wish to give patients some idea of the likely benefit they can expect from treatment … So, until someone can clear the waters for me I think I'll just continue to muddle along."
This letter motivated us to embark on a programme of research, which has recently resulted in a tool that may just be one answer to the pleas of Dr Jeffries and many practice nurses.

Diabetes Decision Support Tool
The Diabetes Decision Support Tool is the first in what we hope will be a series of aids that support practice nurses with prescribing decisions. Available on a CD-ROM that can be loaded onto the practice computer, the tool takes evidence from major clinical trials and guidelines and distils them into a "decision tree", allowing you to apply national guidance to an individual patient. Imagine a Christmas tree with each branch representing a possible option - and with a "yes" or "no" ball hanging at the end. By choosing between "yes" or "no", as to whether the evidence is relevant to this patient, you arrive at the final prescribing recommendation at the top of the tree within about 20 seconds. Just enter the patient's characteristics into a series of drop down boxes and open fields in a screening programme (see Figure 1) and the programme works through the tree for you (see Figure 2).

[[nip36_15_fig1]]

[[nip36_16_fig2]]

The evidence in the tree is drawn together and appraised by our team at the Department of Medicines Management in Keele. In addition, an external advisory group validates it - including primary and secondary care nurses, pharmacists, GPs, and a consultant diabetologist. In this way we aim to marry evidence appraisal to the pragmatic "what we do in practice?" view of diabetes practitioners, providing a tool, which we hope, any practice nurse can use with confidence.
At a recent presentation of the tool to an audience of nonmedical prescribers - 75% of whom were nurses - 46% of delegates said that they believed the tool would be very helpful and 45% said it would be helpful in assisting them to make more informed treatment decisions.(8) Over 75% said it would also be beneficial as a patient consultation/communication tool. This was a gratifying endorsement and matched closely with a GP evaluation of a prototype tool that we had previously developed for stroke management.(9)
Dr Raj Persaud, writing in the March issue of Nursing in Practice (Getting noticed is the key to higher status NiP 2007;33:12), made the case for nurses to "achieve higher personal status in their workplace" and suggested that patients do not think of nurses and doctors in the same manner as they did in the past. Having a strong evidence base for your decisions is today not enough - in this information-hungry age, we need to explain our rationale to patients, and include them in the prescribing decision - in modern parlance, a concordant consultation. Again, the decision support tool can be of benefit here - as well as guiding you to an evidence-based decision, it provides a patient friendly "diabetes hand" (see Figure 3) to help explain risk reduction to your patient, and you can print off an individually tailored report for them to take home (see Figure 4).

[[nip36_16_fig3]]

[[nip36_18_fig4]]

The strength of these tools is that they are dynamic; as the evidence base changes, as it inevitably will, updates can be provided online or on new CDs.
Both PbC and QOF encourage practices to drive forward on commissioning screening and treatment for patients with diabetes where it is most convenient for the patient. Responsibilities are increasingly being devolved to primary care practitioners, and hence to practice nurses. Tools such as this should support them in expanding their traditional role to confidently embrace prescribing and provide a full quality service for their patients.

References

  1. Department of Health. Investing in general practice. The new general medical service contract. Available from: http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Primarycare...
  2. Barber N. What constitutes good prescribing? BMJ 2005;310:923-5.
  3. Avery AJ, Pringle M. Extended prescribing by UK nurses and pharmacists. BMJ 2005;331:1154-5.
  4. NICE. Management of type 2 diabetes (Management of blood glucose). London: NICE; September 2002.
  5. Winocour PH, Shaw KM, Greenwood RH. Will NICE guidelines on the management of type 2 diabetes improve diabetes care? Pract Diabetes Int 2004;21:3-6.
  6. Higgs ER, Krentz AJ. ABCD position statement on glitazones. Pract Diabetes Int 2004;21:7.
  7. Jeffries D. Having so many different guidelines about risk is so confusing. BMJ 2000;321:175.
  8. 3rd NPC conference for qualified nonmedical prescribers. London, January 2007. (Some presentations from this conference are available from: http://www.npc.co.uk/events/non_medical_conf2007.htm
  9. Short D, Frischer M, Bashford J. The development and evaluation of a computerised decision support system for primary care based on "patient profile decision analysis".  Informatics in Primary Care 2003;11:195-202.