Improving Quality of Care in Diabetes Through a Comprehensive Pharmacist-Based Disease Management Program
Sandra Leal, PHARMD, CDE1,2, Jon J. Glover, PHARMD2,3, Richard N. Herrier, PHARMD2 and Anthony Felix, RPH1,2
1 El Rio Health Center, Tucson, Arizona
2 University of Arizona College of Pharmacy, Tucson, Arizona
3 Pfizer Pharmaceuticals, Phoenix, Arizona
Address correspondence and reprint requests to Richard N. Herrier, PharmD, College of Pharmacy, University of Arizona, 1703 E. Mabel, Tucson, AZ 85721-0207. E-mail: herrier@pharmacy.arizona.edu
In the U.S., a large percentage of patients with diabetes receive less than optimal care (1). The use of pharmacists, nurse practitioners, and multidisciplinary teams in a variety of settings have led to improvements in disease control in patients with diabetes and other chronic diseases (2–14). This report describes the utility of a pharmacist-run disease management program in improving the care of predominately indigent, Spanish-speaking patients with diabetes and common comorbid conditions.
The study was conducted at El Rio Health Center, which is a federally qualified health center located in Tucson, Arizona. The patient population is comprised mostly of indigent, Spanish-speaking, and sometimes transient patients with primarily type 2 diabetes. The program was implemented in August 2001, using a residency-trained, bilingual PharmD as the provider for patients referred to the pharmacist-based diabetes service by staff physicians. The pharmacist served as the primary care provider for the patients’ diabetes and comorbid conditions, hypertension, and hyperlipidemia. Using medical staff–approved collaborative practice agreements, the pharmacist provided appropriate diagnostic, educational, and therapeutic management services, including prescribing medication and ordering laboratory tests. The collaborative practice agreements were based on national standards of care for diabetes, hypertension, and hyperlipidemia. The pharmacist used a customized Microsoft Access database to facilitate documentation of services and appropriate patient management.
All patients who had an initial visit, plus at least one additional visit over the following 90 days, were included in this analysis. Patients served as their own controls. Comparisons of continuous data from baseline to follow-up, such as lipid parameters, glucose, weight, BMI, blood pressure, and A1C were compared using a paired t test. Changes from baseline to follow-up in percentages or proportions, such as changes in percentage of patients at LDL cholesterol goal, use of aspirin, or patients at blood pressure goal, were compared using CIs and two-proportion testing. Significance for all statistical comparisons were set at {alpha} = 0.05.
The 2% drop in mean A1C is similar to that achieved in a Veterans Administration pharmacist-based program (6). In the Veterans Administration study, only 26% of patients had their A1C lowered to <8.0%>10% (8 vs. 14.9%). The percentages were also superior for patients receiving dilated eye examinations (99.5 vs. 63.3%) and foot examination (99.5 vs. 54.8%) (1).
Because of the unique population and practice setting, application of these findings to other pharmacist-managed programs may be problematic. Thirty-seven states allow pharmacists to prescribe medications. Arizona, along with several other states, require drug- or disease-specific collaborative practice agreements that have been approved by physicians participating in these programs. Pharmacist clinical privileges in this study were defined by such an agreement. The use of a bilingual pharmacist may have contributed to the service’s success through clearer communication and attention to cultural nuances that contribute to patient adherence. Also, many of the patients included in the data analysis were referred to the pharmacist because of the inability of previous care to obtain adequate disease control. This tended to provide a population that was inherently more difficult to achieve target levels of blood pressure, blood glucose, and lipids. Finally, El Rio Health Center is organizationally a staff model HMO where physicians, other professionals, and ancillary staff are employees of the delivery system. This facilitates the smooth integration of pharmacists into expanded roles and provides a patient care structure that supports the delivery of comprehensive care.
A pharmacist-managed service for the care of diabetes and frequently associated comorbid conditions was effective in significantly lowering A1C, blood pressure, and LDL cholesterol levels and had near-perfect compliance with national standards for diabetes care. This was accomplished in a federally qualified health center treating primarily indigent and transient Hispanic and Native-American populations. This study demonstrates the positive effect of clinically trained pharmacists in managing patients with diabetes and common comorbid conditions.
