PCDO Society news: Response to proposed NICE indicator on semaglutide for cardiovascular disease

The PCDO Society has responded to consultation on a proposed new NICE indicator regarding subcutaneous semaglutide for cardiovascular disease prevention. The proposed indicator, which is open for commenting until 25 August, would be:

The percentage of patients with established cardiovascular disease and a body mass index (BMI) of at least 27 kg/m² in the preceding 12 months who are treated with subcutaneous semaglutide 2.4 mg once weekly, alongside advice on a reduced-calorie diet and increased physical activity.

It would build on NICE’s TA1152 Technology Appraisal, which recommends subcutaneous semaglutide (Wegovy) up to 2.4 mg once a week for people with established cardiovascular disease and a BMI of at least 27 kg/m².

The proposed indicator would be a General Practice indicator suitable for use in the Quality and Outcomes Framework (QOF).

Details of the proposed indicator can be read in full here. The PCDO Society’s response is detailed below.

Response from the PCDO Society

The Primary Care Diabetes & Obesity Society welcomes the Technology Appraisal TA1152, based on the SELECT Trial data, which shows that this agent will improve outcomes for people with cardiovascular disease.

However, the Society firmly disagrees that this is an appropriate indicator to inform QOF. We believe this indicator should inform strategic commissioning of services by Integrated Care Boards from their provider partnerships. Not doing so will likely increase health inequalities and service variation.

QOF should not be used to launch a new pathway.

Technology Appraisals such as this are more suitable for a Directed Enhanced Service or Local Enhanced Service, especially building on the current Neighbourhood Team framework and the cardiovascular disease Modern Service Framework.

The recent flurry of Technology Appraisals is already putting added pressure on Integrated Care Boards and prescribing budgets.

Confusion may arise where people have been started on Wegovy for obesity who happen to have cardiovascular disease, versus those who have started on Wegovy for the management of their cardiovascular disease. Accurate Snomed codes will need to be created for this.

Further confusion is likely to arise over the most appropriate pathway for a person with type 2 diabetes and atherosclerotic cardiovascular disease: NICE NG28 (which limits dose to 1 mg subcutaneously once weekly) or TA1152 (2.4 mg once weekly).

Up to this point, primary care will not have been able to use Wegovy, and it still lacks the capacity to do so. Knowledge gaps will be a major concern.

Primary care is already challenged by dealing with increased numbers of private prescriptions for incretin therapies. Adding a QOF indicator will add further confusion and resource implications. There needs to be clarity over when people move from a private prescription to NHS eligibility.

Each person will require one appointment for initiation and at least four follow-up appointments for dose titration, with further resource implications. In people living with severe mental illness and learning disabilities, this need will be further amplified.

Transparency will be needed about how the numerator and denominator data will be collected and used.

Any decision to move this into QOF will require discussion with organisations such as the Primary Care Diabetes & Obesity Society, Primary Care Cardiovascular Society, Royal College of General Practitioners and British Medical Association, along with Local Medical Committees, before any endorsement would be possible.

Responses to specific questions

Question 5: Should the indicator focus on the target maintenance dose of 2.4 mg or allow achievement at lower doses of subcutaneous semaglutide (Wegovy) to support escalation?

If agreement is reached for this to be a QOF indicator, allow achievement at lower doses for reasons such as tolerability (appropriate coding would be required).

The PCDO Society also notes that contraindications (e.g. preconception) are not listed as situations where care adjustments are required. The indicator should take into consideration both cautions and contraindications.

Question 6: Is there likely to be high levels of personalised care adjustment recording for patients prescribed higher doses of subcutaneous semaglutide (Wegovy), other GLP-1 receptor agonists, or dual GIP/GLP-1 receptor agonists for other indications?

Yes – this has significant resource implications in terms of time, finance and knowledge.