Pharmacist Intervention in Type 2 Diabetes Mellitus Management: Need for the Identification of the Aspects of Care that Drives Optimal Patient Outcomes.. The components of care driving t
Trang 1Pharmacist Intervention in Type 2 Diabetes Mellitus Management:
Need for the Identification of the Aspects of Care that Drives Optimal Patient Outcomes.
The components of care driving the literature-reported statistically significant improvement in T2DM patient outcomes provided by pharmacists remains unclear Although 14 sentinel published studies, examined here,
provide some hint, they do not provide definitive reasons for pharmacist success in T2DM clinic patient management Studies are needed to identify & quantify the aspects of care responsible for pharmacists’ success
METHODS
• PubMed based literature review was conducted including open time
span, English, human only, free full-text articles.
• Inclusion criteria consisted of original research experiments,
pharm-acists in primary care environments, plus studies that documented
pharmacist intervention type.
• Preference was given to studies reporting HbA1c measurements as
tangible, reliable evidence for pharmacists’ interventions, and to key
terms appearing in the Title/Abstract.
• Exclusion criteria consisted of meta-analysis/systemic reviews,
studies without tangible results, and non-United States studies.
• 433 articles were identified, via these search terms:
[diabetes care] AND [pharmacist impact]
[diabetes] AND [pharmacist care] AND [efficacy],
[diabetes care] AND [pharmacists] AND [worse],
[diabetes care] AND [pharmacist led] AND [efficacy],
[a1c lowered] AND [pharmacist-led] AND [diabetes management], and
[pharmacist led] AND [diabetes care] AND [patient satisfaction].
INTRODUCTION / AIM
• Diabetes is growing in prevalence as in 2014 a total of 387
million individuals worldwide were living with type-2
diabetic mellitus (T2DM) ( Forouhi & Wareham, 2014 ).
• Lowering HbA1c is critical in T2DM Every 1% decrease in
HbA1c results in, as it relates to T2DM:
• 21% reduction in risk for any diabetes endpoint
• 21% (95% CI: 15%-27%) decrease in deaths;
• 14% (95% CI: 8% -21%) decrease in MI
• 37% (95% CI: 15%-27%) decrease in microvascular complications
• (p < 0.0001 for all changes listed; (Stratton et al, BMJ 2000)
• In recent years pharmacists have begun playing a larger and
crucial role in the management of (T2DM) ( Sisson & Kuhn,
2009)
• Medications play a vital role in T2DM management; yet, other
components of pharmacists’ interventions (e.g., education,
adher-ence monitoring, more visits, more time allotted per visit, follow
-up telephone/video visits), may play an important role, too.
• In this retrospective research review, we identified 6 pharmacist
intervention factors or components associated with successful
patient outcomes, centered on measures to decrease % HbA1c.
• Our aim was to determine which and what # of factors (#1 to #6 )
were detailed in each article that meet our search criteria.
West Virginia University School of Pharmacy, Morgantown, WV1
CONCLUSIONS:
ACCP
# 56314
Table 1 List of 14 select salient studies (of 25 identified), examining Pharmacist involvement impact in T2DM patient care, plus a list of potential factors of interventions hypothesized to contribute to patient care success.
Disclosures: No grant support was received for this
project JW & AB have nothing to disclose RCR has
received grant funding from UCB and is an Otsuka consultant
#
Study Primary Outcome Study Results Was diabetic
Education utilized ? Type & Frequency
What drug(s) were chosen ?
Was Adherence measured
?
Was time allotted per clinic visit recorded?
Were phone calls used &
frequency ?
Were in-person visits used &
frequency ?
1 Δ HbA1C at 6months
compared to baseline
IG: -0.5 Δ vs CG: no Δ (p=0.04)
☑ drug knowledge, insulin titration
NR ☑ ☑ 20-30 mins ☑every 4-6
weeks ☑every 4-6 weeks
2 Adherence to oral
antidiabetic medication (OAD)& Δ HbA1C
IG: 84.3% adherence,
− 1.5% Δ A1C vs CG:
82.4%, -1.4% Δ A1C (p < 0.0001 )
NR NR ☑ NR ☑ frequency
not defined
☑ average 2.5 times throughout first year
3 Δ HbA1C P<0.01
☑ online educational program 1-2 days a week
NR
NR ☑15-30+ mins ☑ quarterly patient ID and ☑ w/in 14 days of
quarterly if possible
4 Δ HbA1C IG: -0.8 Δ A1C vs CG:
-0.05 Δ A1C (p<0.03)
☑lipid and glycemic control
NR NR NR NR ☑ average of 13.5
visits
5 Δ HbA1C IG: -2.07 Δ A1C vs CG
-0.66 Δ A1C (p<0.001)
☑ glucose control,
DS management
NR NR NR ☑ (telehealth)
Mon-Fri
NR
6 Percent of patients that
achieved HbA1C goal
IG: -0.90±1.6 Δ v CG:
0.0 ±1.5 Δ (p<0.05)
☑ medication, DS, lifestyle
☑ IG more likely to have niacin and
insulin
☑ ☑ 80-140
minutes
NR ☑ 4 sessions
7 Δ ASCVD risk using
UKPDS risk engine
IG: -0.02 ±0.09 Δ vs CG:
-0.04 ±0.09 Δ ( p=0.45)
☑ self care Every visit
NR NR ☑ 2 hours,
pharmacist 2nd
hour only
NR ☑ group visits
weekly x 1mo, 3 mos x13 mos
8 Δ HbA1C from baseline
after 2 years
IG :-1.24 Δ vs CG: -0.59 Δ (p=0.009)
☑ medication, DS monitoring, lifestyle
Every visit
NR NR ☑ 60 min
initial, 30 min thereafter
NR ☑ every 1 mo 1st
year, every 3 mo 2nd
year
9 Patient satisfaction (PS),
perception of self-management (SM), disease state (DS) knowledge
PS: 36.6/40 (SD 3.9), SM:
20.9/25 (3.4), and DS knowledge: 17.6/20 (2.1)
☑ unspecified NR NR ☑ NR ☑
10 Δ HbA1C at 6 months
compared to baseline
IG: -2% Δ HbA1C vs
CG: Δ A1C (p=0.0002)
NR NR NR ☑ ☑
(telehealth)
NR
11 Δ HbA1C within 6 months
of recruitment
IG: -0.83 Δ A1C vs CG +0.43 Δ A1C (p=0.001)
☑ insulin injection technique, general medication
NR ☑ NR ☑ monthly ☑ only if required
hospital visit
12 Percent of patient’s
achieving HbA1C<9%
+6% Δ patients w/ HbA1C
<9%
13 Cost effectiveness of
DIMM “tune-up” clinic/
estimated cost savings
Approx 3 year cost difference IG $3506 vs the CG: $879 (p=0.009)
☑Diabetes education-unspecified Every visit
NR NR ☑ NR ☑ 3 in 6 months
14 Δ HbA1C from baseline to
12 months
IG -0.75 Δ vs -0 79 Δ in CG: (AD +0.04 [95% CI -0.22-0.3)
☑ Adherence, medication
Frequency depended
on care plans
NR ☑ NR ☑ up to 3 in 12
months
NR
• #14 of 25 studies meeting our review
criteria, and spanning from 2000 to
2020 are highlighted in Table 1.
• No study mentioned all 6 potential
components for pharmacists’ success in T2DM clinics; multiple mentioned 5.
• In the 14 studies highlighted here,
Pharmacists have focused on reporting the “what”, namely:
• results re % HbA1c decreases over time,
(#9 studies had statistical ⬇ in %A1c) ,
• physician and/or patient satisfaction,
• improved pharmacoeconomics,
• increased patients’ adherence to meds,
• more accessibility in terms of visits,
and drug regimen changes,
• but not the “how”, with
pharmacist-provided T2DM care.
components for both successful or even for less-than optimal
pharmacist-pro-vided T2DM care is essential to identify the real reason(s) for physicians’,
pharmacists’ or NPs’ success in T2DM
• Since T2DM is expensive to manage, (~$327 billion/yr for 2017 ; (Yang et al.,
management could likely be expanded.
• The reasons-the “how”- for pharmacists’ success and impact in the care of T2DM patients is not clear Rigorous prospec-tive research is needed to best
under-stand how pharmacists improve care.
(Yang et al., 2018)