Pharmacist-led Diabetes Care Associated with Improved Outcomes

Pharmacist-led Diabetes Care Associated with Improved Outcomes
Sara Maki, PharmD, North Memorial Blaine Clinic

Diabetes is a prevalent and complex chronic disease that requires ongoing management for optimal care. While previous literature has clearly shown that pharmacists play a critical role in improving outcomes and decreasing cost of care, this study adds a new perspective by analyzing baseline patient characteristics and various pharmacist interventions to determine predictors of response to pharmacist-led diabetes care. 

This retrospective cohort study was conducted at three primary care clinics in Texas, with two pharmacists practicing under a collaborative practice agreement that allowed for comprehensive medication management. Over a period of four years, adult patients with type 2 diabetes were referred by their primary care provider for diabetes management and participated in at least one visit with the pharmacist. Patients with gestational diabetes, type 1 diabetes, a visit with an endocrinologist, or missing A1c values were excluded. Common comorbid conditions included hyperlipidemia and hypertension. The majority of patients were English-speaking, obese, Hispanic females. 

Of the 180 patients who were included, 119 were deemed to be “responders” and 61 to be “non-responders” to pharmacist-led diabetes management. The term responder indicates that a patient had an A1c reduction of at least 1 percent or otherwise met their documented A1c goal within six months, while a non-responder did not meet either criterion. Baseline demographic characteristics and lab values were similar between the responder and non-responder groups, except that the responder group had a significantly higher baseline A1c (10.1% vs. 9.0%, P = 0.003). 

The median change in A1c from baseline was -2.2% (-3.7 to -1.3) for responders and 0.4% (-0.4 to 1.05) for non-responders (P < 0.001). Common interventions by the pharmacist included starting a new medication (73%), adjusting a medication dose (57%), discontinuing a medication (48%), and providing a log for self-monitored blood glucose (37%). The authors conducted a multivariable logistic regression model of 25 variables to determine predictors of response. Statistically significant predictors of positive response were baseline A1c (OR 1.41; 95% CI 1.08-1.85), completed visits with the pharmacist (OR 1.65; 95% CI 1.03-2.64), and having an intervention to reduce medication dosing frequency (OR 0.69; 95% CI 0.49-0.96).

A1c reduction of greater than one percent is clinically meaningful, as demonstrated by the UKPDS 35 study, which found that each 1 percent reduction in A1c can reduce the risk of microvascular complications by 37 percent and the risk of mortality by 21 percent. This is especially impressive in the short follow-up time frame of 6 months. Other strengths of this study include its diverse patient population, range of antidiabetic medications available as therapeutic options, and multi-site design. One intervention that was challenging to assess was the value of general education provided during the visits, which may impact a patient’s self-efficacy in chronic disease management. An additional limitation of this study is the bias that could be associated with the referral process and the retrospective design that is prone to missing or inaccurate data during chart review.  

Overall, higher baseline A1c, more visits with the pharmacist, and reduction in medication dosing frequency were all predictors of clinical response. This study adds to the growing body of literature that demonstrates that clinical pharmacists should continue to be involved in team-based primary care for improved patient outcomes.

 

Reference:

  1. Palka, SJ, Koeller JM, Davidson DW, Zeidan AR, Reveles KR. Predictors of response to ambulatory pharmacist-led diabetes care. J Am Coll Clin Pharm. 2021;4:450-458.