Impact of pharmacist-involved collaborative care on diabetes management in a primary healthcare setting using real-world data

The involvement of specialists in primary healthcare teams for managing diabetes: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus requires ongoing management and care coordination. The majority of patients with diabetes were managed in primary healthcare settings. Several quality improvement programs have introduced specialist involvement in primary healthcare teams. However, synthesized evidence is needed to support policy improvements regarding the impact of specialist-primary healthcare coordination on glycemic control in diabetes care.

OBJECTIVE

This systematic review and meta-analysis aimed to assess the effectiveness of specialist involvement in primary healthcare teams on glycemic control of patients with diabetes.

METHODS

A search of five electronic databases (PubMed, Embase, Web of Science Core Collection, CNKI, and Wanfang Database) was conducted to identify relevant studies published until October 21st, 2023. We assessed the methodological quality of the included studies using the suggested risk of bias criteria for EPOC (Cochrane Effective Practice and Organization of Care). We conducted the certainty assessment using the GRADE guideline. The outcome measured was the HbA1c level. Meta-analyses were performed using random-effects models.

RESULTS

A total of 12 studies (7 randomized controlled trials and 5 controlled before-after studies) were included in the meta-analysis. The involvement of specialists in primary healthcare teams was associated with a statistically significant reduction in HbA1c level compared to usual or standard care (mean difference - 0.57, 95% CI: -0.86 to -0.27, I2 = 88.17%).

CONCLUSION

The findings revealed that the interventions might improve the care delivered and patients' health outcomes. However, due to the very low certainty of evidence on the effectiveness on glycemic control, the interventions implemented in the included studies should be employed with caution in future policy-making to achieve improved HbA1c levels. Further research with a more rigorous design is needed to provide evidence of higher certainty and quality.

REGISTRATION

The systematic review and meta-analysis was registered in the PROSPERO International Prospective Register of Systematic Reviews (registration No. CRD42022384589 available at https://www.crd.york.ac.uk/prospero/#searchadvanced ).

Interprofessional collaboration in primary care for patients with chronic illness: a scoping review mapping leadership and followership

BACKGROUND

Effective interprofessional collaboration (IPC) in primary care is essential in providing high-quality care for patients with chronic illness. However, the traditional role-based leadership approach may hinder IPC. Instead, physicians should also take followership roles, allowing other healthcare team members (OHCTMs) to lead when they have expertise and/or experience. Understanding of leadership and followership within IPC remains limited in primary care for patients with chronic illness. Hence, this review aims to explore the definitions and conceptualisations of leadership and followership and to map relevant training in this context.

METHODS

Following the Joanna Briggs Institute methodology for scoping reviews, an electronic search was conducted across PubMed, Embase and Web of Science. Three independent reviewers assessed publications for eligibility. Descriptive and thematic analysis were employed.

RESULTS

From 2194 identified articles, 57 were included. Only two articles defined leadership approaches, and none explicitly addressed followership. Nevertheless, our analysis identified leadership shifts from physicians to OHCTMs, and vice versa for followership, driven by complexity of care, physician shortages and healthcare costs. Enablers of these shifts included physician trusting OHCTMs, collaborative practice agreements and physicians' interprofessional experience. Barriers included traditional hierarchies, OHCTMs' lack of competence and physicians' lack of IPC experience. Four articles mentioned relevant training however without detailed information.

DISCUSSION

Leadership in IPC for chronic illness in primary care is rarely defined, and followership is largely neglected. Nevertheless, leadership-followership shifts do occur in leadership and followership roles of physicians and OHCTMs. Further research needs to explore physicians' followership and relevant competencies, and relevant training is required.

Assessing Type 2 Diabetes Risk in the Post-Pandemic Era: A Pharmacy-Led FINDRISC Screening Study

Diabetes mellitus (DM) is a major global health issue, with type 2 diabetes (T2D) accounting for over 90% of cases. Community pharmacies, given their accessibility, are well positioned to assist in early detection and management of T2D. This study evaluated post-pandemic T2D risk in a Portuguese population using the Finnish Diabetes Risk Score (FINDRISC) across five community pharmacies. A total of 494 participants aged 40 or older without a prior diagnosis of diabetes were assessed. The mean FINDRISC score was 12.3, and 29.8% were identified as high or very high-risk, with 8.7% referred to general practitioners for follow-up based on elevated glycated hemoglobin (HbA1c). Key risk factors include age, body mass index, waist circumference, lack of physical activity, and family history of diabetes. Lower educational levels were also associated with higher diabetes risk. Community pharmacies are shown to play an essential role in screening and educating at-risk populations, emphasizing the importance of physical activity, healthy diets, and regular monitoring. These findings reinforce the value of community pharmacists in mitigating T2D risk and enhancing public health outcomes through cost-effective, validated screening tools like FINDRISC. Finally, pre-pandemic FINDRISC studies discussed show similar results suggesting that the COVID-19 pandemic did not significantly impact the overall risk profile for T2D.

[Impact of a primary care pharmacy unit on the optimization of pharmacological treatment of type 2 diabetic patients]

OBJECTIVE

To evaluate the impact of a pharmaceutical intervention on treatment optimization in patients with type 2 diabetes mellitus.

DESIGN

Before-after intervention study. SITE: Health centers of the Primary Care Department of Camp de Tarragona.

PARTICIPANTS

Patients aged ≥ 18 years, diagnosed with type 2 diabetes mellitus and under treatment with antidiabetic drugs.

INTERVENTIONS

Review of pharmacological treatment for type 2 diabetes mellitus and issuance of proposals for its adequacy.

MAIN MEASUREMENTS

Demographic and clinical variables were collected to assess the adequacy of antidiabetic treatment. A consensus meeting was arranged with the patients' primary care physician to evaluate the proposals for improvement. The implementation of the proposals and the variation in postintervention glycemic control were assessed.

RESULTS

A total of 907 patients (59% men) were included. A total of 782 proposals for intervention were made in 65.8% of the patients reviewed. Of the proposals, 43.5% corresponded to drug discontinuation, 16% to intensification of dosing and 12.6% to exchange for a therapeutic equivalent. Of the consensual proposals, 54.7% were implemented. HbA1c was reduced by 0.2% after the intervention (7.4 vs 7.2%).

CONCLUSIONS

Review of the pharmacological treatment of patients with type 2 diabetes mellitus by a pharmacist or pharmacologist facilitates its optimization.

Integration of clinical pharmacists to assist with medication surveillance for patients receiving gender-affirming hormone therapy in a community ambulatory setting within the United States

BACKGROUND

Gender-affirming care (GAC) for gender diverse individuals (includes transgender and nonbinary persons) requires a comprehensive approach to medication surveillance, including monitoring and follow-up. Limited access to these health services can present a barrier to follow-up for routine care. Integration of a pharmacist into therapeutic management has shown positive clinical outcomes; however, their involvement with gender-affirming hormone therapy (GAHT), including routine laboratory monitoring, is not well established.

OBJECTIVE

This study aimed to describe the development and implementation of a protocol involving the integration of clinical pharmacists into GAC for gender diverse patients in a community ambulatory setting.

PRACTICE DESCRIPTION

Cleveland Clinic's Center for LGBTQ+ Care is embedded in a primary care practice and has an established protocol for GAHT management. The health system also has an established model that uses pharmacists for the management of patients, within the primary care and specialty clinic settings, under a collaborative practice agreement (CPA).

PRACTICE INNOVATION

The medical director of the Cleveland Clinic's Center for LGBTQ+ Care and the institution's primary care pharmacists collaborated to propose an update to the CPA to include GAHT monitoring to improve access to routine GAHT follow-up.

EVALUATION METHODS

GAHT management was approved to be added to the pharmacist CPA in May of 2022 and the pharmacists started seeing patients in February of 2023. The team opted to start with those patients already established on GAHT for at least 6 months, at least 1 year after transition, and with a primary care provider managing their GAHT.

CONCLUSION

Access to follow-up for individuals receiving GAHT may be improved through the utilization of pharmacist services. The incorporation of a CPA with pharmacists for GAHT management can allow for a multidisciplinary approach once a patient is on a stable regimen, thereby increasing provider access to new patients.

Efficacy of a pharmacist-managed diabetes clinic in high-risk diabetes patients, a randomized controlled trial - "Pharm-MD" : Impact of clinical pharmacists in diabetes care

BACKGROUND

Diabetes mellitus affects 13% of American adults. To address the complex care requirements necessary to avoid diabetes-related morbidity, the American Diabetes Association recommends utilization of multidisciplinary teams. Research shows pharmacists have a positive impact on multiple clinical diabetic outcomes.

METHODS

Open-label randomized controlled trial with 1:1 assignment that took place in a single institution resident-run outpatient medicine clinic. Patients 18-75 years old with type 2 diabetes mellitus and most recent HbA1c ≥9% were randomized to standard of care (SOC) (continued with routine follow up with their primary provider) or to the SOC + pharmacist-managed diabetes clinic PMDC group (had an additional 6 visits with the pharmacist within 6 months from enrollment). Patients were followed for 12 months after enrollment. Data collected included HbA1c, lipid panel, statin use, blood pressure control, immunization status, and evidence of diabetic complications (retinopathy, nephropathy, neuropathy). Intention-to-treat and per-protocol analysis were performed.

RESULTS

Forty-four patients were enrolled in the SOC + PMDC group and 42 patients in the SOC group. Average decrease in HbA1c for the intervention compared to the control group at 6 months was - 2.85% vs. -1.32%, (p = 0.0051). Additionally, the odds of achieving a goal HbA1c of ≤8% at 6 months was 3.15 (95% CI = 1.18, 8.42, p = 0.0222) in the intervention versus control group. There was no statistically significant difference in the remaining secondary outcomes measured.

CONCLUSIONS

Addition of pharmacist managed care for patients with type 2 diabetes mellitus is associated with significant improvements in HbA1c compared with standard of care alone. Missing data during follow up limited the power of secondary outcomes analyses.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT03377127 ; first posted on 19/12/2017.

A 5-year trend in the use of sodium-glucose co-transporter 2 inhibitors and other oral antidiabetic drugs in a Middle Eastern country

BACKGROUND

Sodium glucose co-transporter 2 inhibitors (SGLT2is) are a novel class of oral antidiabetic drugs. To date, there are no pharmacoepidemiologic studies investigating the pattern of use of SGLT2is compared to other oral antidiabetic drugs in the Middle East, including Qatar.

AIM

This study aimed to explore the trends in the use of SGLT2is compared to other oral antidiabetic drugs in Qatar from 2016 to 2020.

METHOD

This is a descriptive, retrospective cross-sectional study where information on all oral antidiabetic drugs dispensed as in- or out-patient prescriptions from 2016 to 2020 in Hamad Medical Corporation hospitals, Qatar were collected. Outcomes included the number and relative frequency of quarterly prescriptions of different oral antidiabetic drug classes [biguanides, sulfonylureas, dipeptidyl peptidase 4 inhibitors, thiazolidinediones, meglitinides, α-glucosidase inhibitors, and SGLT2is] prescribed from 2016 to 2020.

RESULTS

SGLT2is prescriptions increased from 1045 (2.13%) in 2017 to 8375 (12.39%) in 2020, while sulfonylureas prescriptions declined from 10,436 (21.25%) to 9158 (13.55%) during the same period. Metformin use decreased from 23,926 (48.71%) in 2017 to 30,886 (45.70%) in 2020. The proportions of thiazolidinediones, meglitinides, α-glucosidase inhibitors prescriptions remained stable over the years. Among SGLT2is, empagliflozin prescriptions showed an increase from 537 (10.65%) to 2881 (34.40%) compared to dapagliflozin, which decreased by the end of 2018 from 4505 (89.35%) to 5494 (65.6%).

CONCLUSION

SGLT2is have largely replaced sulfonylureas in Qatar. The increasing trend in their use over the years is similar to that reported in other countries. The trend among SGLT2is suggests greater preference for empagliflozin over dapagliflozin.