Pharmacists help diabetic patients manage better
City of Asheville says educational tool is a success
Has the position of pharmacist devolved into nothing more than a glorified pill counter and pusher of buttons who makes computers spit out patient instruction forms?
Some pharmacists think so.
But not several professionals in Asheville, NC, who say they’ve found a new lease on life by giving diabetic patients a new approach to their disease self-management. It’s a unique method of diabetes management, experts agree, but it’s one that had a stunning affect shortly after its inception. And it’s gaining national attention as a new pathway in patient education.
The recipe is simple:
- Take a group of Asheville city employees, retirees, and their dependents covered under the municipal self-insurance program.
- Add a city risk management director who is not only concerned with reducing the cost of treating diabetics but with improved quality of life for the 46 diabetic plan members, 43 of them on oral agents, insulin, or a combination of the two.
- Add a handful of independent pharmacists willing to take a risk in terms of time and money to work directly with patients.
- Stir in the incentive for patients: new glucose monitoring equipment and zero co-pay for all diabetes-related drugs and supplies.
The outcome? An impressive reduction in the HbA1c levels of the patients and dramatic improvements in terms of sick time, emergency department visits, and hospitalizations.
The numbers were so impressive to John Miall, risk management director for the City of Asheville, that he agreed to pay the pharmacists for their efforts nine months ahead of schedule. In fact, the pharmacist-based diabetes education program was so successful that the city has begun a similar program for asthma patients and the city’s health care partner, Mission-St. Joseph’s Hospital, decided to offer similar services to its employees beginning this year. (See results in the table, below)
| Asheville Project Results | |
| Baseline HbA1c | 7.6 |
| After 8 months | 7.0 |
| After 14 months | 6.2 |
| Baseline total cholesterol | 210 |
| After 8 months | 208 |
| After 14 months | 198 |
| Baseline HDL | 45 |
| After 8 months | 42 |
| After 14 months | 48 |
| Baseline LDL | 118 |
| After 8 months | 113 |
| After 14 months | 98 |
| Baseline number of sick days for all diabetics per year | 1,708 |
| Number of sick days after 12 months of study | 811 |
| Baseline average number of sick days per diabetic patient | 12.6 |
| Average number of sick days after 12 months of study | 6.2 |
| __________________________________ | |
Three months into the diabetes study, the city’s nurse-educator noticed patients were taking better care of themselves in terms of diet, sleep, and exercise. Some patients had already begun to think of their pharmacist as their "coach."
"I’m convinced that having someone knowledgeable to talk to made a big difference to them," Miall says. Six months into the project, the city had begun to save money, even though one of the diabetic patients had been diagnosed with leukemia and had already incurred expenses of $9,000 unrelated to diabetes. "We were already seeing improvements in emotional, physical, and mental health as well as improvements in cholesterol, triglyceride, and hemoglobin levels," he says.
After one year, the city had saved $38,970 in inpatient hospital claims, while adding $2,988 in outpatient claims, adding $5,320 in pharmacists’ fees, adding $2,465 for glucose monitors and adding $8,000 for patient education at the Mission-St. Joseph’s Diabetes Center. The rather unexpected net savings to the city in the first year: $20,246.
While Miall is happy with the savings, he says the implications of this "drop in the bucket" in view of the city’s $4 million health care benefit program are much larger. "If you’re preventing one diabetic patient from facing an amputation in the future by improving his or her care now, [besides patient morbidity] you’re saving between $30,000 and $50,000."
At a cost of approximately $6,000, the city’s health partner, Mission-St. Joseph’s Hospital Diabetes Center brought in 24 community pharmacists for a 32-hour intensive training program spread over two weekends. Physicians, dietitians, nurses, and other pharmacists provided up-to-date disease management information and educational techniques to the participating pharmacists.
Course participants took before and after tests to determine their absorption of the material. Then each patient’s physician was notified of the patient’s participation in the project, and physician input was invited.
Each patient was matched with a pharmacist who spent approximately one hour in an initial assessment session in which a history was taken, a one-page personality preference questionnaire was completed, and compliance goals were set. Patients also receive training in the use of their monitors and, if necessary, in mixing insulin.
Monthly follow-up visits and monitoring lasting 20 to 30 minutes also improved compliance. Study results showed an average of 5.8 patient visits with a pharmacist in a year.
A key to the success of the Asheville Project is making the pharmacist an important part of the team, says Daniel G. Garrett, MS, RPh, FASHP, president of the North Carolina Center for Pharmaceutical Care, a coalition of state pharmacy organizations in Chapel Hill, NC. He points out that patients see a pharmacist about five times as often as they see any other health care professional, so it makes sense that pharmacists can develop a relationship with a patient that encourages compliance.
Pharmacist-educators overcame initial resistance from physicians when they demonstrated they have information that can help all members of the team. For example:
- Pharmacists can let physicians know if a prescription was filled (15% are not).
- Pharmacists can let physicians know if patients are taking the medication (13% do not, even if they fill prescriptions).
- They can provide feedback about whether a medication is working.
- They can find out from the patient is there are problems and head off potentially serious consequences before the patient’s next doctor appointment, which may be months away.
"What’s really different about The Asheville Project," Garrett says, "is that we started with one employer and one pharmacist, and we made it work." Garrett and his association are expanding the program to include five more communities in North Carolina, and they’ve been deluged with requests for information since a 27-page series of articles on The Asheville Project was published in the October issue of Pharmacy Times.
Plus, two drug store chains have added weight to the program by jumping into The Asheville Project, "a little late because of corporate hierarchy," Miall says.
"Pharmacists are attracted to this program because it of the opportunity to do something more meaningful," says Lucinda Maine, PhD, RPh, senior vice president for professional and public affairs of the American Pharmaceutical Association, who calls The Asheville Project an "elegant, small-scale demonstration that this stuff really works. The Asheville Project got all this attention because of the power of the results and the power of the collaboration," she says.
Most importantly, the patients who participated in The Asheville Project are happy. "That’s the most gratifying thing about it," Miall says, recalling a woman who came to a meeting early in the program. "She came up to me crying and grabbed my hand. She said, I can never tell you how much this means to me.’"
For more information, contact Daniel G. Garrett, MS, RPh, FASHP, President of the North Carolina Center for Pharmaceutical Care. Telephone: (800) 852-7343.
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