Costs and effectiveness of pharmacist-led group medical visits for type-2 diabetes: A multi-center randomized controlled trial

Group-delivered interventions for lowering blood pressure in hypertension: a systematic review and meta-analysis

BACKGROUND

Hypertension is the leading modifiable cause of cardiovascular disease. Primary care management is predominantly individual and remains suboptimal. Interventions delivered to groups incorporate peer support and potentially offer efficient use of limited resources. Evidence for the benefits of group-delivered interventions in hypertension is unclear.

AIM

To determine whether group-delivered hypertension interventions improve blood pressure (BP) outcomes compared to usual care (UC).

DESIGN AND SETTING

Systematic review, meta-analyses, and meta-regression of randomised controlled trials in community, primary, or outpatient care settings.

METHOD

MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to 20 March 2024 for randomised controlled trials comparing group-delivered interventions to UC for adults with hypertension. Primary outcomes were changes in systolic and diastolic BP, achievement of study BP targets and medication adherence; quality was assessed using the Cochrane Risk of Bias 2 tool. Data were pooled according to intervention type using random effects meta-analyses; predictors of BP lowering were modelled with meta-regression.

RESULTS

Overall, 5326 citations were retrieved; 59 intervention groups (IGs) from 54 studies (13 976 participants) were included. Compared to UC, systolic BP reduced by 7.2 mmHg (95% confidence interval [CI] = 4.7 to 9.6; 23 IGs) following exercise, 4.8 mmHg (95% CI = 3.2 to 6.4; 26 IGs) following lifestyle education, and 3.6 mmHg (95% CI = 0.3 to 6.9; seven IGs) following psychotherapeutic interventions. Corresponding reductions in diastolic BP were 3.9 mmHg (95% CI = 2.6 to 5.2; 21 IGs), 2.9 mmHg (95% CI = 1.8 to 3.9; 24 IGs), and 1.2 mmHg (95% CI = -1.9 to 4.3; seven IGs). Achievement of target BP and medication adherence were infrequently reported, with equivocal findings (relative risks 1.1, 95% CI = 1.0 to 1.2, P = 0.02, 11 IGs and 1.0, 95% CI = 1.0 to 1.1, P = 0.60, seven IGs, respectively). In multivariable models, higher baseline BP and pre-existing cardiovascular morbidity were associated with greater BP reductions.

CONCLUSION

Group-delivered interventions were effective at lowering BP for people with hypertension compared with UC; their feasibility and cost-effectiveness in primary care require further study.

Health-related quality of life assessment in health economic analyses involving type 2 diabetes

AIM

Incorporating health-related quality of life (HRQoL) measures into health economic analyses can help to provide evidence to inform decisions about how to improve patient outcomes in the most cost-effective manner. The aim of this narrative review was to assess which HRQoL instruments have been used in economic evaluations of type 2 diabetes management including in Indigenous communities.

METHOD

MEDLINE (Ovid), Embase (Ovid) and Cochrane were searched from inception to June 2022. Studies included patients with type 2 diabetes; economic evaluations, derived scores from direct questioning of individuals; and were in English. Records were assessed for bias using the JBI critical appraisal tools.

RESULTS

A total of 3737 records were identified, with 22 publications meeting the criteria for inclusion. Across those 22 articles, nine HRQoL instruments had been utilised. Generic tools were most frequently used to measure HRQoL, including EQ-5D (-3 L and -5 L) (n = 10, 38%); SF-12 (n = 5, 19%); and SF-36 (n = 4, 15%). Two tools addressing the specific stressors faced by people with type 2 diabetes were utilised: Problem Areas In Diabetes tool (n = 1, 4%) and Diabetes Distress Scale (n = 1, 4%). Two publications reported whether the study population included Indigenous peoples.

CONCLUSION

A wide range of HRQoL instruments are used in economic evaluations of type 2 diabetes management, with the most frequent being varying forms of the EQ-5D. Few economic evaluations noted whether Indigenous peoples were featured in the study population. More research into HRQoL in people living with type 2 diabetes is urgently needed to improve evidence on effectiveness and cost-effectiveness of interventions.

Shared Medical Appointments in Heart Failure for Post Acute Care Follow-Up: A Randomized Controlled Trial

BACKGROUND

Shared medical appointments (SMAs) in heart failure (HF) are medical visits where several patients with HF meet with multidisciplinary providers at the same time for efficient and comprehensive care. It is unknown whether HF-SMAs can improve overall and cardiac health status for high-risk patients with HF discharged from acute care.

METHODS AND RESULTS

A 3-site, open-label, randomized-controlled-trial was conducted. Participants within 12 weeks of HF acute care (emergency-room/hospitalization) requiring intravenous diuretic therapy were randomized to receive either HF-SMA or usual HF clinical care (usual-care) on a 1:1 ratio. The HF-SMA team, which consisted of a nurse, nutritionist, psychologist, nurse practitioner and/or a clinical pharmacist, provided four 2-hour session HF-SMAs that met every other week for 8 weeks. Primary outcomes were the overall health status measured by European Quality of Life Visual Analog Scale and cardiac health status by Kansas City Cardiomyopathy Questionnaire, 180 days postrandomization. Of the 242 patients enrolled (HF-SMA n=117, usual-care n=125, mean age 69.3±9.4 years, 71.5% White patients, 94.6% male), 84% of participants completed the study (n=8 HF-SMA and n=9 usual-care patients died). After 180 days, both HF-SMA and usual-care participants had significant improvements from baseline in Kansas City Cardiomyopathy Questionnaire that were not statistically different. Only HF-SMA participants had significant improvements in European Quality of Life Visual Analog Scale (mean change = 7.2±15.8 in HF-SMA versus -0.4±19.0 points in usual-care, P < 0.001).

CONCLUSIONS

Both HF-SMA and usual-care in participants with HF achieved significant improvements in cardiac health status, but only a team approach through HF-SMA achieved significant improvements in overall health status. Future larger studies are needed to evaluate hospitalization and death outcomes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02481921.

Evaluation of a Diabetes Coaching Program on Clinical Outcomes in a Self-Insured Grocery Chain

Background: Diabetes is among the most prevalent and costly disease states to treat. Many self-insured employers offer employee wellness programs to decrease healthcare expenditures for chronic illnesses, such as diabetes. Existing literature demonstrates that pharmacists can positively impact treatment of patients with diabetes and assist in lowering costs of care, but no current literature examines pharmacist intervention within an employee wellness program over a prolonged period of time. Objectives: To quantify the hemoglobin A1c (HbA1c) lowering achieved through participation in a pharmacist-led diabetes coaching program within a self-insured company. Methods: A retrospective chart review was conducted at a self-insured grocery store chain in the Kansas City area with an employee wellness program called Start Now. Patients who enrolled in the Start Now Program for Diabetes Care (SN-DM) between July 1, 2008 and July 1, 2021 with at least two documented HbA1c measurements were included in the analysis. Results: A total of 355 charts were included in the analysis. The average HbA1c reduction observed in program patients was 0.61% (P < .001). At baseline, 40% of program patients were considered to have controlled diabetes (A1c <7%) compared with 60% of patients at most recent HbA1c (P < .001). There was no correlation between HbA1c lowering and number of pharmacist coaching visits; however, greater HbA1c lowering was observed in patients with a higher baseline HbA1c. Conclusion: Patients who participated in the SN-DM program achieved a significant decrease in mean HbA1c. More patients were considered controlled at last or most recent HbA1c according to the American Diabetes Association guidelines.

Effectiveness of shared medical appointments delivered in primary care for improving health outcomes in patients with long-term conditions: a systematic review of randomised controlled trials

OBJECTIVES

To examine the effectiveness of shared medical appointments (SMAs) compared with one-to-one appointments in primary care for improving health outcomes and reducing demand on healthcare services by people with one or more long-term conditions (LTCs).

DESIGN

A systematic review of the published literature.

DATA SOURCES

Six databases, including MEDLINE and Web of Science, were searched 2013-2023. Relevant pre-2013 trials identified by forward and backward citation searches of the included trials were included.

ELIGIBILITY CRITERIA

Randomised controlled trials of SMAs delivered in a primary care setting involving adults over 18 years with one or more LTCs. Studies were excluded if the SMA did not include one-to-one patient-clinician time. All countries were eligible for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and outcomes narratively synthesised, meta-analysis was undertaken where possible.

RESULTS

Twenty-nine unique trials were included. SMA models varied in terms of components, mode of delivery and target population. Most trials recruited patients with a single LTC, most commonly diabetes (n=16). There was substantial heterogeneity in outcome measures. Meta-analysis showed that participants in SMA groups had lower diastolic blood pressure than those in usual care (d=-0.086, 95% CI=-0.16 to -0.02, n=10) (p=0.014). No statistically significant differences were found across other outcomes. Compared with usual care, SMAs had no significant effect on healthcare service use. For example, no difference between SMAs and usual care was found for admissions to emergency departments at follow-up (d=-0.094, 95% CI=-0.27 to 0.08, n=6, p=0.289).

CONCLUSIONS

There was a little difference in the effectiveness of SMAs compared with usual care in terms of health outcomes or healthcare service use in the short-term (range 12 weeks to 24 months). To strengthen the evidence base, future studies should include a wider array of LTCs, standardised outcome measures and more details on SMA components to help inform economic evaluation.

PROSPERO REGISTRATION NUMBER

CRD42020173084.

An Overview of Pharmaceutical Care in Type II Diabetes Mellitus Patients: Current Position and Prospects

Diabetes mellitus is an ongoing disease that is related to a high mortality rate due to severe complications. Diabetes mellitus type 2 (DMT2) is a persistent metabolic deficiency and its prevalence has been increasing consistently worldwide. As a result, it is rapidly turning into a plague in some parts of the world, and the number of people affected is expected to double in the following decade due to an increase in the maturing populace, adding to the overall existing importance for medical service providers, particularly in the underdeveloped nations. Extensive diabetes care is an intricate task that takes a whole group of medical care experts, including drug specialists, to provide multidisciplinary care for the patients. The duty of drug experts has changed significantly in recent years, changing from conventional drug dispensing in the drug store to patient- centered clinical support services. Upgrading the medication treatment to accomplish better remedial results without causing drug-related issues has been considered the essential objective of treatment for diabetic patients. This review discusses the healthcare needs of patients with T2DM, the current evidence for the role of pharmacists in diabetes care, and insight into the upcoming role of pharmacists in its management. The advanced role of clinical pharmacists in diabetes control through drug treatment, diabetes care centers, and diabetes health counselor schooling, is also discussed in this review.

Impact of group medical visits on patient engagement and quality of life

BACKGROUND

Group medical visits (GMV) effectively improve patient care and outcomes through interactive education, increased patient contact, and facilitated social support. This quality improvement research examined if patient activation and quality of life correlate with weight, blood pressure (BP), and hemoglobin A1c (A1C) through GMV interventions.

METHODS

Participants were enrolled in GMV Lighten Up for weight management or GMV Diabetes. At pre- and post-intervention, patients completed the Patient Activation Measure (PAM) and the health-related quality of life measure, the SF-12; and were assessed for weight, blood pressure (BP), and hemoglobin A1c (A1C).

RESULTS

Weight and PAM scores significantly improved regardless of group. For patients in GMV Diabetes, A1C significantly decreased. GMV Lighten Up participants had statistically significant declines in diastolic BP. Both groups improved patient activation, but statistically significantly so only in GMV Diabetes participants. SF-12 scores did not statistically significantly improve. There were no predictors of A1C and PAM score change for the Diabetes GMV. However, age, SBP and SF-12 scores predicted PAM score changes in GMV Lighten up participants.

CONCLUSIONS

Participants in this study showed overall improvement in biomarkers and patient activation. Thus, GMV continue to be a viable method for healthcare delivery.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

The intervention strategies and service model for pharmacist-led diabetes management: a scoping review

BACKGROUND

There is increasing intervention activities provided during pharmacist-led diabetes management. Nevertheless, there is an unclear definition of the activities involved during the intervention. Thus, this study aimed to describe the type of intervention strategies and service model provided during pharmacist-led type 2 diabetes management and service outcomes.

METHODS

This study utilized the scoping review methodology of the Joanna Briggs Institute Reviewers' Manual 2015. Articles on pharmacist-led diabetes management focusing on the service content, delivery methods, settings, frequency of appointments, collaborative work with other healthcare providers, and reported outcomes were searched and identified from four electronic databases: Ovid Medline, PubMed, Scopus, and Web of Science from 1990 to October 2020. Relevant medical subject headings and keywords, such as "diabetes," "medication adherence," "blood glucose," "HbA1c," and "pharmacist," were used to identify published articles.

RESULTS

The systematic search retrieved 4,370 articles, of which 61 articles met the inclusion criteria. The types of intervention strategies and delivery methods were identified from the studies based on the description of activities reported in the articles and were tabulated in a summary table.

CONCLUSION

There were variations in the descriptions of intervention strategies, which could be classified into diabetes education, medication review, drug consultation/counseling, clinical intervention, lifestyle adjustment, self-care, peer support, and behavioral intervention. In addition, most studies used a combination of two or more intervention strategy categories when providing services, with no specific pattern between the service model and patient outcomes.

The cost-effectiveness of different types of educational interventions in type II diabetes mellitus: A systematic review

Aims: Educational interventions are effective to improve peoples’ self-efficacy in managing diabetes complications and lifestyle changes. This systematic review aims to assess and compare various aspects of educational interventions and to provide updated pharmacoeconomics data.

Methods: Literature searches were conducted using databases such as EBSCOhost, Ovid, PubMed, Scopus, and Web of Science. Outcomes such as study characteristics, costs, medication adherence, effectiveness and were narratively summarized, and the quality of each article was assessed.

Results: A total of 27 studies were retrieved. The types of educational interventions were classified as face-to-face strategy, structured programs, telemedicine health education, a combination approach, and others. All types of educational interventions (N = 24, 89%) were reported to be cost-effective. The cost-effectiveness of the other two studies was considered to be not cost-effective while the outcome of one study could not be determined. The majority of the studies (N = 24, 89%) had moderate-quality evidence whereas thirteen (48%) studies were regarded to provide high-quality economic evaluations.

Conclusion: All types of educational interventions are highly likely to be cost-effective. The quality of economic evaluations is moderate but the most cost-effective types of educational interventions could not be determined due to variations in the reporting and methodological conduct of the study. A high-quality approach, preferably utilizing the societal perspective over a long period, should be standardized to conduct economic evaluations for educational interventions in T2DM.

Systematic Review Registration: website, identifier registration number.

Cost-effectiveness analysis of implementing a secondary prevention programme in those patients who visited an emergency department for drug-related problems

OBJECTIVE

To evaluate the cost-effectiveness of a secondary prevention programme in patients admitted to the emergency department due to drug-related problems (DRPs).

METHODS

A decision model compared costs and outcomes of patients with DRPs admitted to the emergency department. Model variables and costs, along with their distributions, were obtained from the trial results and literature. The study was performed from the perspective of the National Health System including only direct costs.

KEY FINDINGS

The implementation of a secondary prevention programme for DRPs reduces costs associated with emergency department revisits, with an annual net benefit of €87 639. Considering a mortality rate attributable to readmission of 4.7%, the cost per life-years gained (LYG) with the implementation of this programme was €2205. In the short term, the reduction in the number of revisits following the programme implementation was the variable that most affected the model, with the benefit threshold value corresponding to a relative reduction of 12.4% of the number of revisits of patients with DRPs to obtain benefits.

CONCLUSIONS

Implementing a secondary prevention programme is cost-effective for patients with DRPs admitted to the emergency department. Implementation costs will be exceeded by reducing revisits to the emergency department.

Impact of Pharmacist-Led Interventions to Improve Clinical Outcomes for Adults With Type 2 Diabetes at Risk of Developing Cardiovascular Disease: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis of randomised controlled trials is to evaluate the impact of pharmacist-led interventions on cardiovascular disease (CVD) risk factors among patients with type 2 diabetes.

METHOD

A literature review was conducted according to PRISMA guidelines using 4 electronic databases: Embase, MEDLINE, CINHAL and the Cochrane Central Register of Controlled Trials. We searched for pharmacist interventions among adults with type 2 diabetes and cardiovascular disease in randomised controlled trials from inception to May 2021 in primary care, diabetes clinics and hospitals. The clinical outcomes measured glycosylated haemoglobin (HbA1c), blood pressure (BP) and lipid profile. The non-clinical outcomes included medication adherence, smoking, health-related quality of life and the cost of the intervention. For the meta-analysis, clinical outcomes were pooled with the random effect model in RevMan 5.3. The Cochrane risk-of-bias tool was used to assess the quality of the included studies.

RESULTS

We retrieved 223 studies,141 of which were included in the review. Ten published articles met the inclusion criteria and were included in the meta-analysis. The pharmacists delivered the interventions alone or collaboratively with other healthcare professionals in hospitals or similar settings. The overall result showed a significant reduction in HbA1c (n = 10; standard deviation in mean value [SDM]: -.53%, 95% CI: -.84, -.23) and systolic BP (n = 10; [SDM]: -.35 mmHg, 95% CI: -.51, -.20) in pharmacist intervention groups. For the non-clinical outcomes, the review revealed variable results from pharmacist intervention compared with those standard care.

CONCLUSION

Pharmacy interventions provide evidence for pharmacists' decisive role in diabetes care management and reducing cardiovascular risk factors among adults with type 2 diabetes.

Impact of pharmacist services on economic, clinical, and humanistic outcome (ECHO) of South Asian patients: a systematic review

BACKGROUND

Pharmacists in high-income countries routinely provide efficient pharmacy or pharmaceutical care services that are known to improve clinical, economic, and humanistic outcomes (ECHO) of patients. However, pharmacy services in low- and middle-income countries, mainly South Asia, are still evolving and limited to providing traditional pharmacy services such as dispensing prescription medicines. This systematic review aims to assess and evaluate the impact of pharmacists' services on the ECHO of patients in South Asian countries.

METHODS

We searched PubMed/Medline, Scopus, EMBASE, CINAHL, and Cochrane Library for relevant articles published from inception to 20th September 2021. Original studies (only randomised controlled trials) conducted in South Asian countries (published only in the English language) and investigating the economic, clinical (therapeutic and medication safety), and humanistic impact (health-related quality of life) of pharmacists' services, from both hospital and community settings, were included.

RESULTS

The electronic search yielded 430 studies, of which 20 relevant ones were included in this review. Most studies were conducted in India (9/20), followed by Pakistan (6/20), Nepal (4/20) and Sri Lanka (1/20). One study showed a low risk of bias (RoB), 12 studies showed some concern, and seven studies showed a high RoB. Follow-up duration ranged from 2 to 36 months. Therapeutic outcomes such as HbA1c value and blood pressure (systolic blood pressure and diastolic blood pressure) studied in fourteen studies were found to be reduced. Seventeen studies reported humanistic outcomes such as medication adherence, knowledge and health-related quality of life, which were found to be improved. One study reported safety and economic outcomes each. Most interventions delivered by the pharmacists were related to education and counselling of patients including disease monitoring, treatment optimisation, medication adherence, diet, nutrition, and lifestyle.

CONCLUSION

This systematic review suggests that pharmacists have essential roles in improving patients' ECHO in South Asian countries via patient education and counselling; however, further rigorous studies with appropriate study design with proper randomisation of intervention and control groups are anticipated.

Group Medical Care: A Systematic Review of Health Service Performance

Group care models, in which patients with similar health conditions receive medical services in a shared appointment, have increasingly been adopted in a variety of health care settings. Applying the Triple Aim framework, we examined the potential of group medical care to optimize health system performance through improved patient experience, better health outcomes, and the reduced cost of health care. A systematic review of English language articles was conducted using the Cochrane Controlled Trials Register (CENTRAL), MEDLINE/PubMed, Scopus, and Embase. Studies based on data from randomized control trials (RCTs) conducted in the US and analyzed using an intent-to-treat approach to test the effect of group visits versus standard individual care on at least one Triple Aim domain were included. Thirty-one studies met the inclusion criteria. These studies focused on pregnancy (n = 9), diabetes (n = 15), and other chronic health conditions (n = 7). Compared with individual care, group visits have the potential to improve patient experience, health outcomes, and costs for a diversity of health conditions. Although findings varied between studies, no adverse effects were associated with group health care delivery in these randomized controlled trials. Group care models may contribute to quality improvements, better health outcomes, and lower costs for select health conditions.

Economic Impact and Health Care Utilization Outcomes of Diabetes Self-Management Education and Support Interventions for Persons With Diabetes: A Systematic Review and Recommendations for Future Research

PURPOSE

Value-driven outcomes are important because health systems determine sustainability of diabetes self-management education and support (DSMES) programming. Health care utilization and clinical outcomes are critical factors when considering the impact of DSMES programs.

OBJECTIVE

The aim of this systematic review was to describe studies that report on the economic and health care utilization outcomes of diabetes self-management programs.

METHODS

A systematic literature review was performed in multiple databases. Studies reporting economic and health care utilization outcomes related to DSMES and including 1 or more of the ADCES7 Self-Care BehaviorsTM from January 2006 to May 2020 were included. Eligible articles needed to compare the intervention and comparison group and report on economic impact. The methodological quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist specific to each individual study design.

RESULTS

A total of 22 of 14 556 articles published between 2007 and 2020 were included. Cost benefits varied, and there were considerable methodological heterogeneity among design, economic measures, population, perspective, intervention, and biophysical outcomes.

CONCLUSION

DSMES interventions may positively impact economic outcomes and/or health care utilization, although not all studies showed consistent benefit. This review highlights an evidence gap, and future health economic evaluations are warranted.

The Impact of Pharmaceutical Care in Multidisciplinary Teams on Health Outcomes: Systematic Review and Meta-Analysis

OBJECTIVES

Pharmacists' care has an essential role in multidisciplinary teams in charge of chronic patients. However, data available on the clinical outcomes of these activities appear inconclusive. This study aimed to systematically investigate the effect of multidisciplinary teams that include coordinated pharmaceutical care on clinical outcomes.

DESIGN

Systematic review and meta-analysis. Relevant studies identified from MEDLINE, Cochrane, Web of Science, Scopus and CINAHL databases were analyzed. The search included randomized clinical trials published in 2000-2018. Included studies were all published studies in English that compared the effectiveness of multidisciplinary teams including pharmacist care to usual care. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity.

SETTING AND PARTICIPANTS

29 studies involving 4186 adult patients were included.

MEASURES

Follow-up time varied from 30 to 180 days. The most common primary endpoint was the frequency of hospitalizations or readmissions, followed by variation in clinical parameter variables related to quality of prescription, treatment adherence and costs.

RESULTS

Twelve (41.3%) of the included studies scored low risk of bias according to the AMSTAR-2 scale, the remaining 17 (58.7%) being classified as intermediate risk. The intervention of a multidisciplinary team reduced the probability of readmission by 32% [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.62-0.89]. Six of the 29 (20.7%) studies included met the inclusion criteria of the meta-analysis on quality-of-life outcomes. The intervention of the multidisciplinary team represented a significant increase in patients' quality of life (OR 0.58, 95% CI 0.47-0.69). Analysis of heterogeneity showed a significant difference between the studies. No evidence of publication bias was identified.

CONCLUSIONS AND IMPLICATIONS

Multidisciplinary programs that include pharmaceutical care reduce the risk of visiting hospitals and improve patients' quality of life. This review supports the importance of the pharmacists as part of multidisciplinary teams.

Impact of clinical pharmacy interventions on health and economic outcomes in type 2 diabetes: A systematic review and meta-analysis

AIM

To examine the effectiveness of clinical pharmacy interventions on health and economic outcomes of people with type 2 diabetes in hospital settings.

METHODS

We searched MEDLINE, EMBASE, PsycInfo, CINAHL, COCHRANE Library and citations and reference lists of key articles. We included randomized and non-randomized controlled trials, cohort and controlled before-after studies. Primary outcomes were glycosylated haemoglobin (HbA_1c ), all-cause mortality, major cardiovascular events, adverse events (AEs), health-related quality of life and economic outcomes.

RESULTS

We retrieved 11,853 studies, of which 44 studies were included in the review (n = 8623). We included 29 randomized controlled studies in the meta-analyses (n = 4055). Clinical pharmacy interventions significantly reduced HbA_1c levels compared to usual care (standardized mean difference: -0.52, p < 0.001). The interventions significantly reduced AEs compared to usual care. No studies were reported on the effectiveness of clinical pharmacy interventions on major cardiovascular events. In one study that examined the impact of clinical pharmacy interventions on all-cause mortality, a non-significant reduction was observed compared with usual care. There was significant improvement in quality of life and significant reduction in costs of type 2 diabetes care compared to usual care.

CONCLUSIONS

Clinical pharmacy interventions were effective in improving glycaemic control, quality of life and reducing the rate of AEs and costs of type 2 diabetes care.

Evaluating the Effectiveness of Diabetes Shared Medical Appointments (SMAs) as Implemented in Five Veterans Affairs Health Systems: a Multi-site Cluster Randomized Pragmatic Trial

OBJECTIVE

To examine whether diabetes shared medical appointments (SMAs) implemented as part of usual clinical practice in diverse health systems are more effective than usual care in improving and sustaining A1c improvements.

RESEARCH DESIGN AND METHODS

A multi-site cluster randomized pragmatic trial examining implementation in clinical practice of diabetes SMAs in five Veterans Affairs (VA) health systems was conducted from 2016 to 2020 among 1537 adults with type 2 diabetes and elevated A1cs. Eligible patients were randomly assigned to either: (1) invitation to participate in a series of SMAs totaling 8-9 h; or (2) continuation of usual care. Relative change in A1c (primary outcome) and in systolic blood pressure, insulin starts, statin starts, and anti-hypertensive medication classes (secondary outcomes) were measured as part of usual clinical care at baseline, at 6 months and at 12 months (~7 months after conclusion of the final SMA in four of five sites). We examined outcomes in three samples of SMA participants: all those scheduled for a SMA, those attending at least one SMA, and those attending at least half of SMAs.

RESULTS

Baseline mean A1c was 9.0%. Participants scheduled for an SMA achieved A1c reductions 0.35% points greater than the control group between baseline and 6-months follow up (p = .001). Those who attended at least one SMA achieved reductions 0.42 % points greater (p < .001), and those who attended at least half of scheduled SMAs achieved reductions 0.53 % points greater (p < .001) than the control group. At 12-month follow-up, the three SMA analysis samples achieved reductions from baseline ranging from 0.16 % points (p = 0.12) to 0.29 % points (p = .06) greater than the control group.

CONCLUSIONS

Diabetes SMAs as implemented in real-life diverse clinical practices improve glycemic control more than usual care immediately after the SMAs, but relative gains are not maintained. Our findings suggest the need for further study of whether a longer term SMA model or other follow-up strategies would sustain relative clinical improvements associated with this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT02132676.

Evaluation of Patient Factors Associated With Achieving Goal Hemoglobin A1c in Collaborative Drug Therapy Management Ambulatory Care Clinics by Clinical Pharmacists: A Retrospective Chart Review

Background: Literature has shown the positive impact pharmacists have on diabetic outcome measures through collaborative drug therapy management (CDTM). There is minimal literature evaluating characteristics and clinical factors of patients who benefit from CDTM diabetes clinics by pharmacists. Objective: Identify patient characteristics and clinical factors that may be associated with patients who reach goal hemoglobin A1c (HbA1c) of <7% at discharge by pharmacists practicing under CDTM agreements. Methods: This retrospective chart review included patients referred to pharmacist CDTM clinics for type 2 diabetes with an HbA1c goal of <7%. Data were extracted from the electronic medical record at enrollment and discharge. Results: Of the 228 patients included, 84 achieved a goal HbA1c of <7%. Factors predictive of patient success were Asian ethnicity (odds ratio [OR] = 19.32), baseline HbA1c of 7% to 7.9% (OR = 2.34), enrolled in clinic for 5 to 6 months (OR = 2.06), in-person visit every 4 to <8 weeks (OR = 3.06), not on insulin initially or at discharge (OR = 1.79, OR = 2.02), or discharged on a glucagon-like peptide-1 receptor agonist (OR = 1.83). Factors predictive of not reaching goal were Black or African American ethnicity (OR = 0.42), <5 encounters of any type (OR = 0.44), an encounter of any type every 8 weeks or more (OR = 0.08), or discharged on a sodium-glucose cotransporter-2 inhibitor (OR = 0.27). Conclusion: Several clinical and demographic factors were identified that influenced a patient's ability to reach a goal HbA1c of <7%. The results of this study may be applied to further advance pharmacist-run clinics in optimizing diabetes care for patients.

Clinical pharmacists´ interventions in the management of type 2 diabetes mellitus: a systematic review

Background

Type 2 diabetes mellitus is a chronic disease that is reaching epidemic proportions worldwide. It is imperative to adopt an integrated strategy, which involves a close collaboration between the patient and a multidisciplinary team of which pharmacists should be integral elements.

Objective

This work aims to identify and summarize the main effects of interventions carried out by clinical pharmacists in the management of patients with type 2 diabetes, considering clinical, humanistic and economic outcomes.

Methods

PubMed and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials assessing the effectiveness of such interventions compared with usual care that took place in hospitals or outpatient facilities.

Results

This review included 39 studies, involving a total of 5,474 participants. Beneficial effects were observed on various clinical outcomes such as glycemia, blood pressure, lipid profile, body mass index and coronary heart disease risk. For the following parameters, the range for the difference in change from baseline to final follow-up between the intervention and control groups was: HbA1c, -0.05% to -2.1%; systolic blood pressure, +3.45 mmHg to -10.6 mmHg; total cholesterol, +10.06 mg/dL to -32.48 mg/dL; body mass index, +0.6 kg/m² to -1.94 kg/m²; and coronary heart disease risk, -3.0% and -12.0% (among the studies that used Framinghan prediction method). The effect on medication adherence and health-related quality of life was also positive. In the studies that performed an economic evaluation, the interventions proved to be economically viable.

Conclusions

These findings support and encourage the integration of clinical pharmacists into multidisciplinary teams, underlining their role in improving the management of type 2 diabetes.

Group education program for hypertension control

Hypertension continues to be a health crisis, with multiple approaches attempting to define best practices for management. The objective of our hypertension group education program is to improve patient health outcomes through engaging a multidisciplinary health professional team. A 6-hour group curriculum was created with a focus on nutrition, lifestyle, and medication approaches to hypertension management, while incorporating personally identified behavior change goals and barriers. Outcomes were tracked pre-program, at program completion, and 6 and 12 months post-program completion. Program participants demonstrated immediate and sustained improvements in blood pressure readings and attainment of personal behavior change goals. Group hypertension education classes are an effective way to care for patients. Additional healthcare resources should be dedicated to creating and evaluating educational delivery models that are sustainable and provide results over time, including financial implications to the health system.

Improving Medication Adherence in an ACO Primary Care Office With a Pharmacist-Led Clinic: A Report From the ACORN SEED

BACKGROUND

As health care moves into the era of value-based medicine, both ambulatory and acute settings are being held accountable for the quality of care provided to patients. Previous studies have shown improved clinical outcomes through medication therapy management (MTM) due to improved medication adherence.

OBJECTIVE

The purpose of this study is to assess the effects of a pharmacist-led MTM clinic in an accountable care organization (ACO) affiliated primary care office on adherence to renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported through Healthcare Effectiveness Data and Information Set (HEDIS) Medicare Star Ratings.

METHODS

In this retrospective cohort study, data were collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated with a RAS antagonist, statin, or diabetic medication. The primary outcome of this investigation was a change in Star Rating scores for medication adherence to RAS antagonists, diabetic medications, and statins from pre- and postpharmacist MTM intervention.

RESULTS

A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25 interventions. One year prior to MTM clinic implementation, most Star Ratings were consistently 3 (out of 5) for RAS antagonists, diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Conclusion: Implementing a pharmacist-led MTM clinic in the ACO primary care setting improves Medicare Star Ratings in patients with chronic conditions.

Impact of Pharmacist-Led Drug Therapy Management Services on HbA1c Values in a Predominantly Hispanic Population Visiting an Outpatient Endocrinology Clinic

PURPOSE

To assess the impact pharmacists have on improving glycemic control among predominantly Hispanic diabetic patients visiting an endocrinology clinic in South Texas. Pharmacists were recently integrated into this clinic to be part of a collaborative team.

METHODS

This study follows a retrospective cohort design. All patients received diabetic care from endocrinologists, and some received pharmacist-led drug therapy management (PDTM). Patients with ≥1 PDTM were categorized as the intervention group and those without PDTM as the standard of care (SOC) group. The outcome variables were the mean absolute change in glycosylated hemoglobin (HbA_1c) from baseline and the proportion of patients at goal HbA_1c (<7%) postintervention.

RESULTS

Data were collected from 222 patients (n = 120 SOC patients, n = 102 PDTM patients). The mean age was 61 ± 14 years, 136 (61%) were female, and 197 (89%) were Hispanic. The mean absolute change in HbA_1c was -1.3%. In the adjusted model, the mean absolute change in HbA_1c in the PDTM compared to the SOC group was not significant (-0.1% ± 0.2%; P < .74), and concurrent interventions from registered dieticians (RDs) and licensed professional counselors (LPC) were identified as effect modifiers of the association. The stratum specific analysis identified the greatest decrease in HbA_1c when the three interventions (ie, PDTM, RD, and LPC) coincided (-1.0% ± 0.3%; P < .01). Postintervention, 25% of those who received PDTM achieved an HbA_1c<7% as compared to 19% in the SOC group.

CONCLUSION

The clinical importance of pharmacists is enhanced when integrated with behavioral modifying programs to achieve additional improvement in HbA_1c.

Palliative Care Consultation Reduces Heart Failure Transitions: A Matched Analysis

Background

Palliative care supports quality of life, symptom control, and goal setting in heart failure (HF) patients. Unlike hospice, palliative care does not restrict life‐prolonging therapy. This study examined the association between palliative care during hospitalization for HF on the subsequent transitions and procedures.

Methods and Results

Veterans admitted to hospitals with HF from 2010 to 2015 were randomly selected for the Veterans Administration External Peer Review Program. Variables pertaining to demographic, clinical, laboratory, and usage were captured from Veterans Administration electronic records. Patients receiving hospice services before admission were excluded. Patients who received palliative care were propensity matched to those who did not. The primary outcomes were whether the patient experienced transitions or procedures in the 6 months after admission. Transitions included multiple readmissions (≥2) or intensive care admissions and procedures included mechanical ventilation, pacemaker implantation, or defibrillator implantation. Among 57 182 hospitalized HF patients, 1431 received palliative care, and were well matched to 1431 without (standardized mean differences ≤ ±0.05 on all matched variables). Palliative care was associated with significantly fewer multiple rehospitalizations (30.9% versus 40.3%, P<0.001), mechanical ventilation (2.8% versus 5.4%, P=0.004), and defibrillator implantation (2.1% versus 3.6%, P=0.01). After adjustment for facility fixed effects, palliative care consultation was associated with a significantly reduced hazard of multiple readmissions (adjusted hazard ratio=0.73, 95% CI, 0.64–0.84) and mechanical ventilation (adjusted hazard ratio=0.76, 95% CI, 0.67–0.87).

Conclusions

Palliative care during HF admissions was associated with fewer readmissions and less mechanical ventilation. When available, engagement of HF patients and caregivers in palliative care for symptom control, quality of life, and goals of care discussions may be associated with reduced rehospitalizations and mechanical ventilation.

Group education for adolescents with type 1 diabetes during transition from paediatric to adult care: study protocol for a multisite, randomised controlled, superiority trial (GET-IT-T1D)

INTRODUCTION

Transition from paediatric to adult care is challenging for adolescents and emerging adults (ages 18 to 30 years) with type 1 diabetes (T1D). This transition is characterised by a deterioration in glycaemic control (haemoglobin A1c (HbA1c)), decreased clinical attendance, poor self-management and increased acute T1D-related complications. However, evidence to guide delivery of transition care is lacking. Given the effectiveness of group education in adult diabetes glycaemic control and improvements in qualitative measures in paediatric diabetes, group education is a potentially feasible and cost-effective alternative for the delivery of transition care. In emerging adults with T1D, we aim to assess the effectiveness of group education visits compared with usual care on HbA1c, T1D-related complications, psychosocial measures and cost-effectiveness after the transfer to adult care.

METHODS AND ANALYSIS

In a multisite, assessor-blinded, randomised, two-arm, parallel-group, superiority trial, 212 adolescents with T1D (ages 17 years) are randomised to 12 months group education versus usual T1D care before transfer to adult care. Visits in the active arm consist of group education sessions followed by usual T1D care visits every 3 months. Primary outcome is change in HbA1c measured at 24 months. Secondary outcomes are delays in establishing adult diabetes care, T1D-related hospitalisations and emergency department visits, severe hypoglycaemia, stigma, self-efficacy, diabetes knowledge, transition readiness, diabetes distress, quality of life and cost-effectiveness at 12 and 24 months follow-up. Analysis will be by intention-to-treat. Change in HbA1c will be calculated and compared between arms using differences (95% CI), along with cost-effectiveness analysis. A similar approach will be conducted to examine between-arm differences in secondary outcomes.

ETHICS AND DISSEMINATION

The study was approved by McGill University Health Centre Research Ethics Board (GET-IT/MP-37-2019-4434, version 'Final 1.0 from November 2018). Study results will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03703440.