Jeremy Thomas

Pharmacist-Physician Collaboration for Diabetes Care: The Diabetes Initiative Program:

BACKGROUND: Multiple complications can arise secondary to poor control of glucose, blood pressure, and cholesterol in a patient with diabetes. OBJECTIVE: To evaluate the effect of a pharmacist-physician collaboration on attainment of diabetes-related measures of control. METHODS: This was a prospective, multicenter, cohort study. Patients were enrolled from 7 practice sites throughout Tennessee if they had been diagnosed with type 2 diabetes, were aged 18 years or older with a life expectancy greater than 1 year, and were English speaking. Pregnant women were excluded. Patients were followed for 12 months following enrollment by informed consent. The pharmacist-physician collaboration method was established prior to study initiation. Primary outcomes included hemoglobin A1c (A1C), number of patients with A1C less than 7%, and percentage of patients with A1C greater than 9%. RESULTS: Of the 206 patients enrolled, the mean age was 59.73 years, and most were male (59.71%) and white (66.02%). The A1C was reduced by an average of 1.16% (p < 0.0001). The proportion of patients with A1C less than 7% increased from 12.75% at baseline to 36.76% at study conclusion (p = 0.0002). The proportion of patients with A1C greater than 9% decreased from 34.15% to 16.50%, (p < 0.0001). CONCLUSIONS: Pharmacist-physician collaborative management at multiple practice locations and types of setting (eg, private, academic, Veterans Affairs medical center) has a positive impact on glycemic control and diabetes-related health maintenance. This was accomplished without increasing the total number of antihyperglycemic agents prescribed and without an increase in patient-reported episodes of hypoglycemia.

An evaluation of peak expiratory flow monitoring: a comparison of sitting versus standing measurements.

Introduction: Current guidelines for the diagnosis and management of asthma suggest that patients perform peak expiratory flow (PEF) measurements while standing; however, recent literature suggests this may not be necessary. The purpose of this study was to determine the impact of patient position on PEF measurements. Methods: A randomized observational analysis of PEF measurements for 211 patients in sitting and standing positions was performed. The highest PEF measurement from tests performed with correct technique in both the sitting and standing position was compared. Results: Overall, PEF measurements did not significantly differ between the sitting and standing positions (506 ± 2 L/min versus 508 ± 2 L/min; P = .45). No differences were seen between mean PEF measurements in the sitting or standing positions for either women or men, nor were there significant differences between mean PEF values for the sitting and standing positions in participants who reported a history of asthma. Conclusions: PEF measurements do not significantly differ based on sitting or standing measurements among healthy participants. Based on the results of this study it may not be necessary for the patient to stand while performing PEF measurements. Further study among patients with asthma is warranted.

The continuation of oral medications with the initiation of insulin therapy in type 2 diabetes: a review of the evidence.

The combination of oral medications with insulin is inevitable in the treatment of type 2 diabetes. Unfortunately, there are no consensus statements available to guide the continuation or discontinuation of specific therapies. The clinician treating the type 2 diabetic patient must be aware of the literature regarding use of oral medications in combination with insulin.

Pharmacist-Physician Collaboration for Diabetes Care Cardiovascular Outcomes

Background: Only 23% of patients are meeting all goals for cardiovascular complications of diabetes. Objective: The purpose of our study is to evaluate the effect of a pharmacist-physician collaboration on attainment of cardiovascular-related goals in patients with type 2 diabetes. Methods: This prospective, multicenter cohort enrolled patients from 7 practice sites that were members of the University of Tennessee Pharmacist Practice Based Research Network (UT Pharm Net). Patients were included if they were diagnosed with type 2 diabetes, at least 18 years of age and English speaking. Pregnant patients were excluded. Patients were followed for 12 months after enrollment. Primary cardiovascular outcomes included reduction in systolic blood pressure, diastolic blood pressure, and low-density lipoprotein (LDL) as well as the proportion of patients achieving a blood pressure goal of <130/80 mm Hg and proportion of patients achieving an LDL goal of <100 mg/dL. Results: For the 206 patients enrolled, the average age was 59.7 years; the majority were male (59.7%) and white (66%). When compared with baseline, the postintervention mean systolic (P < .0001), diastolic blood pressure (P = .0003), and LDL (P < .0001) decreased significantly. The proportion of patients achieving a blood pressure of <130/80 mm Hg increased 21.8% (P < .0001), and the proportion of patients achieving an LDL of <100 mg/dL increased 12% (P = .0023). Conclusions: The results of our study indicate that collaborative management has a positive impact on decreasing cardiovascular risk and assists patients in attaining national goals for blood pressure and cholesterol.

Status of diabetes care among community pharmacy patients with diabetes: Analysis of the Medical Expenditure Panel Survey

OBJECTIVE To determine the status of diabetes care among community pharmacy patients with diabetes. DESIGN Cross-sectional observational study. SETTING United States, 2005. PATIENTS 1,455 community pharmacy patients aged 18 years or older with diabetes who were diagnosed before 2005. INTERVENTION Analysis of the Medical Expenditure Panel Survey. MAIN OUTCOME MEASURES Proportions of patients meeting American Diabetes Association (ADA) standards of medical care in diabetes. RESULTS In 2005, 1,455 patients with diabetes who were diagnosed before 2005 filled prescriptions through community pharmacies. Gaps occurred between the diabetes care of these patients and ADA standards. Examples include the following: ADA recommends at least two glycosylated hemoglobin (A1C) tests annually, but 19.52% of the study population reported less than two A1C tests in 2005; ADA recommends annual influenza vaccinations, but 42.46% of the study population reported not receiving an influenza vaccination in 2005; and ADA recommends weight control, but 83.74% of the study population was overweight or obese. CONCLUSION The current results demonstrate that many patients with diabetes are not receiving adequate care and that pharmacists have an opportunity to improve diabetes management.

Hyperprothrombinemia as a result of a possible warfarin and intravaginal miconazole interaction.

Warfarin, a commonly prescribed anticoagulant, has many potential drug interactions. We describe a case of intravaginal miconazole potentiating the effects of warfarin in a patient previously stable on a consistent dose of 8.5 mg warfarin daily. Following a course of intravaginal miconazole and a dosage increase to 9 mg daily, her international normalized ratio (INR) increased from 2.0 to 5. After the course of miconazole was complete, the patient was stable with a therapeutic INR (mean INR 2.9) on 9 mg warfarin daily. Clinicians should consider the possibility of systemic absorption of intravaginal miconazole, and a resultant increase in warfarins anticoagulant effect.

Pharmacoeconomic Analysis of the Diabetes Initiative Program A Pharmacist-Physician Collaborative Care Model

Background: Diabetes treatment cost increased 41% from 2007 to 2011. Pharmacists have provided collaborative diabetes management for decades with improvement in disease-related end points. Few have reported economic benefits of pharmacist management of type 2 diabetes. Objective: The purpose was to determine if cost savings associated with hemoglobin A1c (A1C) and systolic blood pressure (SBP) change outweighed programmatic pharmacist-physician collaborative care model costs. Methods: This cost analysis of a 12 month, prospective, multicenter, observational study included English-speaking adults, 18 years or older, with type 2 diabetes mellitus, a life expectancy >1 year, and either a A1C >7%, SBP >130 mm Hg, diastolic blood pressure >80 mm Hg, or low-density lipoprotein concentration >100 mg/dL. Pregnant patients were excluded. Primary analysis outcome was average cost per outcome, ratio of net cost (numerator) and percentage achieving outcomes (denominator). Assessment outcomes included A1C reduction by at least 1% and SBP reduction by at least 5.6 mm Hg. Results: 206 patients were seen by pharmacists during 1612 encounters (mean = 7.8 encounters/patient). Pharmacists spent 983 hours caring for type 2 diabetes patients (mean 3.8 hours/patient). Base case net labor and program costs per patient were −

Feasibility of contracting for medication therapy management services in a physician’s office

66.77 and

Using an array of implementation strategies to improve success rates of pharmacist-initiated medication therapy management services in community pharmacies

106.81, respectively. Improvement in A1C and SBP yielded

Development of a primary care pharmacist practice-based research network

421.01 in cost savings per patient. Labor and program average costs per patient for each outcome achieved were −