Barriers interfering with establishment of Collaborative Drug Therapy Management (CDTM) agreements between clinical pharmacists and physicians

PurposeThe current level of awareness among health care providers towards working under collaborative agreements, and the barriers that interfere with establishing CDTM agreements between clinical pharmacists and physicians were studied.MethodsA structured survey was developed after reviewing the literature on CDTM. The questions were validated to assess the level of awareness regarding the role of clinical pharmacists in providing drug therapy management, and to determine the main barriers for not having collaborative agreements with different specialties. In addition to demographic data, physicians’ education background, reasons for not having clinical pharmacy services in their clinics, and their perceptions for signing a collaborative agreement were also collected. The sample for the study was obtained from different health specialties in Saudi Arabia. The validated survey was sent and received within approximately two months, Oct-Nov 2017.ResultsWe have received 55 responses from different sectors, a 79% response rate. Most physicians had worked before with a clinical pharmacist (76%) and of which 60% valued the services provided by the clinical pharmacist as extremely important and very important (29.1%; 30.9%) respectively. When physicians asked if they have heard about the Collaborative Drug Therapy Management agreement or the term CDTM, 67% of respondents haven’t heard that before. Most of the responses, regarding the physicians’ awareness of the actual CDTM agreement services, were correct. Only 18% selected incorrect CDTM services. The results showed higher percentages of physicians agreeing with the benefits of CDTM agreement as it can improve overall patient care, reduces risk of drug related adverse events or interactions and allows clinical pharmacists to be part of patient care; 85.5, 83.6 and 83.6 respectively. Physicians who rated the possibility to be involved or to encourage other health care professionals in signing collaborative agreements as high were 76.3 and 74.5 respectively. Based on their specialty, emergency medicine’s physicians were most likely to have a CDTM agreement and to encourage others too. On a scale from zero to hundred, the average of the responses rating lack of knowledge about such an agreement as potential barrier on preventing CDTM agreements was 69 ± 0.30. While the gender barrier had the lowest rating with a mean of 15.ConclusionThere is a huge lack of knowledge and understanding about the role of clinical pharmacists and in CDTM concept. This lack of knowledge affected on having collaborations between clinical pharmacists and physicians in different settings. Educating health care providers and stakeholders about the role of clinical pharmacists in providing drug therapy management and encouraging the concept of CDTM among healthcare providers are the main solutions to enhance clinical pharmacist’s role in patient care.     

Evaluation of Patient Factors Associated With Achieving Goal Hemoglobin A1c in Collaborative Drug Therapy Management Ambulatory Care Clinics by Clinical Pharmacists: A Retrospective Chart Review

Background: Literature has shown the positive impact pharmacists have on diabetic outcome measures through collaborative drug therapy management (CDTM). There is minimal literature evaluating characteristics and clinical factors of patients who benefit from CDTM diabetes clinics by pharmacists. Objective: Identify patient characteristics and clinical factors that may be associated with patients who reach goal hemoglobin A1c (HbA1c) of <7% at discharge by pharmacists practicing under CDTM agreements. Methods: This retrospective chart review included patients referred to pharmacist CDTM clinics for type 2 diabetes with an HbA1c goal of <7%. Data were extracted from the electronic medical record at enrollment and discharge. Results: Of the 228 patients included, 84 achieved a goal HbA1c of <7%. Factors predictive of patient success were Asian ethnicity (odds ratio [OR] = 19.32), baseline HbA1c of 7% to 7.9% (OR = 2.34), enrolled in clinic for 5 to 6 months (OR = 2.06), in-person visit every 4 to <8 weeks (OR = 3.06), not on insulin initially or at discharge (OR = 1.79, OR = 2.02), or discharged on a glucagon-like peptide-1 receptor agonist (OR = 1.83). Factors predictive of not reaching goal were Black or African American ethnicity (OR = 0.42), <5 encounters of any type (OR = 0.44), an encounter of any type every 8 weeks or more (OR = 0.08), or discharged on a sodium-glucose cotransporter-2 inhibitor (OR = 0.27). Conclusion: Several clinical and demographic factors were identified that influenced a patient’s ability to reach a goal HbA1c of <7%. The results of this study may be applied to further advance pharmacist-run clinics in optimizing diabetes care for patients.     

Pharmacists improve diabetes outcomes: a randomized controlled trial

BackgroundThere is a growing shortage of primary care physicians. Pharmacists can fill the gap, and interdisciplinary teams are being evaluated as part of health care reform.ObjectiveThis study aimed to determine whether adding a pharmacist to an interprofessional health team will improve diabetes outcomes.MethodsIn this 2-phase pilot study, Medicaid-eligible patients with diabetes were randomized to receive standard of care (control arm) or standard of care plus the care of a pharmacist (intervention arm) for 12 months (phase 1). The primary outcome was change in glycated hemoglobin (A1C) from baseline. Secondary outcomes included identifying and correcting medication therapy problems (MTPs) for comorbid conditions, adherence to preventive care visits, health care utilization, self-rated health, and satisfaction surveys. After phase 1, patients in the control arm who did not achieve an A1C of < 8% were eligible to enroll into phase 2 where they received treatment with a pharmacist for 6 months.ResultsOf the 239 patients enrolled, 122 completed phase 1. At 12 months, intervention patients’ mean A1C was 1.85 percentage point (pp) below baseline versus 0.94 pp for control (between-group difference 0.91 pp; P = 0.0218). Most control patients (79%) who completed phase 1 and enrolled into phase 2 improved their A1C by more than 1 pp (P < 0.01). The pharmacists completed 806 patient visits and identified 2638 MTPs. Intervention patients were more adherent to preventive care visits with nutrition (P = 0.043), ophthalmology (P = 0.002), and dentistry (P = 0.007). For intervention patients, 78% rated their experience with the pharmacist as excellent whereas, for control patients, 37% rated their experience with their provider as excellent.ConclusionPharmacist comanagement of patients with diabetes can significantly improve glucose control and patient satisfaction. Creative payment models were used to include pharmacists in the interprofessional patient care team.     

Outcomes of pharmacist-managed diabetes care services in a community health center.

PURPOSE: The outcomes of pharmacist-managed diabetes care services in a community health center were studied. METHODS: Eligible patients were over age 18 years and had a diagnosis of type 2 diabetes mellitus. Patients were randomly assigned by the clinical pharmacist and nurse to the intervention group (n = 76) or control group (n = 73). Patients in the intervention group were enrolled in a pharmacist-managed diabetes care program. Patients in the control group received the standard diabetes care. The primary endpoint was reduction in glycosylated hemoglobin (HbA(1c)); secondary outcome measures included weight loss, an improved body mass index, decreased blood pressure, and an improved lipid panel. Quality-of-life measures (health level, satisfaction, impact, worry about disease, and worry about social and vocational issues) were also assessed. RESULTS: Demographic differences between groups were not remarkable. Mean HbA(1c) levels fell significantly (p < 0.05) from baseline to nine months in both groups. A difference of 1.0 was reported between the groups' HbA(1c) levels (95% confidence interval, 0.08-1.78; p < 0.05). Satisfaction level improved from 63.7 to 77.4 in the intervention group, which was significant when compared with the control group, whose satisfaction score improved from 57.0 to 63.4 (p < 0.05). CONCLUSION: Patients with type 2 diabetes mellitus who received pharmacist-managed diabetes care demonstrated improved HbA(1c), systolic blood pressure, and low-density-lipoprotein cholesterol levels and quality-of-life measures and met treatment goals more often than patients receiving standard care.     

Interdisciplinary patient care in the intensive care unit: focus on the pharmacist

The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings.     

A review of pharmacist contributions to diabetes care in the United States

This paper summarizes the outcomes associated with pharmacist involvement in diabetes care in all pharmacy practice settings. Published literature was identified through a search of MEDLINE (1960 to September, week 1, 2008) and International Pharmaceutical Abstracts using the search terms "pharmacist," "pharmaceutical care," and "diabetes mellitus." Only articles reporting clinical or behavior change outcomes were selected for review; papers written outside the United States and citations only in abstract form were not reviewed. The specific data extracted included the following: practice setting, model of care, roles of the pharmacist, study design, number of patients studied, duration of the evaluation, and documented outcomes such as changes in hemoglobin A(1c) values, adherence to standards of care (lipids, blood pressure, eye exams, foot exams, aspirin use), and changes in quality of life. The greatest improvements in hemoglobin A(1c) values tend to be observed when pharmacists work in collaborative practice models. Growing evidence demonstrates that pharmacists, working as educators, consultants, or clinicians in partnership with other health care professionals, are able to contribute to improved patient outcomes.     

Greater effect of enhanced pharmacist care on cholesterol management in patients with diabetes mellitus: a planned subgroup analysis of the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP)

STUDY OBJECTIVE: To determine the effect of enhanced pharmacist care on cholesterol management in patients with and without diabetes mellitus. METHODS: We conducted a planned subgroup analysis of the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP), a 54-center randomized trial of pharmacist intervention compared with usual care in patients at high risk for cardiovascular events. The patients involved had atherosclerotic disease or diabetes. We compared the effect of pharmacist intervention in patients with and without diabetes. The primary end point was a composite of performing a fasting cholesterol profile, or adding or increasing the dosage of a cholesterol-lowering drug. Secondary end points were individual components of the primary end point and change in 10-year risk for cardiovascular events, using the Framingham risk equation. RESULTS: Of the 675 patients enrolled in the SCRIP study, 294 (44%) had diabetes. Enhanced pharmacist care had a more beneficial effect on cholesterol management in those with diabetes (odds ratio [OR] 4.8) than without diabetes (OR 2.1), p=0.01. Secondary end points showed similar trends, and reduction in Framingham risk was greater in patients with diabetes than without. CONCLUSION: Pharmacist intervention for dyslipidemia appears to have a greater impact in patients with diabetes. Results of this substudy suggest that pharmacists should target this patient group for interventions in cholesterol risk management.     

代谢性疾病管理中心建设联合药学门诊的成效分析

目的探讨临床药师通过建设联合药学门诊,加入国家标准化代谢性疾病管理中心(MMC)的诊疗团队开展药学服务的成效。方法共纳入2型糖尿病患者160例,随机分为对照组和干预组,研究周期3个月。两组患者均接受MMC标准化诊疗,临床药师为干预组患者进行药学服务。观察指标包括:用药依从性、空腹血糖(FPG)、糖化血红蛋白(HbA1c)、血压、血脂等综合管理指标。结果两组患者基线特征相似,差异无统计学意义(均P>0.05)。完成3个月的随访后,干预组用药依从性、HbA1c、FPG、低密度脂蛋白胆固醇(LDL-C)和舒张压较对照组明显改善,差异有统计学意义(均P<0.05),两组间不良事件发生情况差异无统计学意义(P>0.05)。结论临床药师通过建设联合药学门诊,完善MMC一体化诊疗体系,有利于改善糖尿病综合管理效果,为药学门诊工作的发展提供新的思路。     

Treat to Goal: Impact of Clinical Pharmacist Referral Service Primarily in Diabetes Management

Purpose:

To describe the impact of pharmacist services in a collaborative practice providing care to primarily Medicaid and indigent patients. The practice includes primary care physicians, nurses, a care navigator, and pharmacists. Pharmacy services are provided by pharmacists, including PGY-1 pharmacy residents and pharmacy students.

Methods:

A retrospective chart review was conducted to perform a pre-post analysis on all patients referred to pharmacists within an adult medicine clinic. Patients were included if they were more than 18 years old; were referred for type 1 or 2 diabetes mellitus, hypertension, hyperlipidemia, or medication reconciliation; and were seen from August 2010 to March 2011. All charts were reviewed to assess pharmacist impact on adherence to standards of care including hemoglobin A1c; lipids; blood pressure; vaccination status; usage of aspirin, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins; and other criteria. Subgroup analysis was performed on diabetic patients who were not at goal at the time of referral to the pharmacy clinic.

Results:

Ninety-three charts were reviewed. In the overall group, rates of influenza and pneumococcal vaccination improved significantly, as did annual foot and eye exams in diabetics. Pharmacists significantly decreased A1c from 9.12% at baseline to 8.13% (P < .001), systolic blood pressure (SBP) from 142.6 to 133.5 mm Hg (P < .001), and low-density lipoprotein (LDL) from 143.6 to 103.2 mg/dL (P < .001) in diabetic patients who were not at goal at baseline.

Conclusions:

Pharmacists were effective in improving surrogate outcomes for patients with diabetes and in assisting physicians to address all standards of care.     

The pharmacist as physician extender in family medicine office practice.

OBJECTIVE: To describe the role of the pharmacist as a salaried physician extender in a private practice diabetes management clinic. SETTING: Columbus, Ohio. PRACTICE DESCRIPTION: Private suburban family medicine office practice. PRACTICE INNOVATION: Clinical pharmacy physician-extender practice in a private medical office and direct compensation to pharmacist. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Financial reimbursement for providing pharmaceutical care; improvement in disease outcomes; pharmacist and student pharmacist satisfaction. RESULTS: Family medicine physicians hired a pharmacist to extend their diabetes care for complex metabolic syndrome patients and other patients with diabetes who had therapy management problems. The pharmacist, working with student pharmacists, develops treatment plans for drug therapy, nutrition, exercise, and foot care that are reviewed and approved by the managing physician and implemented by the pharmacist and other office staff. More than 260 patients have been referred and managed by the practice with favorable results. The pharmacist is reimbursed as an employee and the practice receives revenue for the pharmacist's practice. CONCLUSION: Working in a private physician office practice provides a unique means of providing pharmaceutical care with reimbursement for the pharmacist.     

Older patient, physician and pharmacist perspectives about community pharmacists' roles

Objectives To investigate older patient, physician and pharmacist perspectives about the role of pharmacists in pharmacist-patient interactions. Methods Eight focus-group discussions were held in senior centres, community pharmacies and primary care physician offices. Participants were 42 patients aged 63 years and older, 17 primary care physicians and 13 community pharmacists. Qualitative analysis of the focus-group discussions was performed. Key findings Participants in all focus groups indicated that pharmacists are a good resource for basic information about medications. Physicians appreciated pharmacists' ability to identify drug interactions, yet did not comment on other specific aspects related to patient education and care. Physicians noted that pharmacists often were hindered by time constraints that impeded patient counselling. Both patient and pharmacist participants indicated that patients often asked pharmacists to expand upon, reinforce and explain physician-patient conversations about medications, as well as to evaluate medication appropriateness and physician treatment plans. These groups also noted that patients confided in pharmacists about medication-related problems before contacting physicians. Pharmacists identified several barriers to patient counselling, including lack of knowledge about medication indications and physician treatment plans. Conclusions Community-based pharmacists may often be presented with opportunities to address questions that can affect patient medication use. Older patients, physicians and pharmacists all value greater pharmacist participation in patient care. Suboptimal information flow between physicians and pharmacists may hinder pharmacist interactions with patients and detract from patient medication management. Interventions to integrate pharmacists into the patient healthcare team could improve patient medication management.     

Patient self-management program for diabetes: first-year clinical, humanistic, and economic outcomes.

OBJECTIVE: To assess the outcomes for the first year following the initiation of a multisite community pharmacy care services (PCS) program for patients with diabetes. DESIGN: Quasi-experimental, pre-post cohort study. SETTING: 80 community pharmacy providers with diabetes certificate program training who were reimbursed for PCS by employers in Greensboro, N.C., Wilson, N.C., Dublin, Ga., Manitowoc County, Wis., and Columbus, Ohio. PATIENTS: 256 patients with diabetes covered by self-insured employers' health plans. INTERVENTIONS: Community pharmacist patient care services using scheduled consultations, clinical goal setting, monitoring, and collaborative drug therapy management with physicians and referrals to diabetes educators. MAIN OUTCOME MEASURES: Changes in glycosylated hemoglobin (AIC), low-density lipoprotein cholesterol (LDL-C), blood pressure, influenza vaccinations, foot examinations, eye examinations, patient goals for nutrition, exercise, and weight, patient satisfaction, and changes medical and medication utilization and costs. RESULTS: Over the initial year of the program, participants' mean A1C decreased from 7.9% at initial visit to 7.1%, mean LDL-C decreased from 113.4 mg/dL to 104.5 mg/dL, and mean systolic blood pressured decreased from 136.2 mm Hg to 131.4 mm Hg. During this time, influenza vaccination rate increased from 52% to 77%, the eye examination rate increased from 46% to 82%, and the foot examination rate increased from 38% to 80%. Patient satisfaction with overall diabetes care improved from 57% of responses in the highest range at baseline to 87% at this level after 6 months, and 95.7% of patients reported being very satisfied or satisfied with the diabetes care provided by their pharmacists. Total mean health care costs per patient were $918 lower than projections for the initial year of enrollment. CONCLUSION: Patients who participated in the program had significant improvement in clinical indicators of diabetes management, higher rates of self-management goal setting and achievement, and increased satisfaction with diabetes care, and employers experienced a decline in mean projected total direct medical costs.     

Diabetes Ten City Challenge: Final economic and clinical results

ObjectiveTo assess the economic and clinical outcomes for the Diabetes Ten City Challenge (DTCC), a multisite community pharmacy health management program for patients with diabetes.DesignQuasiexperimental observational analysis, pre–post comparison.SettingEmployers at 10 distinct geographic sites contracting with pharmacy providers in the community setting.Participants573 patients with diabetes who had baseline and year 1 medical and pharmacy claims and two or more documented visits with pharmacists.InterventionsCommunity-based pharmacists provided patient self-management care services via scheduled consultations within a collaborative care management model.Main outcome measuresChanges in health care costs for employers and beneficiaries and key clinical measures.ResultsAverage total health care costs per patient per year were reduced by $1,079 (7.2%) compared with projected costs. Statistically significant improvements were observed for key clinical measures, including a mean glycosylated hemoglobin decrease from 7.5% to 7.1% (P = 0.002), a mean low-density lipoprotein cholesterol decrease from 98 to 94 mg/dL (P < 0.001), and a mean systolic blood pressure decrease from 133 to 130 mm Hg (P < 0.001) over a mean of 14.8 months of participation in the program. Between the initial visit and the end of the evaluation period, influenza vaccination rate increased from 32% to 65%, eye examination rate increased from 57% to 81%, and foot examination rate increased from 34% to 74%.ConclusionDTCC successfully implemented an employer-funded, collaborative health management program using community-based pharmacist coaching, evidenced-based diabetes care guidelines, and self-management strategies. Positive clinical and economic outcomes were identified for 573 patients who participated in the program for at least 1 year, compared with baseline data.