Pharmacist-Led Self-management Interventions to Improve Diabetes Outcomes. A Systematic Literature Review and Meta-Analysis

Effect of Pharmacist Intervention on Medication Adherence and Clinical Outcomes of Type 2 Diabetes Mellitus Outpatients in Primary Healthcare in Indonesia

OBJECTIVE

In Indonesia, the role of pharmacists in primary healthcare is still very limited or even absent. This study evaluates the effectiveness of programs delivered for type 2 diabetes mellitus (T2DM) patients by pharmacists in primary healthcare through counseling, short message service (SMS) reminders, and medication booklets.

METHODS

A quasi-experimental study with a pretest-posttest design was conducted from April to August 2018 at Merdeka and Dempo primary health-care centers, Palembang, South Sumatra Province, Indonesia. Counseling and medication booklets were distributed three times during the study period, while SMS reminders were sent once a week. Counseling was given for the management of diabetes mellitus (DM), including during the Ramadan fasting period, together with management for acute and chronic complications. The medication adherence level was measured using a medication adherence questionnaire (MAQ) and pill count adherence (PCA). The study sample comprised 80 T2DM patients, who were allocated into either the control group (CG) (n = 40) or intervention group (IG) (n = 40). Clinical outcomes were determined by measuring glycated hemoglobin (HbA1c), blood pressure, and lipid profiles.

FINDINGS

After the intervention, the IG showed significant improvements in most parameters, except for high-density lipoprotein cholesterol and systolic and diastolic blood pressure. HbA1c levels were reduced, while MAQ scores and PCA scores were improved. Lipid parameters were significantly reduced total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), and triglyceride (TG). Compared with the CG, most parameters were significantly improved in the IG. Pharmacist counseling significantly improved almost all clinical parameters (HbA1c, TC, LDL-c, and TG). Pharmacist counseling was 7.1 times greater in lowering HbA1c compared with no counseling, after adjusted by other variables. The variable that most influenced the lowering of HbA1c was infrequent ("not often") consumption of unhealthy foods (OR 14.9; 95% CI 3.5-63.7).

CONCLUSION

The pharmacist primary health-care intervention program implemented in this study significantly improved HbA1c, TC, LDL-c, TG, and medication adherence in outpatients with T2DM.

The impact of pharmacist care on diabetes outcomes in primary care settings: An umbrella review of published systematic reviews

OBJECTIVE

To systematically review published systematic reviews (SRs) examining the impact of pharmacist interventions in multidisciplinary diabetes care teams on diabetes-related clinical, humanistic, and economic outcomes in primary care settings.

METHODS

PubMed, EMBASE, Scopus, Database of Abstracts of Reviews of Effects, Cochrane Library, Joanna Briggs Institute (JBI) Database, Google Scholar, and PROSPERO were searched from inception to 2018. Studies published in English evaluating the effect of pharmacist interventions on diabetes outcomes were included. Two independent reviewers were involved in screening of titles and abstracts, selection of studies, and methodological quality assessment.

RESULTS

Seven SRs were included in the study. Three of them included only randomized controlled trials, while the rest involved other study designs. Educational interventions by clinical pharmacists within the healthcare team were the most common types of interventions reported across all SRs. Pharmacist's interventions compared to usual care resulted in favorable significant improvements in hemoglobin A_1c (HbA_1c), fasting blood glucose, blood pressure, body mass index, total cholesterol, low density lipoprotein, high density lipoprotein and triglycerides in more than 50% of the SRs. Improvement in HbA_1c was the mostly reported clinical outcome of pharmacist intervention in the literature (reported in six SRs). Pharmacist's interventions led to significant cost-saving ($8-$85,000 per person per year), cost-utility, and cost-benefit (benefit-to-cost ratio range from 1:1 to 8.5:1) versus usual care. Pharmacist's interventions improved patients' quality of life (QoL) in three SRs; however, no conclusion can be drawn due to the use of diverse QoL assessment tools.

CONCLUSIONS

Most SRs support the benefit of pharmacist care on diabetes-related clinical, humanistic, and economic outcomes in primary care settings. Improvements in diabetes outcomes can significantly reduce the burden of diabetes on healthcare system. Hence, the incorporation of pharmacists into multidisciplinary diabetes care teams is beneficial and should be strongly considered by clinicians and health policymakers.

A systematic review of pharmacist input to metabolic syndrome screening, management and prevention

Background Metabolic syndrome is a cluster of factors that increase the risk of cardiovascular disease and include: diabetes and prediabetes, abdominal obesity, elevated triglycerides, low high-density lipoprotein cholesterol and high blood-pressure. However, the role of the pharmacist in the metabolic syndrome has not yet been fully explored. Aim of the review This systematic review aimed to critically appraise, synthesise, and present the available evidence on pharmacists’ input to the screening, prevention and management of metabolic syndrome. Method The final protocol was based on the “Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P)”. Studies published in English from January 2008 to March 2020 reporting any pharmacist activities in the screening, prevention or management of metabolic syndrome were included. Databases searched were Medline, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Cochrane and Google Scholar. Studies were assessed for quality by two researchers, data extracted and findings synthesised using a narrative approach. Results Of the 39,430 titles reviewed, ten studies were included (four were randomised controlled trials). Most studies focused on pharmacist input to metabolic syndrome screening and management. Screening largely involved communicating metabolic parameters to physicians. Management of metabolic syndrome described pharmacists collaborating with members of the multidisciplinary team. A positive impact was reported in all studies, including achieving metabolic syndrome parameter goals, reverting to a non-metabolic syndrome status and, improved medication adherence. The populations studied were paediatrics with risk factors, adults with comorbidities and psychiatric patients. Integration of the pharmacist within the multidisciplinary team, an easy referral process and accessibility of service were potential facilitators. Inadequate funding was the key barrier. Conclusion The studies describing pharmacist input in metabolic syndrome provide limited evidence of positive outcomes from screening and management as part of collaborative practice. Further work is required to provide more robust evidence of effectiveness and cost-effectiveness while considering key barriers.

How does the general public balance convenience and cognitive pharmaceutical services in community pharmacy practice

BACKGROUND

Community pharmacy is shifting its focus from traditional, product-focused roles to the provision of cognitive pharmaceutical services (CPS). Previous research has indicated that community pharmacists predominantly want to devote their capacity to CPS. Ideally, services provided also address users' needs. The general public's preferences regarding the services provided by community pharmacists are currently less understood.

AIM

This study investigates the general public's preferences and perceived importance of CPS versus convenience in community pharmacy practice.

METHOD

An online survey of 1.500 members of the Dutch Health Care Consumer Panel containing questions regarding preferences for CPS and convenience was distributed. Descriptive statistics and linear regression analysis were performed to investigate the relationship between preferences and participant characteristics.

RESULTS

516 panel members completed all questions regarding preferences and importance of the availability of services. The majority preferred convenience (68.2%) and a smaller proportion preferred CPS (27.7%). However, participants considered it important from a societal viewpoint that CPS is provided (45.0%). Participants who preferred CPS over convenience were generally older (p < 0.001) and used more medicines (p < 0.001).

CONCLUSION

Convenience of community pharmacy services is most preferred by the general public. However, CPS is perceived as important, especially for elderly who use more medicines. Elderly patients who use more medicines more often rate CPS as more important than convenience. These findings suggest that community pharmacists should ensure that pharmacy logistics are organized efficiently before focusing on the provision of CPS.

Impact of a Multifaceted Pharmacist-Led Intervention on Antimicrobial Stewardship in a Gastroenterology Ward: A Segmented Regression Analysis

BACKGROUND

Irrational use of antimicrobial agents for gastrointestinal diseases deserves attention, but corresponding antimicrobial stewardship programs (ASPs) are generally not a priority for managers. We conducted this study to evaluate the effectiveness of multifaceted pharmacist-led (MPL) interventions in the gastroenterology ward (GW) to provide evidence for the efficacy of ASPs in a non-priority department.

METHODS

This was an interventional, retrospective study implemented in China. The MPL intervention lasting 1.5 years involved daily ward rounds with physicians, regular review of medical orders, monthly indicator feedback, frequent physician training, and necessary patient education. Data on all hospitalized adults receiving antibiotics was extracted from the hospital information system over a 36-month period from January 2016 to December 2018. Segmented regression analysis of interrupted time series was performed to evaluate the effect of the MPL interventions (started in July 2017) on antibiotic use and length of hospital stay, which was calculated monthly as analytical units.

RESULTS

A total of 1763 patients receiving antibiotics were enrolled. Segmented regression models showed descending trends from the baseline in the intensity of antibiotic consumption (coefficient = -0.88, p = 0.01), including a significant decline in the level of change of the proportion of patients receiving combined antibiotics (coefficient = -9.91, p = 0.03) and average length of hospital stay (coefficient = -1.79, p = 0.00), after MPL interventions. The MPL interventions led to a temporary increase in the proportion of patients receiving antibiotics (coefficient = 4.95, p = 0.038), but this was part of a declining secular trend (coefficient = -0.45, p = 0.05).

CONCLUSION

The MPL interventions led a statistically significant decline in the number of patients receiving antibiotics, the antibiotic consumption, and the average hospital stay post-intervention compared to the pre-intervention phase of the study. Health policymakers should actively practice MPL interventions by clinical pharmacists in ASPs in those departments that are not included in priority management.

The role of community pharmacists and their position in the delivery of diabetes care: an update for medical professionals

Pharmacists are the third largest group of healthcare professionals worldwide, but are underused in the delivery of diabetes care. The aim of this narrative was to describe how integration of community pharmacy services into existing healthcare models may improve diabetes care. Relevant literature exploring pharmacy-led interventions for diabetes were identified from a search of Medline, Embase and Cinahl online databases. This review highlights that community pharmacists are accessible, experts in medicine management, trusted by the public and able to achieve financial savings. They are poorly integrated into existing healthcare models, and commissioning arrangements can be poorly perceived by the public and those working in primary care. Community pharmacy interventions in type 2 diabetes have similar, if not greater effects compared to those delivered by other healthcare professionals. It was concluded that community pharmacy interventions in diabetes are feasible, acceptable and deliver improved health outcomes. Future work should build public recognition of pharmacists and improve communication between them and other healthcare professionals.

Clinical pharmacists in diabetes management: What do minority patients with uncontrolled diabetes have to say?

OBJECTIVE

Clinical pharmacist support for patients with type 2 diabetes mellitus (T2DM) can optimize patient outcomes and medication adherence. However, there is limited understanding of what pharmacist roles patients perceive as most helpful in T2DM management interventions. This study describes experiences of minority patients with uncontrolled T2DM in terms of perceived pharmacist helpfulness and specific roles found to be most helpful within diabetes management.

DESIGN

A secondary analysis of a 2-year randomized, crossover trial was conducted.

SETTING AND PARTICIPANTS

This study included 244 African American and Hispanic adults with uncontrolled T2DM who received clinical pharmacist support within a team-based model.

OUTCOME MEASURES

The patients completed a mixed-methods survey regarding their experience with the intervention that included a general helpfulness rating on a 10-point unipolar Likert scale and described the support qualitatively, including their perception of the pharmacist roles. Thematic analysis guided coding of the responses.

RESULTS

One hundred forty-seven (60%) patients completed the survey and had at least 1 encounter with a clinical pharmacist. Of these, 108 (74%) were African American, 39 (27%) were Hispanic, and 101 (69%) were women. The median rating of clinical pharmacist helpfulness was 10 (very helpful). Only 10 (7%) participants rated pharmacist helpfulness as 1 (not at all helpful). "Medication education and management" was the most frequently perceived supportive role of the clinical pharmacists, followed by "non-medication-related patient education," "social support," and "care coordination." Miscommunication related to scheduling was the most common reason cited for not meeting with the clinical pharmacist.

CONCLUSION

This sample of minority patients with uncontrolled T2DM recognized many roles outlined within the American Pharmacists Association Medication Therapy Management framework. Patient experiences with clinical pharmacist T2DM support are crucial for developing effective programs, maximizing patient engagement, satisfying patient needs, and ensuring that a program's intended purpose aligns with the patient perspective.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effectiveness of Diabetes Self-Management Educational Programs For Type 2 Diabetes Mellitus Patients In Middle East Countries: A Systematic Review

AIM

This review study aimed to determine the effectiveness and factors affecting the success of DSME programs in T2DM patients living in ME countries.

METHODS

An extensive manual literature search was conducted using PubMed and Google Scholar for clinical trials assessing the effect of diabetes self-management education (DSME) for type 2 diabetes mellitus patients in Middle East countries. Information from the included studies was summarized in relation to study population, sample size, duration of follow-up, characteristics of DSME program, and follow-up time, besides in addition to parameters used in assessment, results, and conclusions. The risk of bias in the included studies was assessed using the Cochrane risk of bias tool. The effect of DSME on clinical and patient-reported outcomes was measured by calculation of the percentage of DSME studies that produce a significant improvement in these outcomes for patients in intervention group as compared to those in control group. Additionally, the effect of DSME on each clinical outcome was assessed by calculating the mean for the absolute effect of DSME on that outcome.

RESULTS

Twelve studies were included in this review. Heterogeneity was found among included studies in terms of DSME program characteristics, the enrolled patients, duration of follow-up, assessment methods, and obtained outcomes. All clinical glycemic outcomes (glycosylated hemoglobin, fasting, and non-fasting blood glucose), lipid profile (total cholesterol and triglycerides), and body mass index were significantly improved for patients in intervention group as compared to those in control group in at least 60% of the included studies. All patients' reported outcomes (medication adherence, self-management behavior, knowledge, self-efficacy, health belief and quality of life) were significantly improved by the DSME program.

CONCLUSION

DSME programs are highly effective in improving glycemic control, lipid profile and BMI, and modestly effective in improving BP. Thus, they can reduce the risks of developing diabetes complications. Patient diabetes knowledge, DSM behaviors, adherence to medications, self-efficacy, and quality of life can also be significantly improved by DSME.

Recall of Pharmaceutical Pictograms by Older Adults

BACKGROUND

Low health literacy and high medication burden in the older adult population are contributing factors to the misunderstanding of medication instructions, leading to an increased risk of poor adherence and adverse events in this group of patients.

OBJECTIVE

To evaluate the ability of older adults to recall the meaning of 13 pharmaceutical pictograms 4 weeks after receipt of feedback on pictogram meaning.

METHODS

Older adults (aged 65 or older) were recruited from one community pharmacy in Canada. One-on-one structured interviews were conducted to assess the comprehensibility of 13 pharmaceutical pictograms from the International Pharmaceutical Federation's database of pictograms. Each participant was then told the meaning of each pictogram. Recall was assessed 4 weeks later.

RESULTS

A total of 58 participants met the inclusion criteria and agreed to participate. The number of pictograms meeting the ISO threshold for comprehensibility of symbols increased from 10 at the initial comprehensibility assessment to 13 at the recall assessment. Analysis of demographic data showed no associations between initial comprehensibility of the pictograms and age, sex, education level, or number of medications taken.

CONCLUSIONS

The results of this study indicate that after being informed of the meaning of pharmaceutical pictograms, older adults were able to recall the pictogram meanings for at least 4 weeks.

How are medication related problems managed in primary care? An exploratory study in patients with diabetes and primary care providers

BACKGROUND

Medication self-management is important for patients who are controlling diabetes. Achieving medication self-management goals, may depend on treatment complexity and patients' capacities such as health literacy, knowledge and attitude.

OBJECTIVES

The aims of this study were to explore how patients with diabetes self-manage their medications, how patients seek support when experiencing problems and how primary healthcare providers identify patients' medication related problems and provide support.

METHODS

Semi-structured interviews were conducted among patients with diabetes receiving primary care and with their primary healthcare providers - GPs, nurses, pharmacists and technicians - between January and June 2017. A purposive sampling strategy was used to identify and select participants. An interview guide based on the Cycle of Complexity model was developed. Interviews were audiotaped and transcribed verbatim. Transcripts were coded with a combination of deductive and inductive codes. A thematic analysis was performed to identify categories and themes in the data. Findings were compared with the Cycle of Complexity model.

RESULTS

Twelve patients and 27 healthcare providers were included in the study. From the transcripts 95 codes, 6 categories and 2 major themes were extracted. Patients used practical solutions and gaining knowledge to manage their medication. Their problems were often related to stress and concerns about using medications. A trusted relationship with the healthcare provider was essential for patients to share problems and ask for support. Informal support was sought from family and peer-patients. Healthcare providers perceive problem identification as challenging. They relied on patients coming forward, computer notifications, clinical parameters and gut-feeling. Healthcare providers were able to offer appropriate support if a medication management problem was known.

CONCLUSION

Patients are confident of finding their way to manage their medications. However, sharing problems with healthcare providers requires a trusted relationship. This is acknowledged by both patients and healthcare providers.

Clinical inertia, reverse clinical inertia, and medication non-adherence in type 2 diabetes

PURPOSE

Clinical inertia and medication non-adherence are thought to contribute largely to the suboptimal glycemic control in many patients with type 2 diabetes. The present review explores the relations between A1C targets, clinical inertia and medication non-adherence in type 2 diabetes.

METHODS

We searched PubMed for English-language studies published from 2001 through June 1, 2018. We also manually searched the references of selected articles, reviews, meta-analyses, and practice guidelines. Selected articles were mutually agreed upon by the authors.

RESULTS

Clinical inertia is the failure of clinicians to initiate or intensify therapy when indicated, while medication non-adherence is the failure of patients to start or continue therapy that a clinician has recommended. Although clinical inertia may occur at all stages of diabetes treatment, the longest delays were reported for initiation or intensification of insulin. Medication non-adherence to antidiabetic drugs may range from 53 to 65% at 1 year and may be responsible for uncontrolled A1C in about 23% of cases. Reverse clinical inertia can be acknowledged as the failure to reduce or change therapy when no longer needed or indicated. Clinical inertia and medication non-adherence are difficult to address: clinician-and patient-targeted educational programs, more connected communications between clinicians and patients, the help of other health professional figures (nurse, pharmacist) have been explored with mixed results.

CONCLUSIONS

Both clinical inertia and medication non-adherence remain significant barriers to optimal glycemic targets in type 2 diabetes. Moreover, part of clinical inertia may be a way through which clinicians face current uncertainty in medicine, including some dissonance among therapeutic guidelines. Scientific associations should find an agreement about how to measure and report clinical inertia in clinical practice and should exhort clinicians to consider reverse clinical inertia as a cause of persisting inappropriate therapy in vulnerable patients.

Impact of Pharmacist Intervention on Improving the Quality of Life of Patients with Type 2 Diabetes Mellitus

AIM

To analyse the characteristics, and analyse the impact of pharmacist intervention on quality of life (QOL) outpatients with type 2 diabetes mellitus (T2DM).

METHODS

This six-month analytical cohort study was conducted by assessing the patients' characteristics and their quality of life by distributing a questionnaire, and the 36-Item short form instrument to the patients with T2DM (n = 45) admitted to the Tertiary hospital in Tebing Tinggi. Patients who had mental disorders, HIV-AIDS, liver disease, stage 4 chronic kidney disease, and pregnant women were excluded from the study. The patients' quality of life was measured before and after interventions and analysed using the paired t-test. All analyses were performed using the Statistical Package for the Social Sciences (SPSS, version 22, Chicago, IL, USA) (p < 0.05 was considered significant).

RESULTS

The mean age of the patients was 61.96 ± 6.45 (years). Most (66.7%) of them were females. The mean QOL (in the score) of the patients: before the intervention, 61.07 ± 15.13; after the intervention, 70.15 ± 14.23, there was a significant difference between groups with and without interventions, p < 0.001.

CONCLUSION

Active contribution of pharmacists in the management of T2DM patients is urgent and important to improve the patients' QOL.

Characteristics of Future Models of Integrated Outpatient Care

Replacement of fee-for-service with capitation arrangements, forces physicians and institutions to minimize health care costs, while maintaining high-quality care. In this report we described how patients and their families (or caregivers) can work with members of the medical care team to achieve these twin goals of maintaining-and perhaps improving-high-quality care and minimizing costs. We described how increased self-management enables patients and their families/caregivers to provide electronic patient-reported outcomes (i.e., symptoms, events) (ePROs), as frequently as the patient or the medical care team consider appropriate. These capabilities also allow ongoing assessments of physiological measurements/phenomena (mHealth). Remote surveillance of these communications allows longer intervals between (fewer) patient visits to the medical-care team, when this is appropriate, or earlier interventions, when it is appropriate. Systems are now available that alert medical care providers to situations when interventions might be needed.

5. Lifestyle Management: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A Review of Pharmacist-led Interventions on Diabetes Outcomes: An Observational Analysis to Explore Diabetes Care Opportunities for Pharmacists

A strict and adherence treatment is required by the patient with diabetes mellitus and it demands a proper self-medication by the patient. Pharmacists are involved in providing self-management support to the patients. This review evaluates the interventions of pharmacist for patients to improve self-management with diabetes mellitus and also to improve the clinical outcomes of diabetes mellitus. A comprehensive literature search was performed by using different keywords "pharmacist-led intervention," "diabetes," "effect of pharmacist on outcome of diabetes," and "self-management of diabetes" with the help of various electronic databases such as PubMed, Science Direct, Embase, Web of Science, and the Cochrane Library from the beginning of the database through September 2018. The primary outcome was glycated hemoglobin (HbA1c), whereas the secondary outcomes were blood glucose level, blood pressure (BP) measure, body mass index, lipids, adherence to medication, and quality of life. Twenty-five studies comprising 2997 diabetic patients were included in the analysis. Pharmacist-led intervention was involved in all included studies in the form of education on diabetes and its complications, medication adherence, lifestyle, and education about self-management skills. Pharmacist-led interventions are able to reduce HbA1c levels with a mean of 0.75%. Most studies do not expose the material and methods used in pharmacist-led intervention. The variation in the reduction of HbA1c, fasting blood sugar, BP, and lipid profile was due to the lack of this standardization. The included studies indicated that pharmacist-led interventions in diabetes mellitus can significantly improve the outcomes of diabetes mellitus and its complication later on. Hence, these long-term improvements in outcomes added more value of pharmacists in health-care system of the world.

Impact of a Medication Therapy Management Clinic on Glycosylated Hemoglobin, Blood Pressure, and Resource Utilization

BACKGROUND

Medication therapy management is widely promoted to improve care. However, few well-controlled studies have evaluated its impact.

OBJECTIVES

We evaluated whether enrollment in a comprehensive medication therapy management clinic (MTMC) was associated with improved 12-month outcomes.

METHODS

This institutional review board approved study was a retrospective controlled cohort study in an academic health center serving low-income, African American and Latino populations. Between 2001 and 2011 MTMC patients were matched to control patients by age, gender, and comorbidities. Outcomes were mean change in glycosylated hemoglobin (A1C), diastolic (DBP) and systolic blood pressure (SBP), and emergency department (ED) and hospital admissions at 6 and 12 months. A difference-in-difference analysis was conducted for each outcome of interest, adjusting for observed, unmatched confounders.

RESULTS

Patients with diabetes and receiving MTMC had greater A1C improvements, compared with controls, of 0.54% (P = 0.0067) at 6 months and 0.63% (P = 0.0160) at 12 months. At 6 months, SBP and DBP decreased in MTMC patients by 6.5 mm Hg (P = 0.0108) and 3.8 mm Hg (P = 0.0136) more than controls, respectively. At 12 months, those receiving MTMC services had SBP and DBP decreases, respectively, of 8.2 mm Hg (P = 0.0018) and 1.7 mm Hg (P = 0.2691) compared with controls. ED and hospital visits were not statistically significantly different between groups. Conclusion and Relevance: This MTMC potentially improved outcomes for referred patients in whom target goals were difficult to achieve and can serve as a model for other similar medication management programs.

Efficacy of Pharmacist Based Diabetes Educational Interventions on Clinical Outcomes of Adults With Type 2 Diabetes Mellitus: A Network Meta-Analysis

Background: Comparative efficacy of different pharmacist based interventions on glycemic control of type 2 diabetes patients is unclear. This review aimed to evaluate and compare the efficacy of different pharmacist based interventions on clinical outcomes of type 2 diabetes patients. Methods: A systematic search was conducted across five databases from date of database inception to September 2017. All randomized clinical trials evaluating the efficacy of pharmacist based interventions on type 2 diabetes patients were included for network meta-analysis (NMA). The protocol is available with PROSPERO (CRD42017078854). Results: A total of 43 studies, involving 6259 type 2 diabetes patients, were included. NMA demonstrated that all interventions significantly lowered glycosylated hemoglobin (HbA1c) levels compared to usual care, but there was no statistical evidence from this study that one intervention was significantly better than the other for reducing HbA1c levels. Pharmacist based diabetes education plus pharmaceutical care showed maximum efficacy for reducing HbA1c levels [-0.86, 95% CI -0.983, -0.727; p < 0.001]. Pharmacist based diabetes education plus pharmaceutical care was observed to be statistically significant in lowering levels of systolic blood pressure [-4.94; 95%CI -8.65, -1.23] and triglycerides levels [-0.26, 95%CI -0.51, -0.01], as compared to the interventions which involved diabetes education by pharmacist, and for body mass index (BMI) [-0.57; 95%CI -1.25, -0.12] in comparison to diabetes education by health care team involving pharmacist as member. Conclusion: The findings of this review demonstrate that all interventions had a significantly positive effect on HbA1c, but there was no statistical evidence from this study that one intervention was significantly better than the other for achieving glycemic control.Pharmacist based diabetes education plus pharmaceutical care showed maximum efficacy on HbA1c and rest of the clinical outcomes.

Effectiveness of pharmacist-led educational interventions on self-care activities and glycemic control of type 2 diabetes patients: a systematic review and meta-analysis

BACKGROUND

Effectiveness of pharmacist-led educational interventions on self-care activities and glycemic control of type 2 diabetes mellitus (T2DM) patients is vague. The purpose of this review is to appraise the effect of pharmacist-led educational interventions on self-care activities and levels of glycated hemoglobin of T2DM patients.

METHODS

Five electronic databases were searched from date of database inception to September 2017. Randomized clinical trials examining the effectiveness of pharmacist-led educational interventions, directed at T2DM patients only, were included for systematic review and meta-analysis. The protocol is available with PROSPERO (CRD42017078854).

RESULTS

Eleven studies, involving n=1,544 T2DM patients, were included in this systematic review. Meta-analysis demonstrated that pharmacist-led interventions had a significant effect on lowering of the levels of glycated hemoglobin (-0.66; 95% CI [-0.83, -0.50]; I ²=58.3%; P=0.008), in comparison to usual care. Self-care activities were assessed by using Summary of Diabetes Self-care Activities tool in eight studies. Overall meta-analysis of self-care activities for included studies demonstrated a significant effect of pharmacist-led interventions on improvement of self-monitoring of blood glucose (1.62; 95% CI [0.92, 2.32]; I ²=70.5%; P=0.005), foot care (1.20; 95% CI [0.49, 1.90]; I ²=95.0%; P<0.001), and overall diet (1.16; 95% CI [0.38, 1.93]; I ²=64.2%; P=0.094).

CONCLUSION

The findings of this review demonstrate a significantly positive effect of pharmacist-led educational interventions on HbA1c levels and self-care practices among T2DM patients.

Impact of a structured patient support program on adherence and persistence in basal insulin therapy for type 2 diabetes

OBJECTIVE

Treatment adherence and persistence are essential to achieving therapeutic goals in diabetes and may be improved by patient support programs (PSPs). The COACH Program was launched in 2015 with the goal of supporting patients with diabetes who are prescribed insulin glargine 300 U/mL (Gla-300). The study objective was to assess the program's impact on persistence and adherence with therapy among patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective 12-month analysis was conducted to compare treatment adherence and persistence in patients treated with Gla-300 who actively participated in the COACH PSP versus those who did not enroll using COACH engagement and claims data for the identification period from February 1, 2016 to July 31, 2016. COACH (n=544) and non-COACH (n=544) participants were matched on selected baseline characteristics.

RESULTS

COACH participants were more likely to be adherent to (68.0% vs 61.4%, p= 0.0201; OR: 1.81, p=0.0002) and persistent (48.5% vs 42.1%, p= 0.0309; discontinuation HR: 0.60, p<0.0001) with Gla-300 than non-COACH patients during the 12-month follow-up after controlling for clinical confounders. Additionally, both insulin-naive and basal insulin switcher COACH participants, respectively, were more likely to be adherent (OR: 2.25, p=0.0082 and OR: 1.662, p=0.0364) and persistent (discontinuation HR: 0.53, p=0.0054 and HR: 0.67, p=0.0492) than non-COACH patients. Finally, COACH participants with greater level of engagement showed better persistence.

CONCLUSION

These data demonstrate that participation and engagement with COACH PSPs are associated with improved persistence and adherence to Gla-300 among patients with type 2 diabetes.