Audit of monitoring of patients on disea

Audit of monitoring of patients on disease-modifying antirheumatic drugs : 

Audit of monitoring of patients on disease-modifying antirheumatic drugs Samir Dawlatly ST2 GP Trainee 7th October 2009

Outline : 

Outline Who I am and why I’m here Aims and objectives Background Criteria and standards Method Results Conclusions and discussion

Aims and objectives : 

Aims and objectives To establish whether patients are being monitored adequately To establish whether the Practice had access to blood test results To use the data to consider implementation of a protocol for the monitoring of DMARDs to ensure all patients are adequately monitored

Background : 

Background DMARDs used in the treatment of rheumatological conditions and other inflammatory disorders Drugs in this class include Azathioprine methotrexate sulfasalazine. Usually initiated in secondary care, by specialists. General practitioners usually have the responsibility to prescribe such drugs Regular monitoring of DMARDs is needed in order to detect the following potentially serious side-effects at an early stage. [1][2]

Why monitor? : 

Why monitor? Potentially fatal leucopoenia Thrombocytopenia Agranulocytosis aplastic anaemia [3] Hepatatoxicity [3][6] Deranged liver function tests Methotrexate is known to affect the LFT’s in 10% [4] Azathioprine can cause hepatatoxicityin 3-10% of patients The risk of adverse reactions to sulfasalazine occurs mainly in the first 3 months of treatment.[5] A dilemma occurs when treatment is recommended by one party and prescribed by another Responsibility for blood monitoring is not always clear

Criteria : 

Criteria Recommended frequency for all blood tests was assumed to be 3-monthly Previously a patient on methotrexate was expected to have blood tests every month recent update by the British Society for Rheumatology [7] relaxed to “2-3 months” in patients with stable blood tests on treatment

Standards : 

Standards Methotrexate - Both FBC and LFTs in past 3 months – 100% Azathioprine - Both FBC and LFTs in past 3 months – 100% Sulfasalazine - Both FBC and LFTs in past 3 months – 100%

Methods : 

Methods Search of EMIS on 21st April 2009 Identify patients registered currently being prescribed Azathioprine methotrexate sulfasalazine Pathology results and recent letters examined for the dates of the last blood tests If this was not available or clear, the responsible hospital, where possible, was contacted to obtain the date of the latest blood test.

Results : 

Results On 21st April 2009 practice had 12197 registered patients 39 patients were currently being prescribed DMARDs Methotrexate – 23 (4 in combination with sulfasalazine) Azathioprine – 11 Sulfasalazine – 5 as single therapy

Indications for DMARDs : 

Indications for DMARDs *Juvenile Arthritis, ankylosing spondylitis, SLE, chronic active hepatitis, erythrodermic eczema, myasthenia gravis

Main results : 

Main results

Put another way… : 

Put another way…

Discussion : 

Discussion The bottom line: As the standards were not met this suggests that there is a failure to monitor the treatment with DMARDs adequately Why? Patients not having blood test at the correct time Due to patient factors Due to doctor/system factors – i.e. not requested Results in secondary care and/or private practice not being fed back to primary care

Discussion contd : 

Discussion contd Patients of the practice mainly attend two local hospitals Two patients are seen privately their blood tests could not be found. time consuming and frustrating to call hospital pathology departments to obtain the results of tests on patients that are monitored in secondary care. reference to these tests may be made in letters result may be given May be unclear whether monitoring has occurred

Why do problems occur? : 

Why do problems occur? failure of communication between secondary and primary care systematic failure of a particular hospital department? individual variation as to how specialist doctors dictate their letters?

Shifting guidelines : 

Shifting guidelines frequency of testing is dependent on an individual patient’s previous blood results For the sake of simplicity a 3 month time period was adopted for the audit many patients were having bi-monthly tests in secondary care wide variation in the advice on monitoring of sulfasalazine [8]. The safety datasheet (3 monthly) [5] vs. BNF (1st 3 months)[3]

Shared care : 

Shared care Shared care should include shared information As GP’s are generally responsible for prescribing DMARDs they should also be fully informed of the details of monitoring if this is not being carried out in primary care how else can they safely prescribe DMARDs? In the past a Local Medical Committee negotiated with the health authority for the monitoring of patients on DMARDs in primary care [9].

Potential Action plan : 

Potential Action plan Circulate list of all patients on DMARDs to all partners Share result of audit with local hospitals Request that all blood tests done in hospital be copied to the practice Clarify with hospitals and private practice where patients are being monitored Make this clear on EMIS – through READ codes and diary entries Consider setting up a call and recall system for patients being monitored by the practice and who fail to attend for monitoring Consider using a patient-held blood test result book, perhaps the equivalent of the yellow book used by those on anticoagulation Involve LMC to take control of all monitoring

Completing the audit cycle : 

Completing the audit cycle Following implementation of any action Education of partners in form of presentation may be enough re-audit in 6-12 months time

Thank you : 

Thank you Any questions or comments References to follow…

References : 

References Wijnands MJH, van Reil PLCM. Management of adverse effects of disease modifying antirheumatic drugs. Drug Safety 1995; 219-27. MeReC Bulletin 1996; 7: 9-12. BNF, http://www.bnf.org/bnf/bnf/current/. Accessed 18 May 2009. Methotrexate. Clinical Evidence, December 1999, issue 2: 450-1. Datasheet Compendium 1999–2000: Sulfasalazine, p. 1234. Cromer M, Scott D, Doyle D, Huskisson E, Hopkins A. Are slow-acting anti-rheumatic drugs monitored too often? Br J Rheumatol 1995; 34: 966-70. Chakravarty K et al. BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists. Rheumatology (Oxford). 2008; 47:924-5. Hopkinson ND, Saiz Garcia F, Gumpel JM, Haematological side-effects of sulfasalazine in inflammatory arthritis. Br J Rheumatol 1989; 28: 414-17. Watson N. Monitoring patients on disease-modifying antirheumatic drugs. http://www.eguidelines.co.uk/eguidelinesmain/gip/vol_3/june_00/watson_dmards_june00.htm. Accessed 18 May 2009