Pharmacist-managed clinics succeed
Pharmacist-managed diabetes care clinics achieve high screening rates and attain treatment goals more often than national averages, according to two separate studies published in the American Journal of Health-System Pharmacy. Researchers also found that most patients and providers are satisfied with the services provided by a pharmacist-managed lipid clinic. The clinics help improve patients' LDL cholesterol, total cholesterol, and triglyceride levels.
An estimated 20.8 million Americans-7% of the U.S. population-have diabetes mellitus, and the number of Americans living with diabetes is projected to more than double by 2060 or even sooner.
Researchers from the University of California at San Diego and elsewhere said patients can benefit from an individualized approach to comprehensive diabetes care. Comprehensive care involves a multidisciplinary approach with evaluation and education from specialty practitioners, such as endocrinologists, pharmacists, exercise physiologists, diabetes educators, nurses, dietitians, podiatrists, and ophthalmologists. The researchers said a cornerstone of diabetes treatment is drug therapy, often with complex regimens, including multiple oral and injectable agents. A collaborative agreement between physicians and pharmacists is an innovative strategy to treat patients with diabetes that takes advantage of pharmacists' expertise in disease management and drug monitoring. Improved patient outcomes and reduced costs to health care systems are potential benefits of implementing an innovative ambulatory clinic model for diabetes treatment.
The research was conducted at the Naval Medical Center San Diego, a 500-bed comprehensive teaching hospital that treats more than 5,000 patients with diabetes. In mid-1999, ambulatory care pharmacist specialists were specifically hired to expand the current pharmacist-managed ambulatory care services in anticoagulation and lipid clinics and to create new clinics, including two pharmacist-managed diabetes care clinics.
In early 2000, the ambulatory care pharmacist team at the medical center developed two diabetes care clinics for patients in the endocrinology and primary care clinics. Working collaboratively with a board-certified endocrinologist and primary care physicians, clinical practice guidelines and treatment algorithms were created based on national standards of care for diabetes and related comorbidities, including hypertension and hyperlipidemia. The primary care diabetes care clinic was managed by two pharmacists, while the endocrinology diabetes care clinic was managed by one pharmacist who also was a certified diabetes educator.
Effectiveness analyzed at end of year one
One year after the clinics opened, a continuous-improvement report analyzed effectiveness. Data from patients with Type 2 diabetes who were enrolled in the pharmacist-managed diabetes care clinics and had two or more clinic encounters with a clinical pharmacist were analyzed. Primary outcome measures were changes from baseline (clinic enrollment) in diabetes-related markers: glycosylated hemoglobin (HbA1c), fasting plasma glucose, body mass index, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and blood pressure.
Even though other ambulatory care programs were operating at the medical center, collaborative work in a disease requiring such comprehensive management as diabetes was unfamiliar there, the researchers said. Because initial pharmacist-managed diabetes care clinic development met with some resistance from physicians, particularly the primary care clinic, a physician-mandated level of care specifying the extent of care a pharmacist could provide was conceived and implemented. Referring physicians could select from among three levels of diabetes care. Each level indicated the care each physician was comfortable with the pharmacist providing and did not reflect the severity of patients' diabetes and comorbid conditions.
Depending on the scope of the referral, clinical pharmacists provided patients with one of these care levels: diabetes self-care education and counseling (Level 1); Level 1 care plus diabetes treatment and monitoring, including evaluation, laboratory monitoring, and modification of pharmacotherapy (Level 2); and Level 2 care plus education, treatment, and monitoring of co-morbid conditions including hypertension and hyperlipidemia (Level 3).
The pharmacists performed limited physical assessments for Level 2 and 3 patients, including blood pressure measurements and foot examinations. The primary care clinic enrolled patients in all three levels, while the endocrinology clinic enrolled only Level 3 patients. In the primary care clinic a physician could choose to move a patient from one level to another at any time. As their comfort level increased with the pharmacist-provided care, the researchers said, physicians advanced the majority of their patients to Level 3 care.
Individualized programs
Patients who were not meeting their metabolic goals or who needed in-depth disease education and counseling were referred to the clinics from the internal medicine and primary care clinics. After a 90-minute initial visit, patients met with a clinic pharmacist every 4-12 weeks for 45-60 minutes of individualized diabetes education, monitoring, and pharmacotherapy assessment and treatment. The frequency of visits and telephone follow-up was determined by each patient's specific needs. Physicians were located in the same clinic space, so patients were evaluated if the pharmacist identified acute symptoms requiring physician evaluation or diagnosis. Individualized treatment plans were created with patient input to emphasize the patient's role in the process and to empower individuals to take control of their diabetes.
Comprehensive patient education focused on diabetes and long-term complications, identification and self-treatment of hypoglycemia, self-monitoring of blood glucose and pattern management, the importance of preventive care, proper foot and skin care, and nutrition and physical activity guidelines. Pharmacists referred clinic patients to other health care providers when indicated. And once patients met all of their metabolic targets, they were referred back to their primary care physicians for ongoing management.
Pharmacists improved clinical outcomes
One-year outcome data from the clinics demonstrated that pharmacist involvement in caring for patients with Type 2 diabetes mellitus significantly improved clinical outcomes, the researchers said. For that time period, the overall mean reduction in HbA1c was 1.3%. The outcomes remained consistent or improved three years after the clinics opened. Estimated cost avoidance to the medical center was $17,157 per year. When extrapolated to the entire medical center diabetes population, the cost avoidance analysis indicated a potential annual saving of $616,000 to $735,000.
Other diabetes-related markers, including blood pressure and lipid values, also improved in clinic patients. Although improved glycemic control due to increased oral diabetes medication or insulin use may result in weight gain, patients managed in the clinics maintained their body mass index without significant weight gain at the end of year one.
Analysis of a pharmacist-managed lipid clinic was conducted at the Louis Stokes Cleveland Veteran Affairs Medical Center. Most patients and providers were satisfied with the services provided by the pharmacist-managed lipid clinic and the clinic helped improve patients' LDL cholesterol, total cholesterol, and triglyceride levels.
Gap between recommendations and practice
The Lipid Treatment Assessment Project, a large-scale trial to evaluate the achievement of LDL cholesterol goals, found that only 38% of patients achieved their individual National Cholesterol Education Program-specified LDL cholesterol goals. And only 18% of patients at highest risk (those with cardiovascular disease) achieved their goals.
A pharmacist-managed lipid clinic is one strategy to increase patients' attainment of LDL cholesterol goals. Several studies have found improved lipid management, including attaining LDL cholesterol goals, with pharmacist-managed clinics compared with control groups managed by primary care physicians. The success of the pharmacist-managed clinics was attributed to increasing patient education and providing more intensive lipid monitoring. Little research attention has been focused on patient and provider satisfaction with the pharmacist-managed lipid clinics and how satisfaction relates to objective measures of clinical care.
The Stokes Cleveland VA Center established a pharmacist-managed lipid clinic in October 2003. The clinic is primarily telephone-based, with face-to-face sessions occurring only when requested by patients. Patients with complicated dyslipidemia are referred to the clinic by their health care provider. Three types of consultations may be requested—nonformulary drug requests, drug therapy recommendations, and lipid therapy management. The clinic is staffed by one clinical pharmacy specialist who conducts telephone interviews with the patients and is responsible for the prescribing and monitoring of lipid-lowering drugs. The pharmacist also provides information on diet and exercise modification to all clinic patients.
The primary objective of the study was to assess patient and provider satisfaction with the newly-established pharmacist-managed lipid clinic. Secondary objectives were to determine the percent change in lipid levels and the percentage of patients achieving their LDL cholesterol goals.
Ninety percent of patients satisfied
Some 96 patients (91.4%) were strongly or somewhat satisfied with the care received from the clinic. And 88 patients (83.8%) reported that they found the materials provided by the pharmacist about cholesterol, diet, and exercise helpful, while 93 patients (88.6%) said the pharmacist adequately addressed their questions and concerns. Although 91 patients (86.7%) felt they had a better understanding of their lipid-lowering medications after completing the consultation, only 23 providers (46.9%) felt that patients had a better understanding of these medications. One-fifth of patients said they would prefer face-to-face appointments.
Overall, providers reported a high level of satisfaction, as 87.8% of providers responded that they were strongly or somewhat satisfied with the care provided by the pharmacist. And 98% of providers found the progress notes written by the pharmacist to be helpful, and 81.6% of providers reported the monitoring of cholesterol-lowering agents to be appropriate. However, 18 physicians (36.7%) did not believe the lipid clinic helped reduce the amount of time the provider spends with patients with hyperlipidemia.
A total of 87 patients (82.9%) felt that their cholesterol levels had improved. Based on the observation that 91.8% of providers stated that they would refer additional patients to the clinic, continued growth of the pharmacist-managed clinic seems promising.
To further assess clinic effectiveness, objective data were collected from patient charts. Significant improvements in total cholesterol, LDL cholesterol levels, and triglyceride levels were observed from baseline to discharge or to the most recent lipid panel, the researchers reported.
On average, the clinical pharmacist contacted patients and evaluated lipid levels and lipid-lowering therapy every two months. This resulted in achievement of goal LDL cholesterol by 72 patients (68.6%) after a mean of 3.2 months in the pharmacist-managed lipid clinic. The researchers said that although there appears to be a parallel between satisfaction with the care provided and clinic effectiveness, a causal relationship cannot be established with the study methodology. "If patients are more closely monitored and more satisfied with the lipid management," the researchers concluded, "they may be more likely to have a better understanding of their lipid therapy and improved medication adherence."
Pharmacist-managed diabetes care clinics achieve high screening rates and attain treatment goals more often than national averages, according to two separate studies published in the American Journal of Health-System Pharmacy.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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