Diabetes Mellitus Non-Glucose Monitoring: Point-of-Care Testing

Does availability of expanded point-of-care services improve outcomes for rural diabetic patients?

AIMS

The purpose of this study was to assess compliance with American Diabetes Association screening recommendations at Salina Family Healthcare (SFHC) in Salina, Kansas, a large rural town, and to evaluate the impact of point-of-care (POC) dilated eye exams for uninsured patients. POC exams are those performed in the location where patients are treated.

METHODS

There were 462 type II diabetic (DM2) patients seen at SFHC in 2009 and 537 DM2 patients seen in 2010. A chart review of all patients with DM2 was done to assess rates of recommended screening exams, including dilated eye exams and foot exams.

RESULTS

In 2009/2010 urine microalbumin was checked in 57%/75% of DM2 patients. HbA1c and low density lipoprotein (LDL) levels at goal were 46%/48% and 58%/58%, respectively. 47%/67% of DM@ patients received foot exams and 21%/30% received eye exams. In 2009, 23% of the 155 uninsured diabetic patients at SFHC received a dilated eye exam. The following year, after implementation of on-site ophthalmologic services, rates of dilated eye exams increased 1.6 fold to 37% of the 196 uninsured patients.

CONCLUSIONS

SFHC performed similarly to national rates on some diabetic screening exams, but there is room for improvement in all recommended screening exams. The implementation of a novel approach to increasing dilated eye exam rates indicates that expanded POC services can improve outcomes for diabetic patients.

Point of care testing is appropriate for National Health Service health check

BACKGROUND

The Department of Health launched a cardiovascular disease risk assessment initiative with particular reference to reducing health inequalities in ethnic minorities. Collaboration between HEART UK, Royal Free Hampstead NHS Trust and Hindu Temples resulted in vascular screening in North London.

METHODS

Subjects of South Asian origin were screened. A full lipid profile and glucose were measured using a point of care testing (POCT) Cholestech LDX analyser (LDX). Venous samples were analysed in our hospital laboratory.

RESULTS

The results (215 men; 191 women) were divided into tertiles and Bland-Altman plots were used to assess agreement. At high-density lipoprotein cholesterol (HDL-C) concentrations < 1.0 mmol/L the LDX underestimated values by -0.2 mmol/L (P<0.0001). At HDL-C concentrations >1.3 mmol/L this bias disappeared. For total cholesterol the concentration-dependent negative bias was evident at concentrations of < 4.1 mmol/L (P < 0.0001). This bias was less evident at higher concentrations. A similar pattern was seen for low-density lipoprotein cholesterol. There were also small variations in glucose and triglyceride values. However, there was excellent agreement in calculated cardiovascular disease risk using kappa analysis for JBS2, QRISK2, ETHRISK and Framingham (κ = 0.86, 0.92, 0.94 and 0.88, respectively). This was a high-risk population since 9.7-19.4% had a ≥ 20% 10-y probability of a vascular event depending on the risk engine and assay method used. The corresponding values for intermediate risk (11-19%) were 18.6-25.7%.

CONCLUSIONS

There was a minimum mismatch irrespective of the type of risk calculator used. POCT measurements are adequate for the National Health Service Health Check.

Professional development of pharmaceutical care in type 2 diabetes mellitus: a multidisciplinary conceptual model

Objective

To generate a validated model of care providing a framework for continued professional development of the community pharmacist for patients with type 2 diabetes mellitus.

Setting

A purposive sample of medical, nursing and community pharmacist interviewees in 10 health boards in Scotland.

Method

Investigation, using a semi-structured questionnaire approach, of the views held by 19 healthcare practitioners.

Key findings

A model of multidisciplinary diabetes care was generated to aid definition of pharmaceutical care provision. Processes emphasised in the model were: compliance monitoring, agreed multidisciplinary protocols and the continuity of patient education. Potential areas for community pharmacist contributions included the running of diabetes clinics, provision of patient education, near-patient testing, repeat dispensing and identification of clinic defaulters.

Conclusions

Development of the community pharmacists' role for patients with type 2 diabetes mellitus requires extensions to current independently delivered patient-centred services through working in partnership with other professionals. Methods of improved communication and attention to methods of referral, where appropriate, are important focal points. The targeting of this care and the care model that is best suited to particular settings will be subject to local variation. The generation of a diabetes care model offers pharmacists a means of matching learning opportunities to their needs. It is also a step towards the development of appropriate continued professional development tools and systems to equip community pharmacists for the future.

A consensus model for delivery of structured pharmaceutical care for the patient with type 2 diabetes mellitus by Scottish community pharmacists

Objective

To generate a model of pharmaceutical care for the patient with type 2 diabetes mellitus in primary care, from a consensus determined among community pharmacists in Scotland. Setting Community pharmacists within Scotland already involved in providing structured pharmaceutical care.

Method

The Delphi questionnaire was based on a validated multidisciplinary model of care for the patient with type 2 diabetes mellitus in primary care comprising 47 items under five themes: assessment, treatment plan, treatment administration, patient monitoring, confirmation/review. Seventy participants already participating in a pharmaceutical care model schemes initiative to encourage pharmaceutical care from community pharmacies and with an interest in diabetes mellitus were sent an initial questionnaire. Thirty-seven participants agreed to enter two further rounds; response rates were 22/37 (59%) and 18/22 (82%). Final round cut-off defining consensus was 80% scoring 6–7 from a seven-point Likert scale.

Key findings

A model emerged from the achieved consensus. There was an early consensus achieved on the core functions that participants were already delivering to the patient with diabetes mellitus. These are functions that have been highlighted and delivered in previous studies within this disease state: receiving and sharing patient information, individualising treatment, identifying unsatisfactory treatment and monitoring and prescribing analgesia.

Conclusions

For service development and linked continued professional development a well-defined service model for delivering pharmaceutical care to patients is required. This study proposes such a model based on consensus among a self-selected group of community pharmacists leading diabetes pharmacy practice in Scotland.

Comparison of Two Point-of-Care Lipid Analyzers for Use in Global Cardiovascular Risk Assessments

Background:

Point-of-care (POC) lipid testing is increasingly used in community-and office-based practice. Two analyzers commonly used in the US are CardioChek PA and Cholostech LDX. Both directly measure total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C), mandatory values in calculating a Framingham Risk Score (FRS). The FRS in turn informs the clinician of the need for lipid-modifying therapy and the degree of therapeutic intensity.

Objective:

To compare the performance of CardioChek PA and Cholestech LDX.

Methods:

Staff members from the Colorado Prevention Center were included in the study, with all having fasted for 12 hours beforo the testing. No medical history was obtained. A venous blood sample was collected for lipid measurements conducted in a laboratory, and 2 finger sticks were obtained at that time and analyzed immediately on-site using the POC analyzers. Intraclass correlation coefficients (ICCs) were determined for each analyzer versus the laboratory analysis, with values greater than 0.75 defined as Indicators of excellent reproducibility. We then assessed how interanalyzer differences in TC or HDL-C impacted the FRS lipid categorization.

Results:

Thirty-four adults (aged 24-56 y) participated in the study. The ICC between Cholestech LDX and the laboratory standard exceeded 075 for all 4 lipid categories (TC, p = 0.96; HDL-C, p = 0.88; low-density lipoprotein cholesterol, ρ = 0.87; triglycerides, ρ = 0.99). By contrast, the only ICC exceeding 0.75 using CardioChek PA was for triglycerides (ρ = 0.84). When applied in calculating the FRS, the Cholestech LDX analyzer misclassified fewer individuals for TC versus the CardioChek PA analyzer (5 vs 21). Overall, Cholestech LDX provided TC and HDL-C values in the correct FRS category more frequently versus CardioChek PA (TC, p < 0.001; HDL-C, p > 0.001). Limitations of the study include use of only 2 POC products and small sample size with no known risk factors. This project does not prove superior accuracy of either device, but reflects a real-world comparison of the analyzers conducted at a single center.

Conclusions:

The Cholestech LDX analyzer demonstrated better reproducibility than the CardioChek PA analyzer when compared with laboratory gold standard analysis and allowed more accurate categorization for FRS. Since results obtained from these analyzers have the potential to impact treatment decisions, larger, prospective, comparative studies seem warranted.

Stepwise Approach to Developing Point-of-Care Testing Services in the Community/Ambulatory Pharmacy Setting

OBJECTIVE

To provide a stepwise approach to development and implementation of a point-of-care testing (POCT) patient care service.

SETTING

Community and ambulatory care pharmacy practice.

PRACTICE DESCRIPTION

To provide community and ambulatory pharmacists with the steps involved in integrating POCT services into their pharmacy practice site.

PRACTICE INNOVATION

Authors used various resources to detail the process of implementing pharmaceutical care in community or ambulatory pharmacy settings in combination with individual practice experiences. The five steps involved in developing a POCT service include conducting a needs assessment, researching and organizing information, developing program materials, implementing the service, and evaluating the service. The narrative description of each step is illustrated by a case study example.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS/CONCLUSION

POCT patient care services are a valuable addition to a pharmacy's services, benefiting patients, health care providers, and the pharmacy. This article presents a structured, deliberate approach with resources that can be used to develop a successful POCT service within a community or ambulatory pharmacy setting.

Devices for ambulatory and home monitoring of blood pressure, lipids, coagulation, and weight management, part 1

PURPOSE

The equipment and methods used for ambulatory and home monitoring of blood pressure, lipids, coagulation, and weight management are discussed.

SUMMARY

Over 100 million people in the United States have one or more chronic diseases, such as diabetes, hypertension, and asthma. With the goal to improve health while reducing costs and the overall health care burden, ambulatory and home monitoring by pharmacists and patients are receiving more attention. Ambulatory and home monitoring of blood pressure, cholesterol, coagulation, and weight management (including devices for assessing overweight and obese patients, heart rate monitors, and pedometers) are convenient for clinicians and patients. Such monitoring provides pharmacists with an opportunity to differentiate their practices. Studies suggest that patients who are involved in ambulatory and home monitoring take a more active role in their health and may have better adherence to prescribed diet and medication regimens. Studies also show that ambulatory and home monitoring, if done correctly, provide clinicians with a large quantity of reliable readings for future therapeutic decisions. Devices are also a means for pharmacists to increase their provision of pharmacy services. Ambulatory monitoring is billable in many clinic settings, and the devices can be a profitable addition to prescription services.

CONCLUSION

Many devices are available to assist patients and clinicians in monitoring blood pressure, lipids, coagulation, and weight management. Familiarity with the devices will help in their proper selection and use.