By Annette M. Boyle
SAN DIEGO — Many veterans drift for years with out-of-control diabetes, despite regular visits with their primary care physician and prescriptions for anti-glycemic agents.
In an effort to help veterans with complex Type 2 diabetes better manage their care, clinical pharmacists at the VA San Diego Healthcare System have partnered with an endocrinologist—with very positive financial and medical results.
In a pair of recently published articles in the Journal of Managed Care and Specialty Pharmacy and the Annals of Pharmacotherapy, the researchers reported a more than 2.4% improvement in mean A1c and projected a reduction in the cost of care of more than $5,200 per patient over three years for those seen at the clinic, compared to those who continued with usual care.1,2
The Diabetes Intensive Medical Management (DIMM) “tune-up” clinic is a collaboration between a pharmacist, endocrinologist and several pharmacy students. It is designed to personalize medication therapy management and patient education to help veterans better understand how to manage their diabetes.
“The best patients for the clinic are people who have out-of-control diabetes, who have multiple comorbidities and perhaps adherence issues, take a lot of medications and have a tough time understanding when to take them. They really need to be ‘tuned up’ and given a regimen that is completely specialized to them that they can adhere to,” explained Candis Morello, PharmD, CDE, director of the Diabetes Intense Medical Management Clinic at the San Diego VA and an author of both studies.
The researchers compared 99 patients referred to the clinic to 56 veterans who continued to receive diabetes care only through their primary care physician. All participants had Type 2 diabetes mellitus, glycosylated hemoglobin (A1c) above 8%, and a visit to a VAMC within the previous six months. Veterans referred to the DIMM clinic met with a clinical pharmacist for two to four one-hour sessions over six months. Patients in both groups took 12 to 14 medications daily and had about eight comorbidities on average. Demographics were similar between the two groups.
Veterans in the DIMM clinic achieved a 2.4 drop in A1c in six months compared to a reduction of 0.8 in the usual care group. At baseline, patients referred to the clinic had a higher mean A1c than those who continued receiving diabetes care through their usual provider, 10.5 vs. 9.7. After three months, the DIMM group had a mean A1c slightly below the usual care group, 9.9 vs. 9.0, and almost two-thirds had reached the VA performance goal of A1c below 9.0.
At six months, mean A1c levels dropped to 8.2 for those in the clinic and stayed at 9.0 for the controls. Three-quarters of clinic attendees had A1c below 9.0 by six months compared to just over half of those receiving usual care. No patients participating in the clinic experienced a hypoglycemic event requiring medical intervention.
Cost data also showed a marked improvement in the clinic group. The cost per additional patient who achieved treatment goal was between $115 and $164 over the six-month study, but the return on investment exceeded $9 for every $1 spent on the DIMM clinic. The researchers calculated that the improved glycemic control would save the VA $5,287 per patient who was referred to the clinic over three years, compared to continue care through a primary care provider. Quality Adjusted Life Years increased and estimated medical costs decreased over projected two-, five- and 10-year periods, for a wide set of assumptions.
“No matter how we looked at the data, the cost for the DIMM clinic group was always lower, while their predicted Quality Adjusted Life Years were always higher,” pointed out Jan Hirsch, PhD, BSPharm, of the VA San Diego Healthcare Systems and co-director of the study.
The clinical pharmacists focused on empowering and educating the veterans and ensuring that they clearly understood what each medication they took did, how to take it and how to make them most effective. “Every diabetic is unique, so we honed in on their personal issues. We created a regimen that was 100% easy for them to follow,” Morello said.
One patient, for instance, had medication that he took three times a day, as well as basal insulin three times a day and bolus insulin twice a day. Not only did he have issues with hypoglycemia, he had five injections every day, noted Morello. She recommended instead a weekly injection of bydureon, daily insulin glargine and an oral SGLT-2 inhibitor.
“We’re not afraid to make big changes to make it easier. Getting down to one injection a day and one a week made him feel so empowered and happy, and that helps patients stick with it for the long term,” Morello said. “He had had diabetes for 20 years and struggled and struggled. He felt that nothing he did was right, but watching his numbers go down week-by-week changed his mindset.”
Those changes led to long-term improvement for patients. As-yet-unpublished results showed that, after a year, patients still had significant reductions in A1c compared to baseline. Of the patients in the clinic, “100% met goal at discharge and 78% still maintained their target A1c 12 months later.” The typical patient in this group had a baseline A1c of 10, which dropped to 7 at discharge from the clinic and rose to 8 after 12 months.
“This clinic is really good for complex patients; it would work easily for others,” Morello noted. “It could help people who have been recently diagnosed stay healthy a lot longer.”
- CM Morello, Christopher MLD, Ortega L, Khoan J, Rotunno T, et al. Clinical Outcomes Associated with a Collaborative Pharmacist-Endocrinologist Diabetes Intense Medical Management “Tune Up Clinic in Complex Patients. Ann Pharmacother. 2016;50 (1),8-16.
- Hirsch JD, Bounthavong M, Arjmand A, Ha DR, Cadiz CL, Zimmerman A, Ourth H, Morreale AP, Edelman SV, Morello CM. Estimated Cost-Effectiveness, Cost Benefit, and Risk Reduction Associated with an Endocrinologist-Pharmacist Diabetes Intense Medical Management “Tune-Up” Clinic. J Manag Care Spec Pharm, 2017 Mar;23(3):318-326.