Evaluating clinical pharmacist impact on diabetes control: outcomes on hemoglobin A1c Mark Amoo PharmD Candidate, Dalton Walsh PharmD Candidate, Kalyani Sonawane BS, Emily M. Armstrong, PharmD, BCACP

BackgroundSeveral studies have shown that pharmacist collaboration in the management of chronic disease states will improve outcomes4,5

In particular, studies have demonstrated significant improvements in hemoglobin A1c (HbA1c), blood pressure, and lipid levels of diabetic patients who are routinely seen by a clinical pharmacist1,2,3

The objective of this study is to evaluate the impact of a pharmacist’s management in a collaborative care setting on diabetes mellitus in an outpatient internal medicine clinic

MethodsApproved by the Institutional Review Boards for University of South Alabama and Auburn UniversityRetrospective chart reviewPatient population from internal medicine outpatient clinicDe-identified data obtained by chart review and electronic medical recordInclusion Criteria:

ICD-9 code for Type 2 DiabetesValid patient-provider relationship with the clinical pharmacist Seen between January 1, 2010 and December 31, 2012

Exclusion Criteria:PregnantSignificant renal or hepatic diseaseAge less than 19

ConclusionsHbA1c was significantly reduced compared to baseline at all follow-up periodsHbA1c began trending upward at months 9 and 12, however this may be due to the low number of HbA1c levels at the follow-up periodsA significantly higher percentage of patients reached HbA1c goals compared to baselineThe limitation of the small sample size at 9 and 12 months may have contributed to non-significant values in the secondary outcomesThis study illustrates that clinical pharmacists can have a positive impact on diabetes management when working in a collaborative environment

Results & Analysis929 charts identified76 charts with results at this timeAverage number of diabetic medications increased from 1.7 to 1.8 medications per personThe total number of patients converted to insulin was 9 (11.8%)

Strengths Limitations

•Inexpensive•Data readily accessible•Uses existing data•Patient population

•Retrospective•Relies on accuracy of written record•One pharmacist at clinic

References1. Cranor CW, Christensen DB. The Asheville Project: Factors Associated With Outcomes of Community Pharmacy Diabetes Care Program. Journal of the American Pharmaceutical Association [Internet]. 2003 March [cited 2012 November 6]; 43 (2):160-172. Available from: http://www.ncpharmacists.org/associations/4188/files/NCCPCthree.pdf2. Cranor CW, Christensen DB. The Asheville Project: Short-Term Outcomes of Community Pharmacy Diabetes Care Program. Journal of American Pharmaceutical Association [Internet]. 2003 March [cited 2012 November 6]; 43 (2):149-159. Available from: http://www.ncpharmacists.org/associations/4188/files/NCCPCtwo.pdf3. Cranor CW, Bunting BA, Christensen DB. 3. The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program. Journal of American Pharmaceutical Association [Internet]. 2003 March [cited 2012 November 6]; 43 (2): 173-184. Available from: http://www.ncpharmacists.org/associations/4188/files/NCCPCfour.pdf4. Anaya JP, Rivera JO, et al. Evaluation of pharmacist-managed diabetes mellitus under a collaborative drug therapy agreement. American Journal Health-Systems Pharmacy [Internet]. 2008 October [cited 2012 November 6]; 65: 1841-1845. Available from: http://www.ncbi.nlm.nih.gov.libproxy2.usouthal.edu/pubmed/187964265. Wubben DP, Vivian EM. Effects of Pharmacist Outpatient Interventions on Adults with Diabetes Mellitus: A Systematic Review. Pharmacotherapy [Internet]. 2008 November [cited 2012 November 6]; 28(4): 421-436. Available from: http://pharmacotherapyjournal.org.libproxy2.usouthal.edu/doi/pdf/10.1592/phco.28.4.421

Disclosure

Authors of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation.

ObjectivesPrimary Objective•HbA1c levels for patients managed by collaborative patient care

Secondary Objectives•Total number of diabetic medications required•Classes of diabetic medications included•Number of patients initiated on insulin therapy

Baseline CharacteristicsVariable Mean SD Min Max PercentAge 59.77 9.88 36 77Female 70.27%Non-White 45.21%

Total Comorbid Conditions 4.97 2.02 1 11Total Number Medications 8.4 3.9 2 18HbA1C (%) 8.8 2 5.8 13.2Scr (mg/dL) 0.93 0.53 0.47 4.8Na (mmol/L) 139.2 2.81 133 144K (mmol/L) 4.3 0.4 3.4 5.3AST (IU/L) 26.4 18.22 9 116ALT (IU/L) 28.2 20.54 6 116

Urine microalb/Cr ratio (mg/g creat) 57.91 106.37 1.3 653.3

ResultsVariable Baseline 3 months 6 months 9 months 12 months

Patients reaching HbA1c goal (%) 25 64.5* 77.6* 79.0* 77.6*

SCr (mg/dL) 0.93 0.90 0.93 0.83 0.84Urine microalb/Cr 45.5 77.5 40.8 42.9 43.9AST (IU/L) 26.4 24.4 24.9 21.9 22.2ALT (IU/L) 28.2 26.4 27.9 24.1 25.6

*Indicates p < 0.05 compared to baseline

Drug classes not used: α-glucosidase inhbitor , glinides, NPH and regular insulin.

Baseline 3 months 6 months 9 months 12 months6.5

7

7.5

8

8.5

9

Mean HbA1c

**

*

*Indicates p < 0.05 compared to baseline

*

Diabetic Medication Classes Used

Metformin

SU

TZD

GLP agonist

DPP IV inhibitor

Lantus/Levemir

Rapid-acting insulin

Premixed insulin