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How GPs can take on monitoring of DMARDs

A shared care protocol to monitor patients on DMARDs can save on the costs of follow-up outpatient appointments, writes Dr Richard Oliver

A shared care protocol to monitor patients on DMARDs can save on the costs of follow-up outpatient appointments, writes Dr Richard Oliver

Over the past few years there has been a steady move towards earlier use of disease-modifying agents (DMARDs) in the management of rheumatological disease, inflammatory bowel disease and chronic skin disorders.

Although a hospital consultant initiates treatment, it is not always clear who provides ongoing monitoring. Inadequate communication between hospitals and GPs could put patients at risk. GPs are also often uncomfortable if they are asked to prescribe drugs with which they are unfamiliar or that need careful monitoring.

Last year, for example, the National Patient Safety Agency issued an alert after 25 deaths and 25 cases of serious harm were linked to the use of oral methotrexate outside hospital – most commonly due to confusion over the dose.

In Sheffield we have developed a shared care protocol to try to resolve these problems, which will save on the costs of follow-up outpatient appointments.

The three most commonly prescribed DMARDs prescribed in Sheffield are methotrexate, azathioprine and sulfasalazine. It is recommended that patients on these therapies undergo regular blood tests in order to monitor for serious drug-related side-effects. Historically, most prescriptions for these products have been issued by GPs, but most monitoring has taken place in a hospital outpatient setting.

However, initial reviews in Sheffield suggested there were a number of patients on these drugs who did not appear to be attending outpatient departments yet were continuing to have prescriptions issued. At the same time the hospital was finding it increasingly difficult to manage the number of patients without significant extra investment.

We arranged discussions between primary and secondary care supported by medicines management. The hospital was keen to engage and we had the enthusiastic support of Dr Annie Cooper, one of the consultants in rheumatology who, along with Michelle Black, the PCT pharmacist, and myself, developed a shared care protocol (SCP) for methotrexate, azathioprine and sulfasalazine. This was approved by the area prescribing committee and the LMC and was then used to develop a local enhanced service model (LES).

The SCP defines the responsibilities of the hospital to initiate and stabilise patients on these drugs and once they are deemed to be stable, to then consider transferring their ongoing drug monitoring from the hospital outpatient setting to primary care. The SCP describes what blood tests are needed, how often they should be carried out, and outlines the normal parameters to accept.

Clinical monitoring

Clinical monitoring has been deliberately left out of the protocol. Indeed we have asked practices to search their prescribing records to identify any patients who do not appear to be under the care of a hospital consultant and actively consider re-referring them if indicated.

To support the LES we agreed a format for a patient-held record, known as ‘the blue book', which allows the recording of the drug being used, the responsible consultant and the results of blood tests carried out. The book is owned by the patient who is encouraged to bring it to all their hospital appointments.

The practice has to transcribe the results of blood tests into the book as and when they are performed. The results are then used as a proxy for re-authorisation and issuing of a repeat prescription for the DMARD.

Fee agreed for each monitoring contact

Once the SCP had been agreed by the various committees, the LES was approved and actively promoted through a letter to all practices, backed up by a phone call from a PCT manager.

We now have more than 80% of the city's practices signed up to the LES. A transfer process has been agreed with the hospital and we will see increasing numbers of patients transferred to the community.

GPs are being paid a fee of £20 for each monitoring contact, which we estimate will earn an average practice about £1,000 per year. While this may not sound a large sum of money, it is important to recognise that for each community contact, the practice's budget ‘saves' a follow-up outpatient appointment – £80 – and helps the practice to move towards generating a saving to re-invest in further services. We believe as many as 500 patients could be transferred to primary care, saving a potential £145,000 a year at a cost for the LES of £30,000.

As numbers attending follow-up start to drop it will become easier for the hospital to see new referrals earlier in the course of a patient's disease, which helps in the delivery of the challenging 18-week referral-to-treatment target. In short, everyone wins!

The next stage of this project is to develop a similar framework for the monitoring of leflunomide in the community. This presents a slightly different challenge as the much higher price of the drug will also need to be considered in the financial arguments. At present a significant proportion of the drug cost is borne within the outpatient tariff, as much is dispensed from the hospital pharmacy. Moving that cost into the community will offset any savings made against outpatient tariffs.

Practices are welcome to get in touch with us if they would like copies of the Sheffield SCP or LES.

Dr Richard Oliver is a GP in Ecclesfield, Sheffield, and interim chair of Sheffield PCT's professional executive committee

Shared care protocol steps

First outpatient appointment

• Hospital clinic gives patient a drug information sheet and requests baseline investigations.

Outpatient follow-ups

• Patient receives prescription, to be dispensed by hospital pharmacy.

• Results of baseline and subsequent investigations are recorded in patient-held monitoring record and hospital record.

• Clinic is responsible for monitoring and repeat prescriptions until stable dosage has been successfully achieved, usually within three to six months.

• Patient's practice is informed of treatment and monitoring arrangements.

Transfer to practice for monitoring

• At dose stabilisation, responsibility is passed to the practice, if it has agreed to provide the enhanced service.

• Patient receives at least four weeks' supply from the hospital pharmacy ahead of the transfer.

• Formal transfer only takes place once the practice has faxed back an acceptance form to the referring consultant.

• Practice receives £20 per monitoring contact (£80 a year for methotrexate and azathioprine, £40 a year for sulfasalazine).

Practice monitoring

• Practice monitors patient as set out in the shared care protocol, for example:

Methotrexate FBC, full LFTs, creatinine, three-monthly; ask about dyspnoea, cough, fever and presence of oral ulceration or sore throat each time.

• Patient-held monitoring record should be updated at each visit.

• Patient required to demonstrate compliance with monitoring requirements before repeat prescriptions are issued.

• GP should phone the hospital helpline about any significant drug side-effects.

• If a GP wishes to withdraw from monitoring, they must give the clinic three months' notice.

Subsequent alterations by consultants

• The patient will normally still attend secondary care clinics regularly for disease review; any dosage or drug alterations initiated by the clinic will result in the monitoring and prescribing responsibility reverting to the clinic until stable dose monitoring is again achieved.

Copies of the shared care protocol are available for other GPs to adopt or adapt.

Contact Agnes McAuley, PBC manager (Parson Cross Consortium), by email:

practices can earn about £1,000 a year under the LES, plus make savings on the practice budget

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