Evaluation of Diabetes Education and Pharmacist Interventions in a Rural, Primary Care Setting

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Charitable Pharmacies as Catalysts for Coordinated Care: Pharmacist Management of Blood Glucose Among Under-Resourced Patients With Type 2 Diabetes

This community-academic-pharmacy partnership evaluated the impact of a pharmacist-led approach to diabetes management in under-resourced charitable pharmacy patients. Charitable pharmacies serve a large volume of under-resourced patients; pharmacist involvement may improve blood glucose management due to the frequency with which patients access the pharmacy for medications. The purpose of this study was to examine the impact of a pharmacist-led approach to diabetes management (measured by blood glucose levels) by providing medication therapy management (MTM) and leveraging communication between the pharmacist and patients' primary care providers (PCPs). Study participants were Federally Qualified Health Center (FQHC) patients with type 2 diabetes who obtained free diabetes-related medications from the pharmacy. Participants were randomly assigned to treatment as usual (TAU), MTM, or MTM plus coordinated care between the pharmacist and the patient's PCP. The blood glucose levels of patients who received MTM remained stable throughout the duration of the study while blood glucose levels for TAU patients significantly increased. A previously non-existent communication channel between pharmacists and FQHC providers was established and recommendations were exchanged. This relatively small investment on behalf of the pharmacy (e.g., routinely checking blood glucose, sharing medication recommendations) led to a return on health outcomes for a high-risk, low-resource patient population. This study yielded a beneficial change in practice as the pharmacy has institutionalized measuring at-risk patients' blood glucose levels during pharmacy visits. The pharmacy has also continued to enhance their relationship with the FQHC to provide integrated, patient-centered care to this shared vulnerable patient population.

The impact of pharmacist interventions, follow-up frequency and default on glycemic control in Diabetes Medication Therapy Adherence Clinic program: a multicenter study in Malaysia

BACKGROUND

Pharmacist's involvement in optimizing medication adherence among diabetic patients has been implemented for over a decade. Diabetes Medication Therapy Adherence Clinic (DMTAC) was set up to educate diabetic patients, monitor treatment outcomes, and manage drug-related problems. While evidence shows that pharmacist-led DMTAC was effective in reducing HbA1c, there was limited data regarding the impact of different intervention types and default to follow-up on glycemic control.

AIM

To assess the impact DMTAC on glycemic control and the difference in glycemic control between hospital and health clinic settings as well as defaulter and non-defaulter. In addition, the impact of pharmacist's interventions, DMTAC follow-up frequencies, and duration of diabetes on glycemic control were also determined.

METHODS

A retrospective study was conducted among diabetes patients under DMTAC care between January 2019 and June 2020 in five hospitals and 23 primary health clinics. Patients' demographics data, treatment regimens, frequencies of DMTAC visits, defaulter (absent from DMTAC visits) and types of pharmacists' intervention were retrieved from patients' medical records and electronic database. HbA1c was collected at baseline, 4-6 months (post-1), and 8-12 months (post-2).

RESULTS

We included 956 patients, of which 60% were females with a median age of 58.0 (IQR: 5.0) years. Overall, the HbA1c reduced significantly from baseline (median: 10.2, IQR: 3.0) to post-1 (median: 8.8, IQR: 2.7) and post-2 (median: 8.3, IQR: 2.6%) (p < 0.001). There were 4317 pharmacists' interventions performed, with the majority being dosage adjustment (n = 2407, 55.8%), followed by lab investigations (849, 19.7%), drugs addition (653, 15.1%), drugs discontinuation (408, 9.5%). Patients treated in hospitals received significantly more interventions than those treated in primary health clinics (p < 0.001). We observed significantly less reduction in HbA1c in DMTAC follow-up defaulters than non-defaulters after 1 year (- 1.02% vs. - 2.14%, p = 0.001). Frequencies of DMTAC visits (b: 0.19, CI: 0.079-0.302, p = 0.001), number of dosage adjustments (b: 0.83, CI: 0.015-0.151, p = 0.018) and number of additional drugs recommended (b: 0.37, CI: 0.049-0.691, p = 0.024) had positive impact on glycemic control whereas duration of diabetes (b: - 0.0302, CI: - 0.0507, - 0.007, p = 0.011) had negative impact.

CONCLUSION

Glycemic control improved significantly and sustained up to one year among patients in pharmacists-led DMTAC. However, DMTAC defaulters experienced poorer glycemic control. Considering more frequent visits and targeted interventions by pharmacists at DMTAC resulted in improved HbA1c control, these strategies should be taken into account for future program planning.

Exploring barriers and facilitators to pharmacist-provided diabetes self-management education and support

BACKGROUND

Pharmacists have the necessary clinical experience and medication knowledge to effectively provide diabetes self-management education and support (DSMES); however, barriers exist to DSMES implementation by community pharmacists.

OBJECTIVE

The aim of this study is to explore DSMES from the community pharmacists' perspectives, identify barriers and facilitators to pharmacist DSMES implementation, and guide development of pharmacist-provided DSMES programs in Idaho.

METHODS

Implementation climate, the theoretical framework for this project, is focused on how community pharmacists in Idaho perceive they will be supported by patients, health care providers, and insurers in DSMES implementation. Pharmacist investigators with qualitative research experience conducted semistructured interviews with 6 licensed community pharmacists from Idaho via Zoom between March and June 2020. Recordings were transcribed verbatim and analyzed using HyperRESEARCH 4.5.1. Themes, patterns, and dominant concepts that emerged from respondents' about DSMES were explored, labeled, and categorized into modifiable and nonmodifiable barriers and facilitators. This study was granted expedited approval by the Idaho State University Investigational Review Board.

RESULTS

Relevant themes included current scope of practice, barriers, and facilitators. Subthemes related to the current scope of pharmacy practice included unclear roles and responsibilities and legislative constraints to practice. For barriers, subthemes included cost of set-up, billing and coding education, and the sustainability of services based on current reimbursement models. For facilitators, subthemes included the need for additional collaborations (external and internal), technology access, and trained pharmacy staff.

CONCLUSION

Pharmacists are underutilized health care providers, capable of providing DSMES services if provided the necessary resources. This work identifies barriers and facilitators to pharmacist-led DSMES that can be considered by others when implementing DSMES or other disease management services.

A Systematic Review on Pharmaceutical Diabetic Care Services in the United Arab Emirates (UAE)

OBJECTIVE

the aim of this systematic review study is to evaluate the current services and pharmaceutical care practices for diabetic patients in the UAE.

METHODS

systematic review coverage conforms to the guidelines of the PRISMA; the search was limited to primary research articles, which describe the term "pharmaceutical diabetes care services in UAE". The search strategy was developed in collaboration with a health database librarian, and a predetermined protocol was developed in conjunction with the authors for search methods.

RESULTS

The findings showed the effect of a prescription treatment system on disease prevention and health-related quality of life in patients with type 2 diabetes in the United Arab Emirates. A retrospective interventional health evaluation was implemented to evaluate existing health procedures and the impact of conventional treatment on type 2 diabetes treatment (T2DM). The findings of this interventional evaluation were largely favorable, and the viability of changing the existing clinical procedure was stressed. The individualized strategy has helped clinicians finding a great result in terms of glycemic and BP, as well as patient satisfaction. The need for more work to clarify the long-term effect of organized strategy in enhancing the consistency of T2DM treatment in the UAE. The findings also showed increase community pharmacy services might further change the opinions of patients on the level of care provided by such pharmacies. The patients' quality of life would improve by drug treatment efficacy and pharmacist services to mitigate diabetes complications. The findings showed a prescription treatment system on disease prevention and health-related quality of life in patients with type 2 diabetes in the United Arab Emirates. A retrospective interventional health evaluation was implemented to evaluate existing health procedures and the impact of conventional treatment on type 2 diabetes treatment (T2DM). The findings of this interventional evaluation were largely favorable, and the viability of changing the existing clinical procedure was stressed. The individualized strategy has helped clinicians reach a great result in terms of glycemic and BP, as well as patient satisfaction. The need for more work to clarify the long-term effect of organized strategy in enhancing the consistency of T2DM treatment in the UAE. The findings also showed increase community pharmacy services mightfurther change the opinions of patients on the level of care provided by such pharmacies. The patients' quality of life would improve by drug treatment efficacy and pharmacist services to mitigate diabetes complications.

CONCLUSION

This systematic review reported beneficial pharmacist-led diabetic management services in the UAE. Several care strategies were also highlighted to improve service for type 2 diabetes mellitus patients.