Managing Type 2 Diabetes in Frailty within Primary Careipswichandeastsuffolkccg.nhs.uk/Portals/1/Content... · Managing Type 2 Diabetes in Frailty within Primary Care Version Written

Produced by Medicines Management Team-IESCCG-May 2017

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Managing Type 2 Diabetes in Frailty within Primary Care

Contents

Background

Key points

Assessment of Frailty

Method

Table 1: Suggested Changes in Approach to Treatment

Appendix 1: Rockwood Frailty Scale

Appendix 2: How to search for frail patients

Appendix 3: Report

Background There is increasing evidence of the relative risks and benefits of treatment of diabetes in the elderly and frail. This evidence is not reflected strongly in NICE guidance (NG28) or in the QOF targets. Elderly and frail individuals with diabetes are at marked increase in risk of adverse effects of treatments for diabetes, including admissions to hospital, and are less likely to benefit from the long-term protective effects of good glycaemia control. The number of people with diabetes in the older age groups is increasing markedly, particularly in Suffolk. There is a need for local guidance to change the way people think about diabetes management in the frail elderly, to allow a balance between the drive for tight glycaemia and blood pressure control and prevention of harm. This guideline is based on a document produced by South Devon Healthcare NHS Foundation Trust. The recommendations are based on recent published research data and consensus statements published in 2012 from the American Diabetes Association and American Geriatrics Society (Kirkman MS et al, JAGS 60:2342; 2356) and the European Diabetes Working Party for Older People (Sinclair A et al, JAMDA 13: 497-502). Key Points

Patients with life-expectancy less than 10 years may be unlikely to derive microvascular benefits from tight glycaemic control (probably 10 years if free of complications at baseline) or tight BP control.

The aims of treatment for patients who are severely frail (e.g. those living in care homes or who have similar level of dependency living at home) should be (Kirkman et al):

1. To avoid hypoglycaemia

2. To control symptoms and avoid metabolic complications

Author Medicines Management Pharmacist

Version 1.0

Written: May 2017

Next review: May 2018

Approved by IESCCG Workstream

Date approved 27/6/17


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3. To avoid unnecessary hospital admission

4. To maintain/improve quality of life

5. To introduce timely end-of-life care

An unscheduled admission to hospital in an elderly or frail patient may be a marker of increased risk of recurrent hypoglycaemia and of substantial reduction in life-expectancy. De-escalation of treatment may be appropriate.

All changes in medication and treatment targets will need to be discussed/ negotiated with the patient and/or carers/relatives. The reasons for suggested changes need to be understood in terms of increased risk of therapy or low likelihood of benefit.

Patients can be exception reported from QOF if they are on maximal tolerated treatment or due to

frailty and this is documented in the notes.

Assessment of Frailty There is a variety of ‘Frailty’ scales but none is widely used or validated in diabetes. The scale currently utilised in IESCCG is the eFI (electronic frailty index) within SystmOne and EmisWEB which incorporates the Rockwood Scale (Appendix 1). Method

For the purposes of this review, each GP Practice will be asked to identify and review two patients

per thousand registered population, who may fit within the category of “severely frail” described in

Table 1.

A search should be performed to identify all patients over the age of 65 years with a frailty score of

more than 0.36 using eFI (see appendix 2) and type 2 diabetes. If sufficient numbers cannot be

found, patients of moderate frailty (i.e. an eFI of 0.25-0.36) maybe reviewed. Please note there is no

set guidance on how patients with moderate fraility should be managed and the GP will need to

review the medication based on individual patient factors.

Your nominated CCG practice support pharmacist and/or technician can support you with the

searches.

The medication review must be done by a GP. Following the review, a report must be completed by

the reviewing GP (Appendix 3)

The practice can then submit the information highlighting any actions or learning resulting from the

review. This form should be submitted to the CCG Prescribing Team by 1st May 2018


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Table 1: Managing Type 2 Diabetes in Frailty: Suggested Changes in Approach to Treatment

Level of Frailty

Therapeutic targets

Suggested actions and therapeutic options

Severely Frail (eFI score > 0.36)

Symptom control

Avoidance of hypoglycaemia

(no ‘target’ HbA1c necessary except as a means of assessing risk of hypo glycaemia or severe metabolic decompensation)

Avoid low levels of HbA1c <59(7.5%) if on insulin or sulphonyureas

No need to measure alb/creat ratio

De-escalate treatment – Reduce drugs 1. Consider whether possible to stop

sulphonyureas 2. Consider stopping metformin (and caution

with other drugs ) if eGFR is deteriorating, or below 35 or adversely impacting on appetite.

3. Do not use other ‘third line agents’ ( GLP-1, Pioglitazone, SGLT-2blockers )

4. Stop lipid lowering drugs 5. Stop /Reduce other drugs likely to cause

adverse effects, especially Beta-blockers

Please note this serves as a guide and prescribers should make decisions based on individual patient factors.

Patients should be monitored as normal following any medication changes.

Please seek advice from diabetes team if patients are at danger of decompensation or are stable on drugs despite them being used outside

of recommended guidelines e.g. patients stable on metformin with an eFGR of <30ml/min

Appendix 1: Rockwood Frailty Scale


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Appendix 2: How to search for severely frail patients using eFI on SystmOne and EMISWeb

SystmOne

1) Go to the reporting Tab within SystmOne and click on Miscellaneous Reports and then the Electronic Frailty Index Report. A ‘Run Report’ screen will appear.

2) Go to ‘Show top’ column and type 10% in the percentage of practice population you wish to search. This will ensure all relevant patients are identified. Next click ‘Run report’. This will generate eFI scores for patients within a GP Practice.


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3) The eFI scores listed correlate to frailty categories. These range from ‘Fit’ to ‘Severe’ Frailty. - Fit: eFI score = 0-0.12 - Mild frailty: eFI score = 0.13-0.24 - Moderate frailty: eFI score = 0.25-0.36 - Severe frailty: eFI score = > 0.36.

4) You can export the patient data to an Excel spread sheet by right clicking the mouse and selecting ‘Create Table’, then ‘CSV’. An excel spread sheet will open – you are then able to sort the table according to ascending age or eFI score etc. This will be needed once the final report has been generated.

5) Within SystmOne, highlight those patients with eFI of >0.36, click on “Add to patient

group” icon and call it “eFI>0.36”. Please note only 150 patients can be added to a single group. Multiple groups may need to be created depending on the number of patients identified in the eFI report. In such cases it should be named according the range of eFI scores for patients contains within that group e.g. eFI 0.5-0.6

6) Run a report to identify those patients that are more than 65+yrs, have type 2 diabetes and are severely frail by clicking on the reporting tab and selecting “Clinical reporting”

7) Click on new report and name it “Diabetes Type 2 and eFI>0.36” or “Diabetes Type 2 and eFI between … and ….” if multiple groups were created at step 5. The name used to create the group should be reflected in the title of the report.


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8) Click on “Registration” on the drop down menus to the left then select ”Caseload/Team”

9) Select the third option that appears, “Restrict to patient group”, click on “Select group” and pick the group which was created in step 5. If multiple groups were created, select the group with the frailest patients.


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10) Click on “Clinical” on the drop down menus to the left then select ”Read coded entries”

11) Select the second option ”Read codes” and click on “Select read codes”


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12) On the new pop up click the red “R” icon under “Codes and their children to match on”


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13) Type in /dm2 and click ok


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14) On the left side click on the “Demographic” drop down option and click on “Age”. In the box tick “Current age” and configure the options to search patients over 65 yrs and click ok and the report will appear.


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15) Run the report and it will identify the number of patients who are >65yrs old with Type 2 diabetes and are severely frail (depending on the group that was added at step 9).

16) Use the excel file created at step 4 to identify the frailest patients generated as the report cannot specify the frailty score. These patients should be prioritised when undertaking the reviews.

If multiple groups were created at step 5 a separate report would need to be made up for each

group. This should be done if sufficient numbers cannot be identified after running the first

report.

Useful information

If you wish to find the groups that were created in step 5, navigate to the reporting tab, click on

Miscellaneous Reporting and click on Ad Hoc Patient List


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Select on group and double click to show all patients within that group

You can export the table to an Excel spread sheet by right clicking the mouse and selecting

‘Create Table’, then ‘CSV’. An excel spread sheet will open – you are then able to sort the table

according to age, eFI score etc.

EmisWEB

Currently there is no function to search the practice list like the method used for SystmONE.

Patients can only have a score added on if there is a prompt in the QOF alert box in the bottom

right corner after entering each individual patient record.

Once the patient has been scored, it will be added onto the record. A search can be set up to

identify those patients and the other criteria i.e. over 65 and type 2 diabetes can be added

onto the search.

Practices are encouraged to add the eFI score when prompted to do so to allow them the best

possible chance if finding patients for the purpose of this scheme.

The information below will explain how to set up the search. However if practices are not able

to find any patients then they should look at patients in care homes that are aligned to the

practice as these will be the most frail. Their records should be accessed to see if the frailty

prompt appears within the QOF box and score the patient as needed.


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1) Within the main EMIS home screen click on population reporting

2) Right click on the folder you wish you save the search in and select “Add” then “Search”


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3) Choose a title and ensure the option for “Currently registered regular patients” is selected

4) Click on the option and select “Create a new rule”


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5) Click on add criteria then select “Clinical code” and then “New code list”


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6) In the search box type in “frailty” and then select “FI-Fraility Index” so it appears in the selected codes section and click “OK”


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7) On the search screen click on “ Add another rule” and select clinical codes


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8) Type in diabetes and the select” Type 2 diabetes mellitus” on the right side under code hierarchy. All read codes associated with Type 2 diabetes will appear below under selected codes and click “OK”


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9) Click on “add another rule” and select “Patients” then “Patient details”. In the Age criteria box ensure it states older than 65 years and click “OK”. The search is now ready to be used.

Appendix 3 Report

Practice Name

Date report submitted to the CCG

Total number of patients identified and reviewed

List size on 1/1/17

Total number of patients where the management was changed based on the recommendations

Patient review

Date of review

Review undertaken by (inc name and job title)

eFI score of patient

Changes made/comments

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How will you follow up this work?


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Managing Type 2 Diabetes in Frailty within Primary Careipswichandeastsuffolkccg.nhs.uk/Portals/1/Content... · Managing Type 2 Diabetes in Frailty within Primary Care Version Written