Category: Federal Forum Posters
Purpose: Within the Veterans Health Administration (VHA), Patient Aligned Care Teams (PACT) include Clinical Pharmacy Specialists (CPS) who have prescriptive authority and manage diabetic patients referred by Primary Care Providers (PCP). VHA also has performance measures to help assess the quality of diabetes care such as completion of annual foot exams, annual/biennial eye exams, and annual A1c. This project compared the diabetic patients’ characteristics and outcomes between those managed by PCP and those referred to a CPS. The primary objective was to describe the referred diabetes population. The secondary objective was to assess A1c outcomes achieved by CPS compared to PCP.
Methods: This is an institutional review board approved, retrospective chart review, quality-improvement project. Patients were screened to include those who had PCP visit(s) for diabetes between October 1 - October 31, 2015. The index date was set as the first visit date. The study period was 18 months post index date. From the screened cohort, patients were excluded if they have been referred to a CPS within 18 months prior to the index date; patients were also excluded if they had a diagnosis of pre-diabetes, co-managed by the endocrinologist(s) for diabetes, received diabetes care outside of the institution, or expired during the study period. Patients who met inclusion and exclusion criteria were categorized into two cohorts: 1) patients managed by their PCP solely and 2) patients managed by CPS via referrals evidenced by referral consults. Data collected included baseline A1c [grouped into less than 9, 9 – 9.9, and greater than 10 groups], diabetes-related complications [neuropathy, nephropathy, retinopathy], and diabetes medication regimens [diet only, oral medications, on insulin]. Outcome measures were the percentage of patients that completed an annual A1c check during the study period and A1c change between baseline and end of study period. T-Test or Chi-Square tests were used as appropriate.
Results: Of 972 patients screened, 546 patients were included in the study with 434 patients in PCP group and 112 patients in CPS group. At baseline, the CPS group had less percentage of patients with A1c less than 9 and more percentage of patients with A1c greater than 9, all comparisons were statistically significant (49 versus 95, 21 versus 3, and 30 versus 2 percent) for the A1c less than 9, between 9 – 9.9, and greater than 10, respectively. Other statistically significant baseline characteristics were greater presence of patients with 2 or more diabetes complications, diagnosis of cardiovascular disease, and insulin users in the CPS compared to PCP group (15.2 versus 6.5, 26.3 versus 27.7, and 13 versus 47 percent, respectively). CPS were more likely to have completed an annual A1c (92 percent compared to 81 percent, P equals 0.005). Both the CPS and PCP achieved statistically significant reductions in A1c averaging a 1.2 percent reduction in those with baseline A1c 9-9.9, and an average 3.2 percent reduction in A1c in those with baseline A1c greater than 10. However, mean A1c reductions achieved by CPS compared to PCP were not statistically significant.
Conclusion: Of the patients with elevated A1c greater than 9, a vast majority were referred to a CPS for diabetes management. Those referred appeared to be more complicated by having more patients with baseline diabetes complications, diagnosis of cardiovascular disease, and/or on insulin. Patients managed by CPS were more likely to meet the performance measure of completing an annual A1c. Finally, it appeared that at 18 month follow up, patients referred to CPS achieved a similar mean A1c reduction compared to PCP.
Michelle Webb– Pharmacist, VA Long Beach Healthcare System, San Dimas, CA