Assessing Impact of Community Clinic, Updated Care Guidelines on Patients With Diabetes

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Two posters presented at ASHP Midyear 2023 explored the impact of diabetes management interventions among patients with diabetes.

Patients with diabetes require a comprehensive approach to care that addresses key areas of treatment like lifestyle management, medication, and education and support. New diabetes treatment methods and guidelines for care are constantly being developed and shaped, offering hope for a future where diabetes can be managed more effectively.

Two posters presented at the American Society of Health-System Pharmacists 2023 Midyear Clinical Meeting and Exhibition assessed the impact of diabetes management interventions among patients with diabetes.

The first study, which sought to assess the effectiveness of patient-centered team care of patients with diabetes in a stand-alone 501c3 nonprofit facility for hemoglobin A1C (HbA1C), urine microalbumin/creatinine (uACR), and lipids (low-density lipoprotein [LDL], total cholesterol, and triglycerides), determined that continued educational, nutritional, and other community services may help improve the performance of each diabetes-related quality measure.1

Data on patients receiving treatment at the clinic, which provides free medical care, medications, and nutritional and laboratory services to low-income, uninsured patients, was gathered from the Athena Electronic Health Record between October 2021 and March 2023.

Data availability and the number of patients (aged 34-77 years) selected for HbA1c, uACR, and lipids were 90 patients (55 females), 39 patients (21 females) and 63 patients (37 females), respectively. To evaluate and manage each quality measure, investigators implemented the following goals: HbA1c < 9%, uACR < 30 mg/G, LDL < 80 mg/dL, total cholesterol < 150 mg/dL, and triglycerides < 150 mg/dL.

Although investigators noted that chi-square statistics did not exceed critical values for any quality measure, they did mention that each quality measure demonstrated clinical improvement. In the future, investigators noted, the performance of HbA1C, uACR, and lipids may further improve with the implementation of critical community services.

The second study suggested that recent updates published in the American Diabetes Association (ADA) guidelines regarding the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) among patients with type 2 diabetes (T2D) and comorbidities such as atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and heart failure (HF), may contribute to the increased utilization of SGLT2i within the patient population.2

On behalf of updated evidence-based treatment recommendations made to ADA guidelines in 2022, investigators sought to assess rates of guideline-compliant prescribing of SGLT2i among patients with T2D and comorbidities within the Atrius clinical pharmacy chronic disease state management (CDTM) clinic, internal/family medicine (IM/FM), and specialty medicine department (cardiology, nephrology) sites.

The study utilized a retrospective chart review approach and included patients with T2D and either ASVCD, CKD, or HF who were enrolled and managed by either the clinical pharmacy CDTM, IM/FM, or specialty medicine departments between June 2021 and June 2022.

The primary outcome measured the rate of initiation of SGLT2i in patients with T2D and a comorbidity of 1 or more of ASCVD, CKD, or HF 6 months prior to and 6 months post ADA guideline publication, and the secondary outcome compared the number of patients managed by the clinical pharmacy CDTM clinic, the primary care team, or the specialty provider. Further, subgroup analysis outcomes determined the number of SGLT2i prescription starts in patients with T2D across each comorbidity listed.

Among patients who met inclusion criteria, 354 (3.3%) were initiated on an SGLT2i during the study period (92% on empagliflozin, 8% on dapagliflozin). Investigators observed that the average number of SGLT2i initiations increased from 5 prescriptions per week prior to the ADA guideline publication to 7 prescriptions per week after. The most SGLT2i prescriptions were started in the internal medicine department (62%), followed by cardiology (12%) and nephrology (10%).

Patients with T2D and ASCVD (n = 106) had the most SGLT2i prescription starts followed by T2D and CKD (n = 98), and the T2D and CKD group witnessed the largest change in average number of prescriptions (4.9% increase) from 6 months prior to 6 months post the guideline publication.

Investigators noted that although rates of utilization of SGLT2i in the study was low overall, the gradual increase of these rates suggests further opportunities to optimize the use of SGLT2i among patients with T2D and comorbidities like ASCVD, CKD, and HF.

Reference
1. Balasubramanian R, Cooke J, Novak L, Milliken L. Assessment of hemoglobin A1C, urine microalbumin/creatinine, and lipids management in low-income, uninsured patients with diabetes in a community free clinic. Presented at: American Society of Health-System Pharmacists Midyear Clinical Meeting & Exhibition; December 3-7, 2023; Anaheim, CA. Poster 8-004.
2. Bogannam A, DeLeonardo K, McNicol E, Ranade A, Zaiken K. Impact of American Diabetes Assocation 2022 guidelines on prescribing rates of sodium-glucose cotransporter-2 inhibitors in ambulatory care organization patients with type 2 diabetes. Presented at: American Society of Health-System Pharmacists Midyear Clinical Meeting & Exhibition; December 3-7, 2023; Anaheim, CA. Poster 4-005.
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