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Pharmaceutical Services, Efficiency, Delivery of Health Care, United States, Diabetes Mellitus Type 2,
Background: Evidence suggests that patients with type 2 diabetes (T2DM) suffer from a high rate of “clinical inertia” or “recognition of the problem but failure to act.”
Objective: The aim of this study is to quantify the rate of clinical inertia between two models of care: Pharmacist-Managed Diabetes Clinic (PMDC) vs. Usual Medical Care (UMC).
Methods: Patients in a university based medical clinic with type 2 diabetes (T2DM) were analyzed in this retrospective cohort study. Patients were exposed to either PMDC or UMC. The difference in days to intervention in response to suboptimal laboratory values and time to achieve goal hemoglobin A1c (A1c), systolic blood pressure (SBP) and low-density lipoprotein (LDL) was compared in the two models of care.
Results: A total of 113 patients were included in the analysis of this study, 54 patients were in the PMDC and 59 patients were in the UMC group. Median time (days) to intervention for A1c values >7% was 8 days and 9 days in the PMDC and UMC groups, respectively (p>0.05). In patients with baseline A1c values >8%, median time to achieving A1c<7% was 259 days vs. 403 days in the PMDC and UMC groups, respectively (p<0.05). Median time to goal SBP was 124 days in the PMDC group and 532 days in the UMC group (p<0.05). Median time to goal LDL was 412 days in the PMDC group vs. 506 days in the UMC group (p<0.05).
Conclusions: Rates of clinical inertia, defined as time to intervention of suboptimal clinical values, did not differ significantly between patients enrolled in a PMDC compared to patients with UMC with respect to A1c, SBP and LDL. Participation in PMDC, however, was associated with achieving goal A1c, SBP, and LDL levels sooner compared to UMC.
2. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, Goff DC Jr, Bigger JT, Buse JB, Cushman WC, Genuth S, Ismail-Beigi F, Grimm RH Jr, Probstfield JL, Simons-Morton DG, Friedewald WT. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-2559. doi: 10.1056/NEJMoa0802743
3. Greenfield S, Billimek J, Pellegrini F, Franciosi M, De Berardis G, Nicolucci A, Kaplan SH. Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes: a cohort study. Ann Intern Med. 2009;151(12):854-860. doi: 10.7326/0003-4819-151-12-200912150-00005
4. American Diabetes Association. Standards of Medical Care in Diabetes--2013. Diabetes Care. 2013;36(Suppl 1):S11-S66. doi: 10.2337/dc13-S011
5. Rodbard HW, Blonde L, Braithwaite SS, Brett EM, Cobin RH, Handelsman Y, Hellman R, Jellinger PS, Jovanovic LG, Levy P, Mechanick JI, Zangeneh F; AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(Suppl 1):1-68.
6. Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical inertia. Ann Intern Med. 2001;135(9):825-834.
7. Shah BR, Hux JE, Laupacis A, Zinman B, van Walraven C. Clinical inertia in response to inadequate glycemic control: do specialists differ from primary care physicians? Diabetes Care. 2005;28(3):600-606.
8. Grant RW, Buse JB, Meigs JB; University HealthSystem Consortium (UHC) Diabetes Benchmarking Project Team. Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change. Diabetes Care. Feb 2005;28(2):337-442.
9. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):173-184.
10. Cranor CW, Christensen DB. The Asheville Project: short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (2003). 2003 Mar;43(2):149-159. doi: 10.1331/108658003321480696
11. Johnson CL, Nicholas A, Divine H, Perrier DG, Blumenschein K, Steinke DT. Outcomes from DiabetesCARE: a pharmacist-provided diabetes management service. J Am Pharm Assoc (2003). 2008;48(6):722-730. doi: 10.1331/JAPhA.2008.07133
12. Divine H, Nicholas A, Johnson CL, Perrier DG, Steinke DT, Blumenschein K. PharmacistCARE: description of a pharmacist care service and lessons learned along the way. J Am Pharm Assoc (2003). 2008;48(6):793-802. doi: 10.1331/JAPhA.2008.07132
13. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288(15):1909-1914.
14. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. Mar 2001;24(3):561-587.
15. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2005;28(Suppl 1):S4-S36.
16. DeName B, Divine H, Nicholas A, Steinke DT, Johnson CL. Identification of medication-related problems and health care provider acceptance of pharmacist recommendations in the DiabetesCARE program. J Am Pharm Assoc (2003). 2008;48(6):731-736. doi: 10.1331/JAPhA.2008.07070
17. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.
18. Zellmer WA, Cobaugh DJ, Chen D. Three signals from the Pharmacy Practice Model Summit. Am J Health Syst Pharm. 2011;68(12):1077. doi: 10.2146/ajhp110148