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Data from a new study funded in part by the Agency for Healthcare Research & Quality (AHRQ) revealed a robust reduction in patients' blood sugar levels when pharmacists or nurses were utilized as case managers who made independent decisions regarding medication use instead of waiting for physician approval.
The objective of the study, entitled "Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control," was to systemically evaluate the effectiveness of 11 categories of interventions designed to improve the outpatient care of patients with Type 2 diabetes. According to study data, after adjustment for potential publication bias and baseline glycemic control, two strategies-case management and team changes-were associated with the largest pooled reductions in HbA1c (glycosylated hemoglobin) values.
Across the 11 trials in which a pharmacist or nurse case manager could make at least some independent medication changes, the interventions resulted in reduced patient HbA1c values by a mean of 0.96%, compared with 0.41% for the 15 case management trials that did not include this feature.
Smith noted that because diabetes is so complex, often requiring individualized therapy, pharmacists bring a lot to the table as case managers. "It's a big plus having pharmacists on board who are able to coordinate care and who understand the implications of all the different drugs a patient is taking." Smith added that the study is significant, too, because it goes beyond just the pharmacy profession. Smith asserted that for healthcare practitioners outside the pharmacy profession who are looking for ways of structuring interventions, this study makes the case that having a pharmacist on the team is going to make a measurable difference in improving the quality of diabetes care.
Alan Zillich, Pharm.D., assistant professor of pharmacy practice at Purdue University College of Pharmacy, said the study reveals that a multidisciplinary team approach that includes a pharmacist appears to be more effective than a single clinician or just the primary care physician in lowering glucose. "The study provides additional evidence for an expanded role for pharmacists that could involve adjusting medications."
However, Zillich cautioned that because the study was a meta-analysis that combined a lot of trials and attempted to look at what components of quality improvement (QI) might be most effective at lowering HbA1c for diabetes patients, the results have to be carefully interpreted. For example, Zillich pointed out that the study doesn't discuss whether or not the medication adjustments made by pharmacists or nurses were based on a protocol. "Nor did they have their own complete authority where they could switch medications, add new medications, or change doses with just the goal being lowering blood glucose," he said.
Study authors concluded that most QI strategies for diabetes care produced small to modest improvements in glycemic control. Relative to other QI strategies, team changes and case management were associated with larger, more robust reductions in HbA1c values compared with other QI strategies that were evaluated.
However, findings of smaller effects for other QI strategies should be interpreted cautiously, given that some strategies were evaluated in relatively few trials, and heterogeneity or misclassification may have lessened the ability to determine their full effects.