The American Journal of Managed Care April 2010
Pharmacist Collaborative Management of Poorly Controlled Diabetes Mellitus: A Randomized Controlled Trial
Pharmacist management of poorly controlled diabetes mellitus in this randomized trial resulted in more patients decreasing their glycosylated hemoglobin level by at least 1.0%.
Objective: To investigate the effect of pharmacist management of poorly controlled diabetes mellitus in a community-based primary care group.
Study Design: Randomized controlled trial of pharmacist management of diabetes compared with usual medical care.
Methods: Patients 18 years or older with glycosylated hemoglobin (A1C) levels of 9.0% or higher were enrolled. Patients were randomly assigned to an intervention group (n = 52) or a control group (n = 51). Management in the control group included the use of registries and targeted patient outreach. The intervention group participated in the same outreach program plus medication management, patient education, and disease control by a pharmacist.
Results: Nonparametric data showed median A1C decreases of 1.50% for the intervention group and
0.40% for the control group (P = .06). Significantly more patients in the intervention group improved their A1C level by at least 1.0% relative to the control group (67.3% vs 41.2%, P = .02). Most of this benefit was seen for patients of nonwhite race/ethnicity compared with control subjects (56.3% vs 22.7%, P = .03). Male patients showed significantly greater benefit as well, with a median A1C decrease of 1.90% vs 0.15% for controls (P = .03).
Conclusions: Patients with poorly controlled diabetes improved A1C levels significantly when pharmacist management was added to an aggressive organizational diabetes management program. Our results suggest that clinically trained pharmacists can help primary care providers improve diabetes management, especially among male patients and among patients of nonwhite race/ethnicity.
(Am J Manag Care. 2010;16(4):250-255)
Pharmacist management resulted in improved glycosylated hemoglobin level among patients who had failed systematic outreach and regular use of an all-payer registry.
- Improving management of patients with poorly controlled diabetes mellitus using pharmacist intervention is time intensive and resource intensive.
- Our data suggest that male patients and patients of nonwhite race/ethnicity are the greatest responders to pharmacist management. This finding needs to be confirmed by further research.
More recent studies10-15 have used a model whereby pharmacists work in collaboration with primary care physicians. Given the ever-increasing options for treating diabetes, pharmacists should be well positioned to evaluate the merits of each therapeutic option and to provide patient education. Studies showing the benefit of pharmacists serving as case managers have been small and often nonrandomized. The few randomized controlled trials have been performed in large urban academic or diabetes referral centers. As an example, Choe et al10 showed improved A1C levels and process outcome measures in a single-university ambulatory internal medicine clinic for patients with diabetes. We add to the literature a randomized study that describes pharmacist management of patients with diabetes who failed to respond to systematic patient outreach using a regularly updated all-payer registry in the primary care setting.
Study Design and Setting
This was a 12-month prospective randomized controlled study. The primary outcome measure was the change in A1C level at the end of 1 year. Secondary outcomes were the percentage of patients with a 1.0% decrease in A1C level. This outcome was assessed in the population as a whole and asa function of minority racial/ethnic group status. The research committee and the institutional review board of Saint Mary’s Health Care, Grand Rapids, Michigan, approved this study.
The study site was the Advantage Health Physician Network (AHPN), which uses an electronic registry that identifies all adults with diabetes mellitus. Thirteen AHPN offices participated, including 3 urban, 9 suburban, and 1 rural site. Clinical practice guidelines, diabetes indicators, and performance thresholds are tracked routinely and are shared regularly with providers and staff. Each office has specific personnel budgeted to support diabetes quality-related initiatives. The latest quality indicators for individual patients are available at each office visit. In addition, there is systematic telephone and mail outreach to patients who are due for diabetes-related care.
Patients and Randomization
Patients with diabetes 18 years or older having A1C levels of 9.0% or higher or no office visits within 12 months were contacted by a study nurse. The nurse saw the patient at his or her home and determined study eligibility. Patients were excluded from the study if an endocrinologist was managing their diabetes or if they were not expected to live for the duration of the study. Eligible patients were tested using a Bayer DCA 2000 (Bayer Corporation, West Point, CT) point-of-care A1C instrument and were offered enrollment if their A1C level was 9.0% or higher. The study nurse obtained institutional review board–approved informed consent at this point from patients who agreed to participate and to attend all study visits.
Using sequential envelopes containing computer-generated group assignment, the research nurse randomized patients to the intervention group or to the control group. Envelopes were opened after patients were deemed eligible for the study. Both study groups received the aggressive outreach already described.
One pharmacist (JPJ) provided all diabetes-related care for the intervention group. The pharmacist is a board-certified pharmacotherapy specialist, who participated in an American Society of Health-System Pharmacists diabetes management traineeship, an American Diabetes Association postgraduate course in diabetes management, and an American Association of Diabetes Educators training program.
Patients in the intervention group also met with the pharmacist at their respective primary care site for an assessment of adherence, barriers to optimizing blood glucose levels, and current medication regimen.All intervention patients received individualized education regarding diabetes self-management, including diet, exercise, blood glucose level testing, medications, and insulin. The pharmacist followed guidelines of the Management of Hyperglycemia in Type 2 Diabetes.16 This included early switching to insulin therapy after failure of 2 oral medications. The patient’s primary care physician approved any changes in medication or therapy, although the pharmacist was given autonomy to adjust insulin doses as needed. The number of subsequent visits with the pharmacist was based on the need to further educate the patient about diabetes control or to monitor therapeutic changes. Follow-up visits were supplemented with telephone calls as needed for medication management. Patients were followed up for 12 months after study enrollment. We were unable to assess adverse events in the control group. There was 1 severe hypo-glycemic event in the intervention group. Severe adverse events were defined as those requiring assistance from another person.
A power analysis indicated that at least 39 patients were needed in each study group to show a clinically significant decrease in A1C level of at least 1.0% (ß = 0.20 and α = 0.05). X2 Test and Fisher exact test were used where appropriate for nominal data. Mann-Whitney test was used for nonparametric quantitative data and unpaired t test for parametric quantitative data. Significance was set at P <.05. The statistical software used was NCSS 2004 (Kaysville, UT).
Recruitment began in May 2006, and final 1-year follow-up for the last patient was in December 2007. Among all AHPN patients with diabetes, 902 had an A1C level of 9.0% or higher or had not been seen by their primary care provider within the previous 12 months. Of these, 491 patients were successfully contacted and were invited to participate in the study. Two hundred thirty-five patients were excluded; 191 (39.0%) declined participation, and 44 (9.0%) were managed by a specialist. An additional 152 (31.0%) had an A1C level of less than 9.0% at the time they saw the study nurse. The remaining 104 patients were randomized, 52 to the control group and 52 to the intervention group.
One patient in the control group was excluded as an outlier based on A1C level exceeding 3 SDs from the mean A1C change. This patient was hospitalized for 3 weeks because of diabetes complications and subsequently attained an 8.6% decrease in A1C level. Therefore, the final analysis was based on 103 patients, 52 in the intervention group and 51 in the control group. Baseline demographic data are given in Table 1. The only significant difference between study groups at baseline was lower A1C level in the intervention group.
The A1C changes were not normally distributed, so median values were used as the measure of central tendency. The overall median A1C reduction in the intervention group was 1.1% greater than that of the control group. This difference approached but did not achieve statistical significance. Post hoc subgroup analysis showed that male patients in the intervention group achieved a statistically significant improvement in their A1C level (median, −1.90%; interquartile range, −0.05% to −2.95%) versus the control group (median, −0.15%; interquartile range, 0.98% to −1.38%]). Table 2 gives details of these results.
From the perspective of individual patient improvement, statistically more patients in the intervention group achieved at least a 1.0% improvement in A1C level overall. Twice as many patients of nonwhite race/ethnicity and male patients (post hoc) in the intervention group exceeded the 1.0% improvement mark. No treatment effects using this measure were seen for patients of white race/ethnicity or for female patients (Table 3).
This intervention required considerable effort. The pharmacist averaged 6 office visits and 3 telephone calls per patient over the course of a year. Office visits lasted between 30 and 60 minutes. Telephone calls were 10 to 20 minutes in length. The pharmacist changed the drug regimen to basal-bolus insulin in 15 patients (28.8%) and discontinued oral medications completely in 15 patients (28.8%). In the control group, only 1 patient’s regimen was changed to basal-bolus, oral medications were discontinued in 1 patient, and insulin was added for 1 patient. As evidence of aggressive treatment in the control group, there were 6000 patients in the all-payer registry in 2007, and 55.1% had both an A1C level of less than 7.0% and low-density lipoprotein cholesterol (LDL-C) level of less than 100 mg/dL (to convert cholesterol level to millimoles per liter, multiply by 0.0259). This is substantially better than 2007 data in Medicaid beneficiaries, among whom the 90th percentile is 30.2% A1C control and 42.3% LDL-C control.17