Background

Diabetes Facts:

Diabetes is a serious public health problem that continues to rise in the United States. The disease opens the door to several other medical complications, while placing a financial burden on those it affects.1 Diabetes is the 7th leading cause of death in the nation and can lead to heart disease, stroke, kidney disease, non-traumatic lower limb amputations, and blindness.2 Its prevalence in Indiana alone has continued to rise at a rate of 10.7% in 2016.3 The average person without diabetes spends about $2,935 on healthcare per year. This number is increased 4 times for a person with diabetes, who on average spends $11,744 per year for healthcare.1

In 2014, 28.1% of Medicare beneficiaries living in Marion County were being treated for diabetes, compared to 27.4% throughout the state of Indiana, and 26.7% nationwide. From the years 2012-2014, there were 26.1 hospitalizations due to diabetes per 10,000 adult patients in Marion County.  This is significantly higher than the state of Indiana which had about 20.8 hospitalizations due to diabetes per 10,000 adult patients in that same time span.4

Evidence to Support Pharmacist Intervention:

As the pharmacist’s role has continued to grow within multidisciplinary healthcare teams, there have been several studies conducted to evaluate their impact.  With an extensive knowledge of medications, pharmacists are a key component to managing chronic disease states. This can lead to improved outcomes and decreased costs.

One retrospective study compared utilization of written collaborative drug therapy agreements (CDTAs) for the diabetic population in an outpatient clinic in a hospital in El Paso, Texas.  These patients were referred to the pharmacist for either education or clinical management of their diabetes. The interventions made by pharmacists  led to decreased HgbA1c by an average of 0.7% and decreased fasting blood glucose levels by an average of 26.4 mg/dL.  These interventions also lowered the costs for inpatient hospitalization and emergency department services when diabetes was the primary or secondary diagnosis for admission.5

Another study at the Veterans Affairs Maryland Health Care System (VAMHCS) recognized that, although tight glycemic control is recommended by both the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE), many adults living with diabetes in the United States are still unable to meet their goals, which can be attributed to the postponement or all together lack of intensification of insulin therapy. In 2003-2004 at the VAMHCS in Baltimore, 24% of patients with diabetes had either no recent documentation of HgbA1c or it was >9%.  Despite their HgbA1c levels being well above the ADA’s goal of 7%, 91% of these patients’ diabetes were only being managed on oral hypoglycemic medications.  This led to the Insulin Initiation Clinic in 2005, which was created to assist patients who had been unsuccessful in controlling their type 2 diabetes, necessitating insulin therapy.  During the initial visit, education on living with and managing diabetes was provided and then reinforced at subsequent visits when appropriate.  A protocol was established for pharmacists to adjust a patient’s insulin dose based on their self-monitored blood glucose levels. An improvement in patient glycemic control was noted and 28% of patients met their goal HgbA1c of <7.5%.6

Similarly, the Veterans Affairs Center of Central Western Massachusetts (VACWM) implemented the direct involvement of a pharmacist in a multidisciplinary team in order to provide optimum chronic disease state management.  When a clinical pharmacist who was a board-certified diabetes educator joined a multidisciplinary endocrinology team, a referral based, pharmacist run diabetes treatment clinic was developed. To be seen at the clinic, a patient had to meet two of the following criteria: type 2 diabetes for more than 2 years, HgbA1c >7.5%, fasting blood glucose >140mg/dL, sub optimal glucose control despite treatment with stable doses of oral medications for the past 3 months, a need for insulin dose intensification, and intolerance to oral diabetes medications. Although the clinic was only run 2 days a week, the pharmacist had full access to several patient portals such as telehealth and secure messaging portals through which patients could report daily blood glucose measurements.  These portals would also give alerts to the pharmacist when blood glucose readings went beyond their desired range and allowed for a quick response. The purpose of this tight follow-up is to accomplish a steady HgbA1c level for at least 6 months. This clinic’s outcomes thus far demonstrate that pharmacist interventions, through educated understanding of blood glucose readings and medication utilization, can positively impact high risk diabetic patients appropriately using insulin therapy through frequent patient follow-up.7

Pharmacists can also have a positive impact on HgbA1c levels when involved in educating and managing patients beginning therapy using insulin pumps.  A study in Northeast Tennessee followed patients referred to pharmacists who were certified diabetes educators and certified pump trainers to provide continuous subcutaneous insulin infusion (CSII) services. These services included a 60 minute visit for an initial assessment, a 2 hour visit for CSII initiation and training, and at least one 30 minute visit for follow-up. Pharmacists also made follow-up telephone calls 24 hours after CSII initiation and as needed thereafter. Information was also provided by the pharmacists regarding “basics on insulin pump therapy, acute management protocols, carbohydrate counting, insulin infusion site care, and self-monitoring blood glucose plans.  Results noted an average decrease in HgbA1c of 1.17% and a decrease need for visits with the primary care physician in regards to their diabetes.8

Another study looked more specifically at the initiation of U-500 insulin by clinical pharmacists collaborating with primary care physicians.  “Subjects were included for analysis if the pharmacist initiated U-500 insulin therapy, received treatment for at least 6 months, and attended at least one follow-up visit with the pharmacist.”  Results demonstrated improved diabetes control in patients with severe insulin resistance with an average reduction of HgbA1c by 1.1% after just 6 months.9

Benefits to Community Health Network:

The mission of Community Health Network is to provide convenient access to exceptional healthcare services, where and when patients need them.  Diabetes is 1 of 4 health priorities on which Community is trying to focus. Their diabetes program aims to “provide outreach, education, and intervention in the community that ultimately decreases the number of hospital admissions in our service area and Health Districts for long term and short term complications of diabetes in the adult population.”4

Implementation of a pharmacist in this clinic to manage intensive insulin therapy would align with Community Health Network’s PRIIDE values.  It would allow for better outcomes and reduce costs for patients by making their improved health a priority. A monthly, 60 minute appointment with the pharmacist in this clinic would provide the foundation for stronger relationships to be built between patients and their healthcare providers.4

Despite lack of tangible, patient specific data, both the pharmacy and the endocrinology clinic expressed the need for this type of service.  They were innovative and took steps to create something unique in order to benefit the health of their patients.4

References:

  1. Larkin G, Adams D, Garg M, Dwivedi P, Thomaskutty C. Burden of Diabetes in Indiana. Indiana State Department of Health: http://www.in.gov/isdh/files/BR_Diabetes-2011.pdf. 2011. Accessed: February 9, 2017.
  2. America’s Health Rankings. United Health Foundation. http://www.americashealthrankings.org/explore/2016-annual-report/measure/Diabetes/state/IN. 2016. Accessed: February 9, 2017.
  3. (2016). Centers for Disease Control and Prevention; 2016.  http://www.in.gov/isdh/files/2016%20update%20Diabetes.pdf. Accessed: February 9, 2017.
  4. Community Health Network. http://webapp.ecommunity.com/aboutus/. 2016. Accessed: February 9, 2017.
  5. Anays JP, Rivera JO, Lawson K, Garcia J, Luna J, Ortiz M. Evaluation of pharmacist-managed diabetes mellitus under a collaborative drug therapy agreement. Am J Health Syst Pharm. 2008; 65(19):1841-1845.
  6. Rochester CD, Leon N, Dombrowski R, Haines ST. Collaborative drug therapy management for initiating and adjusting insulin therapy in patients with type 2 diabetes mellitus. Am J Health Syst Pharm. 2010; 67(1):42-48.
  7. Collier IA, Baker DM. Implementation of pharmacist-supervised outpatient diabetes treatment clinic.  Am J Health Syst Pharm. 2014; 71(1):27-36.
  8. Ledford JL, Hess R, Johnson FP. Impact of clinical pharmacist collaboration in patients beginning insulin pump therapy: a retrospective and cross-sectional analysis. J Drug Assess. 2013. 2(1):81-86.
  9. Hess R, Brandon S, Johnson F. Effectiveness of pharmacist and physician collaboration in the treatment of type 2 diabetes mellitus with severe insulin resistance using U-500 insulin. South Med J. 2016; 109(11):690-693.