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Pharmacist case management of type 2 diabetes

Study
Results
Comment

Most chronic diseases have some patients who do not do well with usual care. Reasons will be different for different people, but what to do remains problematical. One strategy might be to provide extra, individualised education, help, and feedback for a period. A randomised trial [1] indicated that directed input from a clinical pharmacist can improve results for patients with poorly controlled type 2 diabetes.

Study

The setting was a primary care university-affiliated clinic with 10 primary care physicians and an established clinical pharmacist as part of the team. Patients were those with type 2 diabetes whose recent Hb A1c value was 8% or more, who were younger than 70 years and who did not have serious co-morbid conditions. Randomisation was balanced across four strata of Hb A1c (8-8.9%, 9-9.9%, 10-10.9%, and ≥11%).

The intervention was by a clinical pharmacist. It consisted of a one hour educational and medicines management visit, with emphasis on self-care, medications, and screening processes for complications. Subsequent visits were as needed, with monthly telephone contact. Periodic reviews provided status updates to physicians. Non-intervention patients received usual care.

The main outcome was Hb A1c at the end of follow up over 12 to 24 months. Other assessments were take up of screening and examinations.

Results

Eighty patients were randomised. Their average age was 51 years, and the average baseline Hb A1c was 10.2%. There were no differences in medications used between intervention and control patients.

The mean decrease in Hb A1c in intervention periods over an average 14 months follow up was 2.1%. For control patients over an average 15 months it was 0.9%. The result was statistically significant, with and without any imputed values from the few patients lost to follow up.

Intervention was much more effective in those with the highest (worse) Hb A1c levels. Figure 1 shows that the additional decrease over control patients receiving usual care was 3.6% for those with average baseline Hb A1c of 13%, and 1.4% for those with a baseline of 11%. In addition, there were significantly increased rates of cholesterol measurement, retinal examination, and foot examination in intervention patients (Table 1).



Figure 1: Decrease of HbA1c (%) for intervention over control according to initial HbA1c value







Table 1: Recent processes and examinations (shaded significantly different)



Percent with measure
Process
Control
Intervention
HbA1c
83
92
LDL
86
100
Retinal examination
74
97
Urine albumin screen
86
95
Foot examination
63
92


Comment

This may not be rocket science, but it does demonstrate that relatively simple interventions for the patients who need help can make a big difference, however good usual care may be. The setting was real world, and the intervention simple. This was an intervention that could be introduced for many primary care practices, and with the potential for extrapolation to other chronic diseases. Key to success may well have been the way physicians and pharmacist acted as a team, and how the pharmacist made the patient a de-facto member of that team.

Because resources, especially staff time, are limited, being able to determine which patients are most likely to respond to an intervention is obviously important. In this case it was those with an initial Hb A1c of about 10% or more. Here the results were particularly good, with an absolute reduction of 3-6% in Hb A1c in those with the worst glycaemic control. This would be expected to produce significant and substantial reductions in risk of microvascular complications. The UKPDS indicated that a 1% reduction in HbA1c levels leads to a 21% reduction in the risk of diabetes related complications and death.

Reference:

  1. HM Choe et al. Proactive case management of high risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. American Journal of Managed Care 2005 11: 253-260.

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