Our ref:MMT/AdvisoryNote/BGM and Respiratory
DateAugust 2016
To:Practice Prescribing Leads
Practice Managers / Unit 1
St James Business Park
Grimbald Crag Court
Knaresborough
HG5 8QB

Re:Blood Glucose Monitoring and Respiratory Corticosteroids

Dear Colleague,

For the August “Hints and Tips on Prescribing”, the Medicines Management Team would like to provide some supporting advice and data around two of the topics in the HaRD CCG Prescribing Incentive Scheme for 2016-17.

1). Blood Glucose Monitoring

This section of the incentive scheme is based on the CCG’s new guidance on the self-monitoring of blood glucose.

This guidance recommends that patients who are self-monitoring their blood glucose should be reviewed to ensure that they are testing at appropriate intervals, using a meter which complies with the current ISO standards (ISO15197:2013) and uses cost-effective strips.

The guidance recommends the following 3 meters for use in the majority of Type 2 patients:

  • GlucoRx Nexus
  • Contour Black
  • GluNeo

These 3 meters all meet the ISO standards, have been assessed by clinical staff and patients locally and use strips which cost under £10 per pot of 50 strips. The incentive scheme measures the average spend (NIC) on blood glucose testing strips per diabetic patient registered at the practice. This will be measured using prescribing data from January to March 2017 for the blood glucose testing strips listed within section 6.3.2 of the BNF, and the patients on the QOF register of patients with diabetes at each practice. This section is given a 30% weighting of the total incentive scheme.

Actions

All practices are now encouraged to

  • Circulate the self-monitoring of blood glucose guidance to all prescribers in the practice.
  • Select one or more of the above meters for use in their practice and contact the appropriate company for supplies of their chosen meter(s) and request a demonstration of any new meters.
  • Contact companies which have left non-recommended meters in the practice and ask for a representative to collect them from the practice.
  • Inform local pharmacies of the planned switch.
  • Review the frequency of self-monitoring of all Type 2 patients, to ensure it is appropriate. This can be estimated from the frequency of re-ordering. The quantity of strips on repeat should be amended if appropriate. The MM team can assist with this work. Any patients who are not testing appropriately should be seen by a nurse or GP to discuss their self-monitoring regime. (See “Who should test and when?” in the CCG’s guidance on the self-monitoring of blood glucose.
  • CCG guidance on self-monitoring of blood glucose for advice re appropriate frequency of testing under Review the meters currently being used by all Type 2 patients and identify which patient can switch to one of the 3 recommended meters where possible. The MM team are able to assist with this work.
  • Patients should be invited into the practice to be shown how to use any new meter. The companies supplying the meters can assist with this either in 1:1 or group sessions.
  • The new testing strips should be added to each patient’s repeat list of medicines and previous strips should be removed from the repeat list, to prevent patients re-ordering their old strips.

Percentage of strips prescribed as one of recommended strips for Type 2 patients (March to May 2016)

Prescriber Name / Percentage of strips prescribed as Gluco Rx, Contour or GluNeo
CHURCH LANE SURGERY / 44%
STOCKWELL ROAD / 15%
PARK PARADE SURGERY / 8%
BEECH HOUSE SURGERY / 7%
NORTH HOUSE SURGERY / 8%
RIPON SPA SURGERY / 4%
LEEDS ROAD PRACTICE / 8%
DR INGRAM & PTRS / 4%
DR AKESTER & PARTNERS / 3%
KINGSWOOD SURGERY / 5%
THE MOSS PRACTICE / 4%
SPRINGBANK SURGERY / 4%
NIDDERDALE GROUP / 3%
EAST PARADE SURGERY / 4%
THE SPA SURGERY / 2%
EASTGATE MEDICAL / 3%
CHURCH AVENUE / 1%
CCG Average / 8%

Contact details of company representatives:

  • GlucoRx Nexus (Gluco Rx): Avril Smart Tel: 01483 755 133. Mobile: 07880 031 033. Email:
  • Contour Black Meter (Bayer) Joanne Richardson. Mobile: 07818 587890.

Email:

  • GluNeo (Neon). Gillian Baxter. Mobile: 07860 265 646

2). Respiratory Corticosteroids

This section measures the total spend (NIC) per cost based Astro-PU per quarter. This includes combination inhalers. Each practice’s target relates to their individual starting position compared to the CCG, using the average weighted spend during Q3 and Q4 2015/16. Practices with highest spend are expected to make the greatest reduction to achieve the target.

•Practices more than 20% above CCG value: 15% reduction in NIC per Astro-PU

•Practices above CCG value: 10% reduction in NIC per Astro-PU

•Practices below CCG value: 5% reduction in NIC per Astro-PU

•Practices more than 20% below CCG value – remain 20% below CCG’s NIC per Astro-PU (from Q3-Q4 2015/16).

This section will be assessed using data from January to March 2017 and is given a 30% weighting of the total incentive scheme.

In COPD

Inhaled corticosteroids can improve breathlessness and reduce exacerbations for patients with COPD, however opinion would suggest that where patients require step-up from a SABA, that a LAMA would be considered next followed by a LABA/LAMA in patients with <2 exacerbations and no admissions in the last year. ICS/LABA combination used too early in the treatment pathway can result in significant adverse effects such as non-fatal pneumonia.

NICE CG 101 COPD

Local COPD Guidelines can be found here:

Suggested actions in COPD patients

  • Consider stepping down corticosteroids and introducing a LAMA /LABA combination.
  • Preferred LABA/ICS inhaler of choice is Relvar Ellipta or Fostair MDI .
  • Aim to prescribe the same type of device to a patient, e.g.

Incruse Ellipta (LAMA). Dry powder device containing Umeclidinium.

Anoro Ellipta (LAMA/ LABA). Dry powder device containing Umeclidinium and Vilanterol

Relvar Ellipta (LABA/ICS). Dry powder device containing fluticasone furoate and vilanterol trifenatate

In Asthma

The Prescribing Incentive scheme is not intended to encourage inappropriate reductions in inhaled corticosteroid use in patients with asthma; however it does encourage the regular review of inhaled corticosteroid doses according to the BTS guidelines and stepping down treatment doses where symptom control is adequately maintained. Consideration should be taken about device choice based on good patient technique in line with local guidelines.

Local Asthma in Adults Treatment Pathway for Inhaled Therapy:

Suggested actions in asthma patients

  • Review patients on inhaled corticosteroids (ICS) and step down where appropriate.
  • When prescribing ICS alone, consider using Clenil MDI or Budesonide Easyhaler instead of fluticasone mdi as more cost effective
  • Fostair inhaler should be considered as a first line option for new patients requiring a combination of ICS / LABA, or Fostair Nexthaler if a dry powder device is required.

Costs per ASTRO-PUs for inhaled corticosteroids prescribed in HaRD CCG GP practices

October 2015 to June 2016)

HaRD versions of OptimiseRx and SystmOne and EMIS formularies will be amended to incorporate these recommendations. Should you have any queries, recommendations or ideas about these or future initiatives then we would be pleased to hear from you.

Yours sincerely,

The Medicines Management Team, HaRD CCG.

BGM and Respiratory Corticosteroids

Monthly briefing/letter – Aug 16Page 1 of 4HaRD Medicines Management Team