Metabolic Control and Adherence to American Diabetes Association Practice Guidelines in a Pharmacist-Managed Diabetes Clinic

The provision of diabetes care has shifted from the specialist to the generalist in primary care practice. Evidence suggests utilization of nonphysician providers in conjunction with physician-directed protocols improves glycemic control (1). The purpose of this study was to evaluate the impact of a pharmacist-managed diabetes clinic (PMC) on glycemic control and adherence to American Diabetes Association (ADA) standards of medical care in a collaborative physician-pharmacist practice. This was a retrospective analysis comparing patients referred to the PMC for diabetes management with a randomly selected group of patients with diabetes, managed exclusively by their primary care physicians. Only patients with a minimum of 3 months of laboratory data and two visits to the pharmacist or physicians were included.

Pharmacist-managed clinic patients (16 women, 12 men) were 51.8 ± 14.7 years of age and had a BMI of 35.4 ± 9.2 kg/m² (mean ± SD). The physician-managed group (16 women, 13 men) were 56.4 ± 13.8 years of age and had a BMI of 33.5 ± 9.2 kg/m². Over 90% of patients in each group were African-American and had type 2 diabetes. Average duration of diabetes was not significantly different between groups.

Baseline HbA_1c values were significantly higher in PMC patients compared with the physician-managed group (10.3 ± 2.1 vs. 8.2 ± 2.8%, respectively; P = 0.008). The PMC patients had significant improvements in glycemic control; HbA_1c levels decreased from 10.3 ± 2.1 to 7.9 ± 1.8% (P < 0.0001) and RPG concentrations from 12.94 ± 5.80 to 8.09 ± 3.10 mmol/l (P = 0.002). Patients in the physician-managed group had nonsignificant reductions in HbA_1c levels (8.2 ± 2.8 to 6.8 ± 1.8%, P = 0.065) and RPG concentrations (11.88 ± 4.40 to 10.44 ± 4.73 mmol/l; P = 0.49). More PMC patients were placed on aggressive combination antihyperglycemic medications compared with the physician-managed group (61 vs. 21%; P = 0.003). Blood pressure, body weight, and lipid parameters did not change significantly within or between groups.

Adherence to ADA guidelines was significantly greater in PMC patients compared with patients managed by their physicians. HbA_1c measurements were obtained in 85.7 and 62.1% (P = 0.04), albumin-to-creatinine determinations in 89.3 and 35.7% (P = 0.0001), FLP assessment in 92.9 and 65.5% (P = 0.021), and foot examination 82.1 and 6.9% (P = 0.0001) of patients in PMC compared with physician-managed group, respectively. Referrals for dietary instruction, podiatry care, and evaluation of diabetic retinopathy were made significantly more often in PMC compared with physician-managed patients, (57.1 vs. 10.3%, P = 0.02; 85.7 vs. 34.4%, P = 0.0001; and 85.7 vs. 55.2%, P = 0.02, respectively). Rates for aspirin use and annual influenza vaccinations were similar between groups.

In agreement with previous studies, pharmacist-managed diabetes programs have been shown to improve glycemic control (2,3). This is the first study to evaluate guideline adherence in a PMC. Compliance with these guidelines in primary care practices is reportedly suboptimal (4). Adherence rates in this study are superior to those reported in primary care practices and similar to those described in multidisciplinary programs (1,4). Adherence to guidelines and provision of quality healthcare require continuous long-term education and monitoring of patients. An environment in which a physician-extender is continuously working with a physician on site can provide this type of care. Further studies should examine the cost-effectiveness of collaborative physician-pharmacist practice models.