Research Article
The Impact of Clinical Pharmacist Integration on a Collaborative Interdisciplinary Diabetes Management Team
Journal of Pharmacy Practice 2017, Vol. 30(3) 286-290 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190016631894 journals.sagepub.com/home/jpp
Courtney S. Davis, PharmD1, Leigh Ann R. Ross, PharmD1, and Lauren S. Bloodworth, PharmD1
Abstract Objective: The national initiative, Project IMProving America’s Communities Together (IMPACT): Diabetes, was intended to scale a proven American Pharmacists Association (APhA) Foundation process model, which integrates pharmacists on the collaborative health-care team, in communities greatly affected by diabetes to improve key indicators of diabetes. This article discusses the results from 1 community in Mississippi. Methods: This national prospective study followed patients with a hemoglobin A1c (HbA1c) >7% from September 2011 to January 2013. Pharmacists collaborated with providers and other healthcare professionals to provide medication therapy management services for a minimum of 3 visits. Outcome measures included HbA1c, systolic and diastolic blood pressure (SBP and DBP), fasting cholesterol panel, body mass index (BMI), influenza vaccine and smoking status, and foot and eye examination dates. Results: At this site, there were statistically significant outcomes including mean HbA1c decrease of 1.2% in SBP and DBP of 8.3 mm Hg and 3.5 mm Hg, respectively, and reduction in low-density lipoprotein of 16.6 mg/dL, all of which were greater improvements compared to overall results from combined sites. Conclusion: Patients in this community who received care from the collaborative team, including a pharmacist, had improvement in most key indicators of diabetes, with a clinically significant reduction in HbA1c. Keywords ambulatory care, endocrinology In the United States, the incidence of diabetes continues to rise with an estimated 29.1 million adults affected.1 In 2012, Mississippi ranked second in overall diabetes prevalence with more than 12.5% of the population having type 2 diabetes.2 Diabetes is the sixth leading cause of death in Mississippi with 4 of every 1000 deaths attributed to diabetes.2,3 A total of 69% of Mississippians are either overweight or obese, which increases their risk of developing type 2 diabetes.3 Multiple studies evaluating the impact of pharmacist involvement in the management of patients with diabetes in the primary care, and community pharmacy settings have also revealed improvement in hemoglobin A1c (HbA1c) values as well as other clinical parameters.4-9 The Asheville Project and Diabetes Ten City Challenge were 2 important studies, which resulted in positive clinical and economic outcomes from the implementation of pharmacist-provided medication therapy management (MTM) services in the community pharmacy setting. 4,5 Project IMPACT: Diabetes was a national initiative of the American Pharmacists Association (APhA) Foundation. 10 IMPACT stands for IMProving America’s Communities Together. The project was created to scale a proven APhA Foundation process model (establishing collaborative interdisciplinary care with pharmacists, ongoing quality improvement, use of patient self-management credentialing for baseline knowledge
assessment, and documenting set outcome measures) to 25 communities across the United States that are underserved or greatly affected by diabetes. The national initiative had the following 4 key objectives set forth by the APhA Foundation: (1) expand a proven community-based model of care in highrisk areas of the country, (2) improve key indicators of diabetes care in the targeted communities, (3) establish peer-to-peer mentoring in order to scale the existing model nationally, and (4) establish a sustainable platform for permanent change.10 Each community established a specific model of care that worked for their individual site and patient population. The University of Mississippi School of Pharmacy partnered with the Diabetes Care Group™ in Jackson, Mississippi, to establish clinical pharmacy services in an outpatient collaborative interdisciplinary diabetes clinic in order to meet the stated objective of improving key indicators of diabetes care in this community.
1
Department of Pharmacy Practice, The University of Mississippi School of Pharmacy, Jackson, MS, USA Corresponding Author: Courtney S. Davis, Department of Pharmacy Practice, The University of Mississippi School of Pharmacy, 2500 N State Street, Jackson, MS 39216, USA. Email: [email protected]
Davis et al This article describes pharmacy involvement on the diabetes management team at the Diabetes Care Group and clinical findings from the site. While the overall study results have been previously published, these site-specific results may be of particular interest to pharmacists practicing in settings that involve pharmacist collaboration with physicians, nurse practitioners, registered nurses, and other health-care professionals to manage patients with diabetes. This study site was one of few physicianbased clinics included in the large study population. For this reason, it may provide more applicability compared to reviewing data from the large data set consisting of multiple types of practice sites.
Methods This prospective study was approved by the University of Mississippi Institutional Review Board prior to initiation. The clinical pharmacist, along with the assistance of community pharmacy residents, recruited patients at the diabetes clinic from September 2011 until January 2012. Patients included were those with a diagnosis of diabetes, prescribed diabetes medication(s), had a HbA1c greater than 7% within the past 3 months of enrollment, and were able to present to the clinic for visits. Eligible patients were identified through review of existing clinic data and recruited on site. Exclusion criteria included those younger than 18 years of age, institutionalized, unable to give written informed consent, and known to be pregnant. The Diabetes Care Group utilizes a team comprised of physicians, nurse practitioners, and diabetes educators, which consist of both dieticians and registered nurses to care for patients with diabetes. Prior to Project IMPACT: Diabetes, there was no clinical pharmacist involvement in patient care at this site; however, at each visit, patients interact with both an educator (dietician or nurse) for the first half of the visit and a provider (physician or nurse practitioner) for the second half of the 30-minute return visits. Enrolled patients were scheduled for a minimum of three 30-minute visits with the provider-clinical pharmacist team scheduled 3 months apart. During each of these visits, at least half of the allotted time was spent with the clinical pharmacist. In the time spent with the clinical pharmacist, a comprehensive medication review was completed, an individualized self-management plan was developed, and disease education was provided and tailored to each patient’s individual needs. Reviewing medication lists provided the opportunity for counseling on individual medications and potential interactions. The clinical pharmacist or pharmacy resident reviewed medications and counseled patients about the medications and potential interactions. This provided the opportunity for counseling on individual medications and potential interactions. After review of the medication list, blood glucose log, and laboratory values, the clinical pharmacist provided guideline-based therapeutic recommendations to the provider to add, stop, or change doses of any oral or injectable medications and after discussion the pharmacist implemented a therapeutic plan for the patient. The provider joined the clinical pharmacist and patient at the end of the visit to perform the
287 physical examination, fill out the Superbill, and make any necessary referrals. The provider then moved on to the next patient visit, and the clinical pharmacist reviewed and gave the patient written instructions to take home, input requested refills, and delivered any further needed device, medication, or diseaserelated education. Each visit not only addressed diabetes but also hypertension, dyslipidemia, and obesity for comprehensive cardiometabolic management. Being an academic institution, students and residents were incorporated in the project as a part of their experiential rotations. There were 2 community pharmacy residents and several students who rotated through the clinic during this time, with the pharmacist serving as the preceptor of record. The community pharmacy residents screened patients, recruited, obtained informed consent, administered a baseline knowledge survey, and referred patients to the front office staff to arrange scheduling. Community pharmacy residents were also able to provide the same interaction during patient visits as the pharmacist did once they were trained. Students assisted with medication reconciliation, drug information questions, reviewing blood glucose logs, and writing down instructions for the patient to take home. They were also able to practice patient counseling and making therapeutic recommendations during the visits with the pharmacist’s supervision. Outcomes were measured based on the following parameters: HbA1c, systolic and diastolic blood pressure (SBP and DBP), fasting cholesterol panel, body mass index (BMI), dates of diabetic foot examinations, dates of comprehensive eye examinations, influenza immunization status, and smoking status. Nonsmokers were defined as either never smoked or had quit for longer than 12 months prior to enrollment. Results were evaluated using a 1-tailed t test for matched data. The APhA Foundation completed statistical analysis for all study sites. The site-specific results were compared to the reported results from the larger data set. Statistical significance was indicated if P < .05. Additionally, a baseline knowledge assessment, the patient self-management credential, developed by the APhA Foundation, was given at baseline to determine whether the patient was considered to be a beginner, proficient, or advanced in their knowledge of diabetes.11
Results A total of 71 patients were consented, and 64 patients completed the minimum study requirements of at least 3 documented encounters with the clinical pharmacist at least 3 months apart. Those not meeting minimum study requirements were mostly due to lost to follow-up or dismissal from the clinic as a result of continual payment issues. The average number of visits per patient was 4.2, and average reported length of visits was 39.9 minutes. During the course of the project, the pharmacist conducted a total of 156 patient encounters over an average time span of 343 days. There were 48% male patients and 52% female patients enrolled (Table 1). The majority were caucasian and African American (64% and 33%, respectively) with the remaining being Hispanic and Native American
288
Journal of Pharmacy Practice 30(3)
Table 1. Baseline Data. Category Age Ethnicity
Gender Clinical measures
Knowledge level
Smoking status Eye examination Foot examination Influenza vaccine
Age, years Caucasian, % Hispanic, % African American, % Native American, % Female, % Male, % HbA1c, % BMI, kg/m2 SBP, mm Hg DBP, mm Hg LDL-C, mg/dL HDL-C, mg/dL Triglycerides, mg/dL Total cholesterol, mg/dL Beginner, % Proficient, % Advanced, % Smoker, % Nonsmoker, % Up to date, % Needs examination, % Up to date, % Needs examination, % Up to date, % Needs vaccine, %
Table 2. Clinical Outcomes. n 64 41 1 21 1 33 31 64 64 64 64 32 40 41 41 8 34 22 3 61 46 16 55 0 25 28
Mean Value or Percentage 54.9 + 12.6 64.1 1.6 32.8 1.6 51.6 48.4 9.2 + 1.7 36 + 8.2 136.8 + 19.8 79.4 + 10.7 99.2 + 31.7 36.3 + 12.2 233.4 + 167.9 174.9 + 37.9 12.5 53.1 34.4 4.7 95.3 74.2 25.8 100 0 47.2 52.8
Abbreviations: HbA1c, hemoglobin A1c; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; LDL-C, low-density lipoprotein-cholesterol; HDL-C, high-density lipoprotein-cholesterol.
(Table 1). Mean HbA1c at baseline was 9.2% (Table 1). Over the course of the study, mean HbA1c dropped by an average of 1.2% (P < .001), resulting in a final mean HbA1c of 8.0% (Table 2). The distribution of the final HbA1c values is given in Figure 1. On average, patients experienced statistically significant reductions in both mean SBP and mean DBP (8.3 mm Hg, P < .001 and 3.5 mm Hg, P ¼ .031, respectively; Table 2). Of the 26 patients who had either an SBP greater than 140 mm Hg or DBP greater than 90 mm Hg, 19 had a final reading of less than 140/90 mm Hg. There were 57 patients on hypertension therapy at baseline, and by the end of the study, there were 62 patients on at least 1 antihypertensive. Changes in number of hypertension medications and dosage was not recorded. There were statistically significant changes in all fasting lipid parameters. Low-density lipoprotein (LDL) values dropped by an average of 16.6 mg/dL (P ¼ .006), high-density lipoprotein (HDL) increased by 4.3 mg/dL, (P ¼ .001), triglycerides decreased by 57.1 mg/dL (P ¼ .006), and total cholesterol decreased by 13.8 mg/dL (P ¼ .024; Table 2). BMI was unchanged during the study (Table 2). At enrollment, 95.3% of patients were considered nonsmokers (Table 1). While the pharmacist discussed smoking cessation at each visit with all smokers, this percentage did not change at the conclusion of the study. There were 40.3% of patients with recent documented eye examinations at the
Outcome Measure
Final
HbA1c, % BMI, kg/m2 SBP, mm Hg DBP, mm Hg LDL-C, mg/dL HDL-C (mg/dL) Triglycerides (mg/dL) Total Cholesterol (mg/dL)
8.0 35.8 128.5 75.9 82.6 40.6 176.3 161.0
Change 1.2 0.1 8.3 3.5 16.6 4.3 57.1 13.8
+ 1.7 + 1.8 + 18.3 + 10.6 + 35.2 + 8.1 + 139.8 + 43.6
P Value
The Impact of Clinical Pharmacist Integration on a Collaborative Interdisciplinary Diabetes Management Team
Journal of Pharmacy Practice 2017, Vol. 30(3) 286-290 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190016631894 journals.sagepub.com/home/jpp
Courtney S. Davis, PharmD1, Leigh Ann R. Ross, PharmD1, and Lauren S. Bloodworth, PharmD1
Abstract Objective: The national initiative, Project IMProving America’s Communities Together (IMPACT): Diabetes, was intended to scale a proven American Pharmacists Association (APhA) Foundation process model, which integrates pharmacists on the collaborative health-care team, in communities greatly affected by diabetes to improve key indicators of diabetes. This article discusses the results from 1 community in Mississippi. Methods: This national prospective study followed patients with a hemoglobin A1c (HbA1c) >7% from September 2011 to January 2013. Pharmacists collaborated with providers and other healthcare professionals to provide medication therapy management services for a minimum of 3 visits. Outcome measures included HbA1c, systolic and diastolic blood pressure (SBP and DBP), fasting cholesterol panel, body mass index (BMI), influenza vaccine and smoking status, and foot and eye examination dates. Results: At this site, there were statistically significant outcomes including mean HbA1c decrease of 1.2% in SBP and DBP of 8.3 mm Hg and 3.5 mm Hg, respectively, and reduction in low-density lipoprotein of 16.6 mg/dL, all of which were greater improvements compared to overall results from combined sites. Conclusion: Patients in this community who received care from the collaborative team, including a pharmacist, had improvement in most key indicators of diabetes, with a clinically significant reduction in HbA1c. Keywords ambulatory care, endocrinology In the United States, the incidence of diabetes continues to rise with an estimated 29.1 million adults affected.1 In 2012, Mississippi ranked second in overall diabetes prevalence with more than 12.5% of the population having type 2 diabetes.2 Diabetes is the sixth leading cause of death in Mississippi with 4 of every 1000 deaths attributed to diabetes.2,3 A total of 69% of Mississippians are either overweight or obese, which increases their risk of developing type 2 diabetes.3 Multiple studies evaluating the impact of pharmacist involvement in the management of patients with diabetes in the primary care, and community pharmacy settings have also revealed improvement in hemoglobin A1c (HbA1c) values as well as other clinical parameters.4-9 The Asheville Project and Diabetes Ten City Challenge were 2 important studies, which resulted in positive clinical and economic outcomes from the implementation of pharmacist-provided medication therapy management (MTM) services in the community pharmacy setting. 4,5 Project IMPACT: Diabetes was a national initiative of the American Pharmacists Association (APhA) Foundation. 10 IMPACT stands for IMProving America’s Communities Together. The project was created to scale a proven APhA Foundation process model (establishing collaborative interdisciplinary care with pharmacists, ongoing quality improvement, use of patient self-management credentialing for baseline knowledge
assessment, and documenting set outcome measures) to 25 communities across the United States that are underserved or greatly affected by diabetes. The national initiative had the following 4 key objectives set forth by the APhA Foundation: (1) expand a proven community-based model of care in highrisk areas of the country, (2) improve key indicators of diabetes care in the targeted communities, (3) establish peer-to-peer mentoring in order to scale the existing model nationally, and (4) establish a sustainable platform for permanent change.10 Each community established a specific model of care that worked for their individual site and patient population. The University of Mississippi School of Pharmacy partnered with the Diabetes Care Group™ in Jackson, Mississippi, to establish clinical pharmacy services in an outpatient collaborative interdisciplinary diabetes clinic in order to meet the stated objective of improving key indicators of diabetes care in this community.
1
Department of Pharmacy Practice, The University of Mississippi School of Pharmacy, Jackson, MS, USA Corresponding Author: Courtney S. Davis, Department of Pharmacy Practice, The University of Mississippi School of Pharmacy, 2500 N State Street, Jackson, MS 39216, USA. Email: [email protected]
Davis et al This article describes pharmacy involvement on the diabetes management team at the Diabetes Care Group and clinical findings from the site. While the overall study results have been previously published, these site-specific results may be of particular interest to pharmacists practicing in settings that involve pharmacist collaboration with physicians, nurse practitioners, registered nurses, and other health-care professionals to manage patients with diabetes. This study site was one of few physicianbased clinics included in the large study population. For this reason, it may provide more applicability compared to reviewing data from the large data set consisting of multiple types of practice sites.
Methods This prospective study was approved by the University of Mississippi Institutional Review Board prior to initiation. The clinical pharmacist, along with the assistance of community pharmacy residents, recruited patients at the diabetes clinic from September 2011 until January 2012. Patients included were those with a diagnosis of diabetes, prescribed diabetes medication(s), had a HbA1c greater than 7% within the past 3 months of enrollment, and were able to present to the clinic for visits. Eligible patients were identified through review of existing clinic data and recruited on site. Exclusion criteria included those younger than 18 years of age, institutionalized, unable to give written informed consent, and known to be pregnant. The Diabetes Care Group utilizes a team comprised of physicians, nurse practitioners, and diabetes educators, which consist of both dieticians and registered nurses to care for patients with diabetes. Prior to Project IMPACT: Diabetes, there was no clinical pharmacist involvement in patient care at this site; however, at each visit, patients interact with both an educator (dietician or nurse) for the first half of the visit and a provider (physician or nurse practitioner) for the second half of the 30-minute return visits. Enrolled patients were scheduled for a minimum of three 30-minute visits with the provider-clinical pharmacist team scheduled 3 months apart. During each of these visits, at least half of the allotted time was spent with the clinical pharmacist. In the time spent with the clinical pharmacist, a comprehensive medication review was completed, an individualized self-management plan was developed, and disease education was provided and tailored to each patient’s individual needs. Reviewing medication lists provided the opportunity for counseling on individual medications and potential interactions. The clinical pharmacist or pharmacy resident reviewed medications and counseled patients about the medications and potential interactions. This provided the opportunity for counseling on individual medications and potential interactions. After review of the medication list, blood glucose log, and laboratory values, the clinical pharmacist provided guideline-based therapeutic recommendations to the provider to add, stop, or change doses of any oral or injectable medications and after discussion the pharmacist implemented a therapeutic plan for the patient. The provider joined the clinical pharmacist and patient at the end of the visit to perform the
287 physical examination, fill out the Superbill, and make any necessary referrals. The provider then moved on to the next patient visit, and the clinical pharmacist reviewed and gave the patient written instructions to take home, input requested refills, and delivered any further needed device, medication, or diseaserelated education. Each visit not only addressed diabetes but also hypertension, dyslipidemia, and obesity for comprehensive cardiometabolic management. Being an academic institution, students and residents were incorporated in the project as a part of their experiential rotations. There were 2 community pharmacy residents and several students who rotated through the clinic during this time, with the pharmacist serving as the preceptor of record. The community pharmacy residents screened patients, recruited, obtained informed consent, administered a baseline knowledge survey, and referred patients to the front office staff to arrange scheduling. Community pharmacy residents were also able to provide the same interaction during patient visits as the pharmacist did once they were trained. Students assisted with medication reconciliation, drug information questions, reviewing blood glucose logs, and writing down instructions for the patient to take home. They were also able to practice patient counseling and making therapeutic recommendations during the visits with the pharmacist’s supervision. Outcomes were measured based on the following parameters: HbA1c, systolic and diastolic blood pressure (SBP and DBP), fasting cholesterol panel, body mass index (BMI), dates of diabetic foot examinations, dates of comprehensive eye examinations, influenza immunization status, and smoking status. Nonsmokers were defined as either never smoked or had quit for longer than 12 months prior to enrollment. Results were evaluated using a 1-tailed t test for matched data. The APhA Foundation completed statistical analysis for all study sites. The site-specific results were compared to the reported results from the larger data set. Statistical significance was indicated if P < .05. Additionally, a baseline knowledge assessment, the patient self-management credential, developed by the APhA Foundation, was given at baseline to determine whether the patient was considered to be a beginner, proficient, or advanced in their knowledge of diabetes.11
Results A total of 71 patients were consented, and 64 patients completed the minimum study requirements of at least 3 documented encounters with the clinical pharmacist at least 3 months apart. Those not meeting minimum study requirements were mostly due to lost to follow-up or dismissal from the clinic as a result of continual payment issues. The average number of visits per patient was 4.2, and average reported length of visits was 39.9 minutes. During the course of the project, the pharmacist conducted a total of 156 patient encounters over an average time span of 343 days. There were 48% male patients and 52% female patients enrolled (Table 1). The majority were caucasian and African American (64% and 33%, respectively) with the remaining being Hispanic and Native American
288
Journal of Pharmacy Practice 30(3)
Table 1. Baseline Data. Category Age Ethnicity
Gender Clinical measures
Knowledge level
Smoking status Eye examination Foot examination Influenza vaccine
Age, years Caucasian, % Hispanic, % African American, % Native American, % Female, % Male, % HbA1c, % BMI, kg/m2 SBP, mm Hg DBP, mm Hg LDL-C, mg/dL HDL-C, mg/dL Triglycerides, mg/dL Total cholesterol, mg/dL Beginner, % Proficient, % Advanced, % Smoker, % Nonsmoker, % Up to date, % Needs examination, % Up to date, % Needs examination, % Up to date, % Needs vaccine, %
Table 2. Clinical Outcomes. n 64 41 1 21 1 33 31 64 64 64 64 32 40 41 41 8 34 22 3 61 46 16 55 0 25 28
Mean Value or Percentage 54.9 + 12.6 64.1 1.6 32.8 1.6 51.6 48.4 9.2 + 1.7 36 + 8.2 136.8 + 19.8 79.4 + 10.7 99.2 + 31.7 36.3 + 12.2 233.4 + 167.9 174.9 + 37.9 12.5 53.1 34.4 4.7 95.3 74.2 25.8 100 0 47.2 52.8
Abbreviations: HbA1c, hemoglobin A1c; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; LDL-C, low-density lipoprotein-cholesterol; HDL-C, high-density lipoprotein-cholesterol.
(Table 1). Mean HbA1c at baseline was 9.2% (Table 1). Over the course of the study, mean HbA1c dropped by an average of 1.2% (P < .001), resulting in a final mean HbA1c of 8.0% (Table 2). The distribution of the final HbA1c values is given in Figure 1. On average, patients experienced statistically significant reductions in both mean SBP and mean DBP (8.3 mm Hg, P < .001 and 3.5 mm Hg, P ¼ .031, respectively; Table 2). Of the 26 patients who had either an SBP greater than 140 mm Hg or DBP greater than 90 mm Hg, 19 had a final reading of less than 140/90 mm Hg. There were 57 patients on hypertension therapy at baseline, and by the end of the study, there were 62 patients on at least 1 antihypertensive. Changes in number of hypertension medications and dosage was not recorded. There were statistically significant changes in all fasting lipid parameters. Low-density lipoprotein (LDL) values dropped by an average of 16.6 mg/dL (P ¼ .006), high-density lipoprotein (HDL) increased by 4.3 mg/dL, (P ¼ .001), triglycerides decreased by 57.1 mg/dL (P ¼ .006), and total cholesterol decreased by 13.8 mg/dL (P ¼ .024; Table 2). BMI was unchanged during the study (Table 2). At enrollment, 95.3% of patients were considered nonsmokers (Table 1). While the pharmacist discussed smoking cessation at each visit with all smokers, this percentage did not change at the conclusion of the study. There were 40.3% of patients with recent documented eye examinations at the
Outcome Measure
Final
HbA1c, % BMI, kg/m2 SBP, mm Hg DBP, mm Hg LDL-C, mg/dL HDL-C (mg/dL) Triglycerides (mg/dL) Total Cholesterol (mg/dL)
8.0 35.8 128.5 75.9 82.6 40.6 176.3 161.0
Change 1.2 0.1 8.3 3.5 16.6 4.3 57.1 13.8
+ 1.7 + 1.8 + 18.3 + 10.6 + 35.2 + 8.1 + 139.8 + 43.6
P Value
