Adherence to NICE guidance on glucagon-like peptide-1 receptor agonists among patients with type 2 diabetes mellitus: an evaluation using the Clinical Practice Research Datalink

<div><p></p><p><b>Aims:</b></p><p>To assess adherence to the UK’s National Institute for Health and Care Excellence (NICE) guidelines for initiating and continuing glucagon-like peptide-1 (GLP-1) receptor agonists in patients with type 2 diabetes (T2DM).</p><p><b>Research design and methods:</b></p><p>A retrospective cohort study of 7133 primary care patients ≥40 years with a first prescription for a GLP-1 receptor agonist following publication of NICE guideline/guidance. Patient characteristics and levels of clinical monitoring were assessed using descriptive analyses.</p><p><b>Main outcome measures:</b></p><p>Main outcomes were the proportion of patients initiating GLP-1 receptor agonists as part of NICE-recommended dual- or triple-therapy regimens; the proportions meeting NICE triple therapy initiation criteria (glycosylated hemoglobin [HbA1c] ≥7.5% and body mass index [BMI] ≥35 kg/m²) and the proportions continuing GLP-1 receptor agonist at 6 months according to NICE recommendations.</p><p><b>Results:</b></p><p>Mean age at initiating GLP-1 receptor agonists was 58.2 years (SD 9.4), BMI 38.4 kg/m² (SD 6.8) and HbA1c 9.2% (SD 3.2%). Overall, only 25% of patients initiated GLP-1 receptor agonists as part of a NICE-recommended regimen. Of patients initiated on a recommended triple-therapy regimen, 50% (646/1284) fulfilled both NICE HbA1c and BMI initiation criteria. Approximately 18% (32/174) of patients continuing NICE-recommended dual therapy at 6 months achieved a 1% reduction in HbA1c and 6.4% (33/515) continuing with NICE-recommended triple therapy achieved NICE’s target reductions for both HbA1c and body weight. About 8% of patients continuing exenatide as triple therapy (<i>N</i> = 243) achieved both targets.</p><p><b>Conclusions:</b></p><p>Adherence to NICE guidance for initiating and continuing GLP-1 receptor agonists is low. However, lack of data on ethnicity (for assessing NICE’s BMI criteria) and on contraindications and/or hypersensitivity to other diabetes medication in the treatment pathway have limited our ability to fully assess adherence to GLP-1 prescribing. Further research is warranted to better understand general practitioners’ prescribing decisions given the cost of prescribing GLP-1 receptor agonists.</p></div

Determining the date of diagnosis – is it a simple matter? The impact of different approaches to dating diagnosis on estimates of delayed care for ovarian cancer in UK primary care

Background Studies of cancer incidence and early management will increasingly draw on routine electronic patient records. However, data may be incomplete or inaccurate. We developed a generalisable strategy for investigating presenting symptoms and delays in diagnosis using ovarian cancer as an example. Methods The General Practice Research Database was used to investigate the time between first report of symptom and diagnosis of 344 women diagnosed with ovarian cancer between 01/06/2002 and 31/05/2008. Effects of possible inaccuracies in dating of diagnosis on the frequencies and timing of the most commonly reported symptoms were investigated using four increasingly inclusive definitions of first diagnosis/suspicion: 1. "Definite diagnosis" 2. "Ambiguous diagnosis" 3. "First treatment or complication suggesting pre-existing diagnosis", 4 "First relevant test or referral". Results The most commonly coded symptoms before a definite diagnosis of ovarian cancer, were abdominal pain (41%), urogenital problems(25%), abdominal distension (24%), constipation/change in bowel habits (23%) with 70% of cases reporting at least one of these. The median time between first reporting each of these symptoms and diagnosis was 13, 21, 9.5 and 8.5 weeks respectively. 19% had a code for definitions 2 or 3 prior to definite diagnosis and 73% a code for 4. However, the proportion with symptoms and the delays were similar for all four definitions except 4, where the median delay was 8, 8, 3, 10 and 0 weeks respectively. Conclusion Symptoms recorded in the General Practice Research Database are similar to those reported in the literature, although their frequency is lower than in studies based on self-report. Generalisable strategies for exploring the impact of recording practice on date of diagnosis in electronic patient records are recommended, and studies which date diagnoses in GP records need to present sensitivity analyses based on investigation, referral and diagnosis data. Free text information may be essential in obtaining accurate estimates of incidence, and for accurate dating of diagnoses

Management of epididymo-orchitis in primary care: results from a large UK primary care database

Background Epididymo-orchitis is a common urological presentation in men but recent incidence data are lacking. Guidelines for management recommend detailed investigation and treatment for sexually transmitted pathogens, such as Chlamydia trachomatis. Data from secondary care indicate that these guidelines are poorly followed. It is not known how epididymo-orchitis is managed in UK general practice. Aim To estimate the incidence of cases of epididymo-orchitis seen in UK general practice, and to describe their management. Design of study Cohort study. Setting UK general practices contributing to the General Practice Research Database (GPRD). Method Men, aged 15-60 years, consulting with a first episode of epididymo-orchitis between 30 June 2003 and 30 June 2008 were identified. All records within 28 days either side of the diagnosis date were analysed to describe the management of these cases (including location) and to compare this management with guidelines. Results A total of 12 615 patients with a first episode of epididymo-orchitis were identified. The incidence was highest in 2004-2005 (25/10 000) and declined in the later years of the study. Fifty-seven per cent (6943) of patients were managed entirely within general practice. Of these, over 92% received an antibiotic, with ciprofloxacin being the most common one prescribed. Only 18% received a prescription for doxycycline. Most men, including those under 35 years, had no investigation recorded and fewer than 3% had a test for chlamydia. Conclusion These results indicate low rates of specific testing and treatment for sexually transmitted infections in males who attend general practice with symptoms of epididymo-orchitis. There is a need for further research to understand the pattern of care delivered in general practice

Management of first-episode pelvic inflammatory disease in primary care: results from a large UK primary care database

Background Prompt and effective treatment of pelvic inflammatory disease (PID) may help prevent long-term complications. Many PID cases are seen in primary care but it is not known how well management follows recommended guidelines. Aim To estimate the incidence of first-episode PID cases seen in UK general practice, describe their management, and assess its adequacy in relation to existing guidelines. Design of study Cohort study. Setting UK general practices contributing to the General Practice Research Database (GPRD). Method Women aged 15 to 40 years, consulting with a first episode of PID occurring between 30 June 2003 and 30 June 2008 were identified, based on the presence of a diagnostic code. The records within 28 days either side of the diagnosis date were analysed to describe management. Results A total of 3797 women with a first-ever coded diagnosis of PID were identified. Incidence fell during the study period from 19.3 to 8.9/10 000 person-years. Thirty-four per cent of cases had evidence of care elsewhere, while 2064 (56%) appeared to have been managed wholly within the practice. Of these 2064 women, 34% received recommended treatment including metronidazole, and 54% had had a Chlamydia trachomatis test, but only 16% received both. Management was more likely to follow guidelines in women in their 20s, and later in the study period. Conclusion These analyses suggest that the management of PID in UK primary care, although improving, does not follow recommended guidelines for the majority of women. Further research is needed to understand the delivery of care in general practice and the coding of such complex syndromic conditions