How Pharmacists Are Helping Patients with Diabetes in a Rural Area

While previous studies have shown how the involvement of pharmacists in diabetes care can greatly improve health outcomes, a recent study demonstrates their success in rural settings.

The rate of diabetes is 17% higher in rural compared to urban areas. Because of this, researchers set out to compare diabetes-related outcomes for patients with type 2 diabetes managed by a pharmacist diabetes clinic in a rural setting to those of patients who received care only from a primary care physician.

The retrospective study was led by Cynthia Moreau, PharmD, who was an ambulatory care pharmacy resident at the University of Florida College of Pharmacy/UF Health Family Medicine at the time of the study. It was published in the January 7 issue of the Annals of Pharmacotherapy.

At the University of Florida Health Family Medicine Clinic in Dixie County, FL, medical records from 21 patients were matched with those from control patients seen only by primary care physicians. Pharmacists and/or primary care providers had seen these patients at least twice at the clinic over a one-year period.

The sole pharmacist at the clinic is a certified diabetes educator, assisted by a postgraduate year 2 (PGY2) ambulatory care pharmacy resident. Both were funded by the UF College of Pharmacy to provide counseling services four days a week. The clinic is also staffed by five physicians and two physician assistants specializing in family medicine.

The pharmacist and resident worked under a collaborative practice agreement to provide a number of services, including anticoagulation monitoring, diabetes management, hypertension and hyperlipidemia management, smoking cessation, and Medicare Annual Wellness Visits. On average, pharmacists completed a total of 90 patient visits per month for all the services, of which approximately 20 to 30 were for diabetes management.

At the clinic, the pharmacists met with patients for 45 to 60 minutes to review the patient’s medication list, assess self-monitoring of blood glucose values, discuss dietary patterns, activity status, appropriate self-care behaviors (i.e., foot self-exams), and evaluate adherence to recommended screenings. Patients were typically seen every four weeks, although they could be seen more frequently if there were recent changes to their diabetic regimen or as deemed otherwise necessary by the pharmacist.

The type2 diabetes patients included as cases in the study were at least 18 years old with an A_1C ≥7% and were established with the pharmacist diabetes clinic. They were seen between July 1, 2013, and July 1, 2014. The patients were followed for 12 months after their first visit.

Patients who were managed by the pharmacists were found to have had a statistically significant A_1C reduction of greater than 0.5%. Statistically significant secondary improvements included angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, statin use, achievement of blood pressure of 40/90 mm Hg, and adherence to recommended nephropathy screenings.

In addition, patients receiving pharmacist care also achieved a 1.11% mean A_1c reduction from baseline compared to a 0.58% reduction in non-pharmacist managed patients, but these results were not statistically significant.

“Although the change in A1C from baseline was not statistically significant between cases and controls, the clinical significance of this result has been well documented in large randomized controlled trials of T2DM patients, and has been shown to significantly decrease the risk of microvascular complications,” Moreau wrote.

The “significant differences” observed in angiotensin converting enzyme inhibitor/angiotensin receptor blocker and statin use and nephropathy screenings suggest that pharmacists may be more adherent to guideline recommendations regarding the instituting of therapies and monitoring of disease progression. “This also demonstrates that pharmacists can help meet diabetes-related objectives outlined in Healthy People 2020, including decreasing the proportion of persons with an A_1C >9%, improving lipid control, increasing the proportion of patients who obtain an annual urinary microalbumin measurement, and increasing the proportion of patients who receive diabetes education,” Moreau wrote.