Pharmacist-Led Group Medical Appointments for the Management of Type 2 Diabetes with Comorbid Depression in Older Adults

Background::

Depression is associated with poor glycemic control, increased number of microvascular and macrovascular complications, functional impairment, mortality, and 4.5 times higher total health care costs in patients with diabetes. Shared medical appointments (SMAs) may be an effective method to attain national guideline recommendations for glycemic control in diabetes for patients with depression through peer support, counseling, problem solving, and improved access to care.

Objective:

To test the efficacy as assessed by attainment of a hemoglobin A1c (A1C) <7% of pharmacistted group SMA visits, Veterans Affairs Multidisciplinary Education in Diabetes and Intervention for Cardiac Risk Reduction in Depression (VA-MEDIC-D), in patients with type 2 diabetes mellitus.

Methods:

This was a randomized controlled trial of VA-MEDIC-D added to standard care versus standard care alone in depressed patients with diabetes with A1C >6.5%. VA-MEDIC-D consisted of 4 once-weekly, 2-hour sessions followed by 5 monthly 90-minute group sessions. Each SMA session consisted of multidisciplinary education and pharmacist-led behavioral and pharmacologic interventions for diabetes, lipids, smoking, and blood pressure. No pharmacologic interventions for depression were provided. The change in the proportion of participants who achieved an A1C <7% at 6 months was compared.

Results:

Compared to standard care (n = 44), a lower proportion of patients in VA-MEDIC-D (n = 44) had systolic blood pressure (SBP) <130 mm Hg at baseline, but were similar in other cardiovascular risk factors and psychiatric comorbidity. The change in the proportion of participants achieving an A1C <7% was greater in the VA-MEDIC-D arm than in the standard care arm (29.6% vs 11.9%), with odds ratio 3.6 (95% CI 1.1 to 12.3). VA-MEDIC-D participants also achieved significant reductions in SBP, low-density lipoprotein cholesterol, and non–high-density lipoprotein (HDL) cholesterol from baseline, whereas significant reductions were attained only in non–HDL cholesterol with standard care. There was no significant change in depressive symptoms for either arm.

Conclusions:

Pharmacist-led group SMA visits are efficacious in attainment of glycemic control in patients with diabetes and depression without change in depression symptoms.

Pharmacist-Led Shared Medical Appointments for Multiple Cardiovascular Risk Reduction in Patients With Type 2 Diabetes

Purpose

To assess whether VA MEDIC-E (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH] Extended for 6 months), a pharmacist-led shared medical appointments program, could improve attainment of target goals for hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to standard primary care after 6 months of intervention.

Methods

A randomized, controlled trial of VA MEDIC-E (n = 50) versus standard primary care (n = 49) in veterans with type 2 diabetes, hemoglobin A1c (A1C) > 7%, blood pressure (BP) > 130/80 mmHg, and low density lipoprotein cholesterol (LDL-C) > 100mg/dl (2.59 mmol/l) in the previous 6 months was conducted. The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions. Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist. Evaluation measures included lab values of A1C, LDL cholesterol, BP, and goal attainment of these values, and diabetes self-care behavior questionnaires at 6 months.

Results

The randomization groups were similar at baseline in all cardiovascular risk factors except for LDL, which was significantly lower in the MEDIC-E arm. At 6 months, significant improvements from baseline were found in the intervention arm for exercise, foot care, and goal attainment of A1C, LDL-C, and BP but not in the control arm.

Conclusions

The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk.

The association between C-reactive protein levels and insulin therapy in obese vs nonobese veterans with type 2 diabetes mellitus

The authors studied the association between insulin use and C-reactive protein (CRP) levels in obese (body mass index > or = 30 kg/m(2)) and nonobese (body mass index <30 kg/m(2)) patients with type 2 diabetes at the Providence Veterans Affairs Medical Center. There were 64 nonobese participants (insulin use and average daily dose, 23.4% and 7.0+/-18.2 units at baseline and 27.1% and 9.3+/-21.0 units at follow-up, respectively) and 106 obese participants (insulin use and daily dose, 39.6% and 28.2+/-47.3 units at baseline and 43.0% and 28.7+/-47.7 units at follow-up, respectively). Both use and daily dose of insulin were modeled with CRP levels of participants upon discharge from an intensive cardiac risk management clinic and at a 1-year follow-up visit using a linear mixed effects model for repeated measures. There was a significant direct association between log CRP and both insulin use and daily dose for nonobese participants (beta=0.3, P=.03 and beta=0.01, P=.02, respectively) but not for obese participants (P=.8 and P=.5, respectively). Due to the association between insulin therapy and CRP in nonobese patients, these results may aid clinicians in deciding on the initiation of insulin therapy for nonobese diabetic patients when noninsulin alternatives are available.

Pharmacist-Led Group Medical Appointment Model in Type 2 Diabetes

Purpose

The purpose of this study was to assess whether the VA-MEDIC (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction), a pharmacist-led group medical visit program, could improve achievement of target goals in hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to usual care.

Methods

This was a randomized controlled trial of VA-MEDIC intervention in addition to usual care versus usual care alone in diabetic patients to reduce cardiac risk factors. VA-MEDIC consisted of a 40- to 60-minute educational component by nurse, nutritionist, physical therapist, or pharmacist followed by pharmacist-led behavioral and pharmacological interventions over 4 weekly sessions.

Measures

The attainment of target goals in hemoglobin A1C (A1C), blood pressure, fasting lipids, and tobacco use recommended by the American Diabetes Association.

Results

Of 118 participants, 109 completed the study. VA-MEDIC (n = 58) participants were younger and had greater tobacco use at baseline than usual care but were similar in other cardiovascular risk factors. After 4 months, a greater proportion of VA-MEDIC participants versus controls achieved an A1C of less than 7% and a systolic blood pressure less than 130 mm Hg. No significant change was found in lipid control or tobacco use between the 2 study arms.

Conclusion

Pharmacist-led group medical visits are feasible and efficacious for improving cardiac risk factors.

Change in hemoglobin A(1c) and C-reactive protein levels in patients with diabetes mellitus

The authors studied the effects on C-reactive protein (CRP) levels of an intensive intervention to reduce hemoglobin A(1c) (HbA(1c)) among 58 veterans with type 2 diabetes. Weekly group sessions of behavioral and pharmacologic intervention were conducted for 4 weeks at Providence Veterans Affairs Medical Center. Change in cardiovascular risk factors and CRP levels were compared at baseline and 3 months postintervention. There was a significant decrease in HbA(1c) (-0.7%+/-1.9%, P<.01), total cholesterol (-20.3+/-41.1 mg/dL, P=.01), low-density lipoprotein cholesterol (-11.7+/-31.4 mg/dL, P=.05), systolic blood pressure (-6.9+/-21.2 mm Hg, P=.03), and diastolic blood pressure (-6.0+/-10.6 mm Hg, P<.01) over 4 months. There was no significant change in CRP levels (1.1+/-6.6 mg/L, P=.2). These results suggest that CRP effects may not be adequate to predict changes in cardiovascular risk among diabetic patients and should not be a surrogate for achieving evidence-based goals in traditional cardiovascular risk factors.

Does cardiovascular risk reduction alleviate erectile dysfunction in men with type II diabetes mellitus?

Veterans (N=41) with type II diabetes were enrolled in a behavioral and pharmacologic intervention for cardiac risk reduction for 4 weeks at the Providence Veterans Affairs Medical Center during 2004-2007 and were followed up 3 months post intervention. Erectile dysfunction (ED) was assessed using the 5-item version of the International Index of Erectile Function (IIEF-5). Participants experienced significant improvements in hemoglobin A1c (HbA1c), diastolic blood pressure and total cholesterol levels over the course of the intervention. Change in systolic and diastolic blood pressure and reduction in or maintenance of HbA1c below 7.0% were significantly associated with change in IIEF-5 (P=0.01, P=0.01, P=0.04, respectively). These results suggest that improved blood pressure and glycemic control in men with diabetes may lead to an improvement in ED.