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Quality improvement
Pharmacist led, primary care based disease management reduced risk factors and improved glycaemic control in diabetes
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  1. Merideth D Smith, BA,
  2. Steven A Smith, MD
  1. Mayo Clinic Rochester
 >Rochester, Minnesota, USA

    http://dx.doi.org/10.1136/ebm.10.5.154

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      Rothman RL, Malone R, Bryant B, et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am J Med 2005;118:276–84.
      OpenUrlCrossRefPubMedWeb of Science

      
 
 Q In vulnerable patients with poorly controlled type 2 diabetes mellitus, does a pharmacist led, primary care-based, disease management programme reduce cardiovascular risk factors and improve glycaemic control?

      Clinical impact ratings GP/FP/Primary care ★★★★★☆☆ Internal medicine ★★★★★★☆ Cardiology ★★★★★★☆ Endocrine ★★★★★★☆

      METHODS

      Embedded ImageDesign:

      randomised controlled trial.

      Embedded ImageAllocation:

      {concealed*}†.

      Embedded ImageBlinding:

      blinded (outcome assessors {and data collectors}†).

      Embedded ImageFollow up period:

      1 year.

      Embedded ImageSetting:

      University of North Carolina General Internal Medicine Practice, Chapel Hill, North Carolina, USA.

      Embedded ImagePatients:

      217 English speaking patients who were ⩾18 years of age, had a clinical diagnosis of type 2 diabetes, had poor glucose control (glycated haemoglobin [HbA1C] concentration ⩾8.0%), and had a life expectancy >6 months.

      Embedded ImageIntervention:

      primary care disease management programme (n = 112) or usual care (n = 110). The intervention consisted of usual care supplemented with intensive diabetes management; 3 clinical pharmacists who had training in outpatient disease management delivered intensive educational sessions and used evidence-based algorithms and proactive management of clinical parameters. See www.evidence-basedmedicine.com.

      Embedded ImageOutcomes:

      blood pressure (BP), HbA1C concentrations, aspirin use, and lipid concentrations.

      Embedded ImagePatient follow up:

      89% at 1 year (intention to treat analysis).

      MAIN RESULTS

      Systolic and diastolic BP, HbA1c concentrations, and aspirin use for cardiovascular risk prevention were more improved in patients who received the primary management programme than in those who received usual care (table). Cholesterol concentrations did not differ significantly between groups.

      View this table:

      Pharmacist led, primary care management programme v usual care in type 2 diabetes*

      CONCLUSION

      In vulnerable patients with poorly controlled type 2 diabetes mellitus, a pharmacist led, primary care-based, disease management programme reduced cardiovascular risk factors and improved glycaemic control.

      Commentary

      Rothman et al add to the literature on models of disease care management that empower health professionals other than primary care physicians with standardised guidelines and procedures. These professionals (pharmacists in this intervention) are responsible for tracking, coordinating, and implementing individualised patient care.

      What could limit adoption of these models? Firstly, as in other guideline implementation efforts,1,2 these models yield modest improvements. Secondly, if protocols are not sufficiently explicit and unambiguous, non-physician professionals may be challenged for extending their “scope of practice.” Thirdly, successful translation requires system redesign to support new roles and detailed protocols to ensure adequate implementation.

      Also, a wider scope of intervention, beyond monitoring and medication adjustment, may be more effective. Notably, supporting patient self efficacy and problem solving by using family and peer counselling and other psychosocial interventions can lead to healthier behaviours3 that may enhance patient outcomes.

      References

      1. ↵
        Norris SL, Nichols PJ, Caspersen CJ. et al. Am J Prev Med 2002;22:15–38.
        OpenUrlPubMedWeb of Science
      2. ↵
        Grimshaw JM, Thomas RE, MacLennan G, et al. Health Technol Assess 2004;8:1–72.
      3. ↵
        Lorig KR, Holman H. Ann Behav Med 2003;26:1–7.
        OpenUrlCrossRefPubMedWeb of Science
      View Abstract

      Supplementary materials

      • The appendix is available as a downloadable PDF (printer friendly file).

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      Footnotes

      • ↵* See glossary.

      • ↵† Information provided by author.

      • For correspondence: Dr R Rothman, Vanderbilt University Medical Center, Nashville, TN, USA. russell.rothmanvanderbi

      • Sources of funding: Robert Wood Johnson Clinical Scholars Program, University of North Carolina, and Vanderbilt Center for Health Services Research.

      Linked Articles

      • Glossary
        Glossary
        BMJ Publishing Group Ltd
        BMJ Evidence-Based Medicine 2005; 10 160a-160a Published Online First: 30 Sep 2005. doi: 10.1136/ebm.10.5.160a