Clinical Review

Efficacy of Patient Aligned Care Team Pharmacist Services in Reaching Diabetes and Hyperlipidemia Treatment Goals

The services provided by clinical pharmacy specialists can improve low-density lipoprotein cholesterol and hemoglobin A1c levels in the veterans enrolled in a disease management clinic.

Fed Pract. 2015 November;32(11):42-47

Author(s):

Jaymee L. Gaspar, PharmD

Megan E. Dahlke, PharmD, BCACP

Barbara Kasper, BCACP

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References

1. Centers for Disease Control and Prevention. Diabetes report card, 2014. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014. www .cdc.gov/diabetes/pdfs/library/diabetesreport card2014.pdf. Accessed August 25, 2015.

2. Fryar CD, Chen T-C, Li X. Prevalence of uncontrolled risk factors for cardiovascular disease: United States, 1999-2010. National Center for Health Statistics Data Brief, No. 103. National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services Website. http://www.cdc.gov /nchs/data/databriefs/db103.htm. Updated August 3, 2012. Accessed August 10, 2015.

3. American Diabetes Association. Statistics about diabetes. American Diabetes Association Website. http://www.diabetes.org/diabetes-basics/statistics. Updated May 18, 2015. Accessed August 10, 2015.

4. U.S. Department of Veterans Affairs. Close to 25% of VA patients have diabetes. U.S. Department of Veterans Affairs Website. http://www.va.gov/health /NewsFeatures/20111115a.asp. Updated April 17, 2015. Accessed August 11, 2015.

5. Centers for Disease Control and Prevention. National ambulatory medical care survey: 2012 summary tables. Centers for Disease Control and Prevention Website. http://www.cdc.gov/nchs /data/ahcd/namcs_summary/2012_namcs_web _tables.pdf. Accessed August 25, 2015.

6. Utilization of Veterans Affairs Medical Care Services by United States Veterans. New York, NY: Pfizer Inc; 2003.

7. U.S. Department of Veterans Affairs. Primary care services. U.S. Department of Veterans Affairs Website. http://www.va.gov/primarycare/pcmh. Updated May 13, 2015. Accessed August 11, 2015.

8. U.S. Department of Veterans Affairs. Clinical Pharmacy Services. VHA Handbook 1108.11. http://www.va.gov/vhapublications/ViewPublication .asp?pub_ID=3120. Accessed August 25, 2015.

9. Mazzolini TA, Irons BK, Schell EC, Seifert CF. Lipid levels and use of lipid-lowering drugs for patients in pharmacist-managed lipid clinics versus usual care in 2 VA medical centers. J Manag Care Pharm. 2005;11(9):763-771.

10. Fabbio KL, Bradley M, Chrymko M. Evaluation of a pharmacist-managed telephone lipid clinic at a Veterans Affairs Medical Center. Ann Pharmacother. 2010;44(1):50-56.

11. Charrois TL, Zolezzi M, Koshman SL, et al. A systematic review of the evidence for pharmacist care of patients with dyslipidemia. Pharmacother. 2012;32(3):222-233.

12. Smith MC, Boldt AS, Walston CM, Zillich AJ. Effectiveness of a pharmacy care management program for veterans with dyslipidemia. Pharmacother. 2013;33(7):736-743.

13. Till LT, Voris JC, Horst JB. Assessment of clinical pharmacist management of lipid-lowering therapy in a primary care setting. J Manag Care Pharm. 2003;9(3):269-273.

14. Machado M, Nassor N, Bajcar JM, Guzzo GC, Einarson TR. Sensitivity of patient outcomes to pharmacist interventions. Part III: systematic review and meta-analysis in hyperlipidemia management. Ann Pharmacother. 2008;42(9):1195-1207.

15. Collins C, Kramer A, O’Day ME, Low MB. Evaluation of patient and provider satisfaction with a pharmacist-managed lipid clinic in a Veterans Affairs medical center. Am J Health Syst Pharm. 2006;63(18):1723-1727.

16. American Association of Diabetes Educators. The scope and standards for the practice of diabetes education by pharmacists. American Association of Diabetes Educators Website. http://www .diabeteseducator.org/docs/default-source/legacy -docs/_resources/pdf/PharmDScopeStandards.pdf. Updated 2011. Accessed August 11, 2015.

17. Wubben DP, Vivian EM. Effects of pharmacist outpatient interventions on adults with diabetes mellitus: a systematic review. Pharmacother. 2008;28(4):421-436.

18. Armor BL, Britton ML, Dennis VC, Letassy NA. A review of pharmacist contributions to diabetes care in the United States. J Pharm Pract. 2010;23(3):250-264.

19. Jarab AS, Alqudah SG, Mukattash TL, Shattat G, Al-Qirim T. Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan. J Manag Care Pharm. 2012;18(7):516-526.

20. Kirwin JL, Cunningham RJ, Sequist TD. Pharmacist recommendations to improve the quality of diabetes care: a randomized controlled trial. J Manag Care Pharm. 2010;16(2):104-113.

21. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497.

22. Kennedy SP, Barnas GP, Schmidt MJ, Glisczinski MS, Paniagua AC. Efficacy and tolerability of once-weekly rosuvastatin in patients with previous statin intolerance. J Clin Lipidol. 2011;5(4):308-315.

23. Stone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25, pt B):2889-2934.

According to the CDC, diabetes mellitus (DM) and hyperlipidemia have been distinguished as major contributors to death and disability among adults within the U.S. Although these diseases may often escape a directly malignant etiology, the complications of these metabolic disorders are correlated with long-term disability. Uncontrolled diabetes contributes to  5 major complications in U.S. adults, including myocardial infarction,  cerebral vascular accident, lower extremity amputation, renal failure, and hyperglycemic crisis. Hyperlipidemia is another major risk factor listed for advancing heart disease and ischemic stroke. Medical and preventive care are effective means for  declining complication rates, but these chronic diseases continue to increase in frequency.^1,2

The prevalence of DM and hyperlipidemia among U.S. veterans is uniquely higher than that of the general population. About 9.3% of the U.S. population has been diagnosed with diabetes compared with almost 25% of veterans receiving care through the VHA.^3,4 According to the 2012 National Ambulatory Medical Care Survey, 15.2% of  patients receiving nonfederal care had a hyperlipidemia diagnosis compared with > 20% of the U.S. veteran population.^5,6

Patient-Centered Care

A key initiative of the VHA Office of Patient Care Services in providing coordinated health care is the patient aligned care team (PACT). The PACT model seeks to provide communicative patient-centered care and involves primary care providers (PCPs) as well as other clinical and nonclinical affiliates.⁷ These team members often include a PCP, a registered and licensed practical nurse, a dietitian, a social worker, clerical support, and a clinical pharmacy specialist (CPS). Each professional uses his or her unique specialty to provide evidence-based care to the veteran. Clinical pharmacy specialist integration into the PACT model is one way to provide greater continuity of care for patients and more comprehensive treatment of chronic diseases. Given the need for regular medication titration, these patients may require a greater allocation of time and resources than PCPs can feasibly give. For this reason, CPSs were integrated into PACTs to allow for focused management of chronic conditions.

Most PACT CPSs at the VA Illiana Health Care System (VAIHCS) have advanced residency training and/or board certification, making them proficient in patient communication, drug knowledge, pharmacology, and therapeutics. Within the VHA, CPSs practice as midlevel providers with a scope of practice. This scope grants them the ability to clinically assess drug therapy, order and evaluate laboratory data, prescribe pertinent medications to treat the disease within the scope, and order consults with other professionals of the PACT team.⁸

Research Studies

Several studies have revealed that pharmacist-driven outpatient interventions for patients with dyslipidemia have significantly reduced low-density lipoprotein cholesterol (LDL-C).^9-14 Mazzolini and colleagues found that VHA pharmacist intervention produced a mean LDL-C reduction of 24.5 mg/dL and increased the percentage of patients reaching their LDL-C goal from 36.8% to 64.3%.9 Similarly, at another VHA facility, telephone interventions with patients were also effective in reducing veterans’ LDL-C levels. Fabbio and colleagues found a mean LDL-C reduction of 44.3 mg/dL when performing retrospective chart reviews of pharmacist interventions.¹⁰ Other pharmacist-driven LDL-C outcomes were also positive compared with that of usual care by PCPs, showing mean LDL-C reductions of 10.7 mg/dL and  10.4 mg/dL.^11,12 All these studies showed positive impacts on outcomes for patients with dyslipidemia. Additionally, these types of interventions have been shown to maintain both patient and PCP satisfaction.¹⁵

Clinical pharmacist interventions in the primary care setting have shown positive impacts in DM control with hemoglobin A_1c (A_1c) reductions by as much as 1.3% to 3.4%.^16-19 The highest A_1c reductions were evident when pharmacists had the ability to prescribe medications or work in a collaborative practice model with PCPs.^16-18Independent practice and the ability to prescribe medications have been shown to have more impact than recommendations to physicians alone. Recommendation letters from pharmacists did not produce a significant reduction of A_1c in one physician group compared with another physician group not receiving DM management recommendations.²⁰Given the increased prevalence of chronic diseases in the veteran population and the literature to support the value of CPSs as provider extenders, the focus of this analysis was to determine the potential benefit of CPS services to the PACT.

The primary objectives of this analysis were to determine the true impact of PACT CPSs on LDL-C and A_1c in the veterans enrolled in VAIHCS Disease State Management (DSM) clinics. If positive impacts were revealed, this study would support expansion of CPS services to include additional staff and the management of additional diseases.

Methods

This analysis was a retrospective chart review approved by the VA  Illiana Publication and Presentation Committee as a quality improvement (QI) project. Data were collected through the VistA electronic medical record. Subject data were analyzed in a multicenter fashion. A total of 5 sites within VAIHCS were included for review. The study subjects acted as their own controls and were distributed proportionally by volume of DSM visits at each VAIHCS location.