Medicines

Under-prescribing of heart medicines in at-risk patients ‘striking’


Huge gaps in cardiovascular screening and prescribing practices for patients with diabetes persist despite the introduction of practice incentive payment schemes and targeted quality improvement programs, new research shows.

The study of some 38 725 patients (6909 of who had diabetes) presenting to 60 primary care practices around the country revealed that about half of the patients with diabetes did not meet the recommended HbA1c targets and nearly a quarter with HbA1c levels over 69 mmol/mol were not prescribed glucose-lowering medication.

The analysis, published in the MJA this week, is part of a bigger study designed to assess the impact of an electronic decision making tool on improving CVD screening and prescribing rates. It also revealed that half the patients with diabetes did not meet BP targets and more than one-quarter of those patients were not prescribed  antihypertensive therapy.

Researchers said the under prescribing of recommended treatments was ‘striking’ among patients at risk of CVD whether they had a diabetes or not.

Some 39% of those with established CVD and 48% of those at high risk of CVD were not prescribed the recommended treatments and almost half of those with diabetes and LDL-cholesterol levels above 2.0 mmol/L were not receiving statin therapy.

Endocrinologist and researcher at The George Institute for International Health, Dr Santhi Chalasani told the limbic that while the gaps are ‘huge’ and ‘worrying’ they do reflect modest improvements when compared with the findings of previous Australian studies of lipid and BP management.

But while she puts that down to a number of targeted quality improvement (QI) programs such as the introduction of targeted incentive payments to general practitioners and practices, Dr Chalasani said patient focused strategies were needed for Australia to meet global targets of reducing mortality from CVD and diabetes by 25% over the next 10 years.

Patients with diabetes who had a formal care plan, were older, indigenous, or who had a higher HbA1c level, higher systolic BP, or albuminuria, faired better and were more likely to be prescribed the recommended combination treatment, the report showed.

According to Dr Chalasani the [treatment] gaps that remain may well be explained by the proliferation of treatment guidelines each with disparate perspectives.

“All the studies show that guidelines are not being followed and that’s probably because there are so many of them – it’s a 15 minute consultation and GPs don’t have time to look at all these different recommendations.”

She also suspects there is some uncertainty about prescribing newer therapies.

“There’s been a real explosion of glucose lowering agents in the last 10 or 15 years and I think GPs are confused about what’s available, what’s PBS subsidised and what the next step after metformin is – and that may breed a bit of complacency,” she suggested.

She added that there would also be clinically valid reasons for not prescribing certain medications or aiming for recommended targets.

A follow on study will update the original electronic decision making tool so that it amalgamates all the relevant guidelines and provides recommendations based on individualised patient information.

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