Multidisciplinary clinic with pharmacist improves care

Can a multidisciplinary diabetes management clinic that includes a pharmacist improve care for patients with Type 2 diabetes mellitus? The answer is a resounding yes, according to Erin Newkirk, PharmD, of the University of Iowa Hospitals and Clinics.

Newkirk tells Drug Formulary Review that while the American Diabetes Association supports medical care from a multidisciplinary team that includes a pharmacist, studies with such teams are lacking. Three earlier studies evaluated a multidisciplinary team that did not include a pharmacist and were conducted outside the United States.

The purpose of this study, then, was to evaluate patient outcomes in a multidisciplinary diabetes management clinic compared to usual care, which the researchers defined as primary care provided to patients with Type 2 diabetes mellitus in the internal medicine and family medicine clinics at the University of Iowa Hospitals and Clinics. Results of the research were presented at a recent meeting of the American College of Clinical Pharmacists.

The study population included 70 patients from the diabetes clinic that was formed at the hospital in 2002 and 35 patients each from the internal medicine and family medicine clinics. The diabetes clinic has scheduled appointments with patients and is conducted by a multidisciplinary team including a physician, physical therapist, dietitian, pharmacist, and nurse.

The primary study outcome measures compared at baseline and again at six months included changes in blood glucose, blood pressure, and weight; percentage of patients reaching blood glucose and blood pressure goals; percentage of patients receiving appropriate drug therapy; and appropriate urine microalbumin testing.

Newkirk says that at baseline, patients from the internal and family medicine clinics had lower blood glucose levels and lower diastolic blood pressure, and more patients were at blood glucose goal versus patients in the diabetes clinic group.

Blood glucose decreased significantly during the study period in patients in the diabetes clinic group and also in the usual care (internal and family medicine clinics) group. The diabetes clinic patients also had a significant decrease in diastolic blood pressure and weight.

Significant improvements

When the researchers compared change in the outcome measures from baseline to follow-up, they found that diabetes clinic patients had a larger drop in blood glucose levels and diastolic blood pressure than did those in usual care. More patients in the diabetes clinic than in usual care were prescribed aspirin at follow-up and more were screened for microalbuminuria by follow-up.

Newkirk says that patients referred to the diabetes clinic are generally those with newly-diagnosed Type 2 diabetes mellitus or those with poorly controlled Type 2 diabetes in need of counseling, education, and management. Patients are seen by each team member initially and at follow-up visits as necessary and as time permits. The clinic is held one-half day per week for both new and return patients.

Because patients see each of the team members individually at the first appointment, that appointment generally lasts the full half-day.

Team members each have their own defined responsibilities in the diabetes clinic. Thus, the registered nurse, who is a certified diabetes educator, is responsible for educating patients on their diabetes diagnosis, signs and symptoms of hypoglycemia and hyperglycemia, treating hypoglycemia, ADA recommended goals, self-monitoring of blood glucose, and administering insulin. The physician performs a thorough physical exam and gathers much of the patients' past medical history, social history, and family history.

The dietitian evaluates patients' eating habits and helps them create a healthy and balanced food intake plan for each day. Newkirk says many individuals are taught how to count carbohydrates and plan means accordingly. The physical therapist is responsible for discussing an appropriate patient-specific exercise regimen and proper foot care. And the clinical pharmacist is responsible for obtaining a correct medication list, evaluating patients' current therapy based on their home blood glucose measurements and other lab tests, recommending lab tests to evaluate for safety and efficacy of their medications, recommending changes to the medication regimen based on these findings, and counseling on newly prescribed medications while in the clinic.

Collaborative plan development

Team members work together to collaboratively develop a plan for each patient. Patients are followed for anything from a one-time educational session to ongoing follow-up after the education session. Newkirk says the diabetes clinic's goal is to eventually refer patients back to usual care as provided by their primary care provider, although they want to also comply with an American Diabetes Association recommendation for annual educational sessions.

The study is important, Newkirk says, because the number of patients diagnosed with diabetes mellitus in the United States is quickly escalating. It is estimated that between 2000 and 2050 the number of people diagnosed with diabetes mellitus will increase by 165%.

The estimated direct medical costs and indirect expenditures associated with diabetes in 2002 were $132 billion, a figure that is expected to rise to some $192 billion by 2020. "There will be more patients to treat to optimal goals and due to the swelling medical costs associated with the increased number of patients developing diabetes, it will become exceedingly important that all of these patients receive optimal care," she says. "For optimal care, the American Diabetes Association recommends that patients with diabetes receive care from a multidisciplinary team. Therefore, it may be advantageous to develop more diabetes management clinics throughout the United States such as the one established at the University of Iowa Hospitals and Clinics."

Overall, according to Newkirk, the study showed that care provided by the diabetes clinic with a pharmacist lowered blood glucose by 1.4%, which may translate to lowering the patients' chance of any diabetes related endpoint by 21%. She says this is an important concept because many of the clinic patients were referred after their primary care physician found they were difficult to control.

[Editor's note: Contact Dr. Newkirk at (319) 384-5100 or by e-mail at erin-newkirk@uiowa.edu.]