Pharmacists' Interventions to Improve Control and Management in ...

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REVIEW ARTICLE

Literature Review: Pharmacists’ Interventions to Improve Control and Management in Type 2 Diabetes Mellitus Mohamed Azmi Hassali, BPharm, MPharm, PhD; Saeed Ur Rashid Nazir, BPharm, MPhil, MBA, PhD; Fahad Saleem, BPharm, MPhil, MBA, PhD; Imran Masood BPharm, MBA, PhD

ABSTRACT Diabetes mellitus (DM) is a common disease in which excessive levels of blood glucose (sugar) occur. In simple terms, diabetes is generally due to failure in the effective functioning of insulin. Common types of diabetes include type 1 and type 2, which have different treatment options. In the general population, type 2 diabetes is more prevalent than type 1, and type 2 accounts for more than 90% of all known cases of diabetes. The current review examines the contributions of pharmacists to the more positive, longterm prognosis of patients with DM through improvements in its control and management. The authors conducted a systematic literature search. Twenty-seven studies were

Mohamed Azmi Hassali, BPharm, MPharm, PhD, is an associate professor of social and administrative pharmacy in the School of Pharmaceutical Sciences at Universiti Sains Malaysia in Penang, Malaysia. Saeed Ur Rashid Nazir, BPharm, MPhil, MBA, is a PhD Student in the School of Pharmaceutical Sciences at Universiti Sains Malaysia. Fahad Saleem, BPharm, MPhil, MBA, PhD, is a senior lecturer of social and administrative pharmacy in the School of Pharmaceutical Sciences at Universiti Sains Malaysia. Imran Masood BPharm, MBA, PhD, is an assistant professor in the Department of Pharmacy at Islamia University of Bahawalpur in Bahawalpur, Pakistan.

Corresponding author: Saeed Ur Rashid Nazir, B-Pharm, MPhil, MBA E-mail address: [email protected]

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identified that demonstrated the effects of a pharmacist’s intervention on glycated hemoglobin (HbA1c). In all cases, it was reported that the intervention was successful in reducing HbA1c in patients with DM. Pharmacist interventions have also proven successful in improving patient lipid profiles, cardiovascular outcomes, and body mass indexes (BMIs), and in reducing other complications associated with the disease. It was also reported that economic advantages were associated with a pharmacist’s management of DM. (Altern Ther Health Med. 2015;21(1):28-35.)

D

iabetes mellitus (DM) is metabolic disorder characterized by chronic hyperglycemia, polyuria, polydypsia, polyphagia, emaciation, and weakness due to disturbances in carbohydrate, fat, and protein metabolism, which are associated with an absolute or relative deficiency in insulin secretion and/or insulin action.1-5 Diabetes is the most common endocrinal disorder, and as of the year 2010, it was estimated that more than 200 million people worldwide had DM, with 300 million subsequently to have the disease by 2025.6-8 DM may be categorized into several types, but the 2 major types are type 1 and type 2.9-11 Table 1 contrasts the features of type 1 and type 2 DM.12 Type 1 Diabetes β-Cell destruction occurs in pancreatic islets. The majority of the cases involve autoimmune antibodies that destroy β-cells and that are detectable in the blood, but some cases are idiopathic. In all type 1 cases, levels of circulating insulin are low or very low, and patients are more prone to ketosis. This type is less common and has a low degree of genetic predisposition.

Hassali—Pharmacist Interventions and Type 2 Diabetes


Table 1. Contrasting Features of Type 1 and Type 2 Diabetes Mellitus13 Serial No. 1 2 3 4 5

Features Frequencya Age of onset Type of onset Weight HLA

6 7 8 9

Family history Genetic locus Diabetes in identical twins Pathogenesis

10 11

Islets of cell antibodies Blood insulin level

Type 1 10%-20% Early, 7.5%) and used more than $600 of prescription medications. A control group was also identified. The most frequently used interventions were optimal patient care through avoidance or treatment of DRP and increase medication adherence. Total monthly health care costs for the intervention group increased from $1448 to $1756, a difference of $308 ± $2016, whereas the control group increased from $1089 to $1745, a difference of $656 ± $2641; the increase was lower in the intervention group. Although none of the results were statistically significant (P = .46), patients in the intervention group trended toward better medication adherence and a greater decline in HbA1c than controls.36 To evaluate the impact of pharmacist interventions on health care costs, approximately 218 interventions involved “explained and advised the use of Hassali—Pharmacist Interventions and Type 2 Diabetes

Figure 3. Comparison of health care costs of diabetes patients before and after pharmacist intervention. Before pharmacists’ intervention: health care costs of diabetes patients After pharmacists’ intervention: health care costs of diabetes patients

pattern management” and “alerted the physician of an abnormal HbA1c level” were made by pharmacists in a 53-week study with 700 diabetic patients from 2 employer groups in Toledo. A significant decrease in health care costs occurred for diabetic patients who received an intervention from a pharmacist.50 This study aimed at finding if physicians’ therapy decisions based on pharmacist recommendations lead optimal outcomes. Approximately 700 patients from 2 employer groups have participated in pharmacist provided disease state management program at 7 independent pharmacies across northwest Ohio. A team of clinical pharmacists and researchers had participated in interventions program. A team of clinical pharmacists and physicians were participated in this interventions program. Approximately 446 pharmacist interventions with corresponding physician responses and patient outcomes were made. The most frequent interventions involved drug therapy and formulary management. The most frequent responses by physicians were “physician acknowledged recommendation, monitoring added” and “physician added a medication.” Physicians responded favorably to the pharmacist recommendations were 54.1% of the time. An improvement was seen in 91.2% of patient outcomes compared with only 64% when physicians did not response to pharmacist interventions. In an effort to save costs and improve care, pharmacist-physician collaboration is essential.51 For patients receiving pharmacist interventions, Cranor et al52 reported that medical costs decreased by $1200 per patient per year whereas Garrett et al53 reported that costs per patient were $918 lower than expected. Ragucci et al54 estimated that their study led to a cost avoidance of $59 040 across all patients (N = 142) as a result of decreases in HbA1c. Effects on Knowledge A lack of knowledge about the DM and its management can be considered an important reason for improper control of DM. A patient’s knowledge is usually assessed to evaluate how it corresponds to biomedical concepts.55 Education on self-management is the cornerstone of care for all patients with diabetes and is necessary for the improvement of patients’ outcomes. It is defined as an ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care.56 Evaluation of diabetes knowledge has been an important composition in the overall assessment of patients with diabetes for many years. Researchers have concluded that metabolic control of diabetes can be affected by a patient’s knowledge.57,58 A 12-month, noncrossover, single-group trial was conducted by Berringer et al, with 82 ALTERNATIVE THERAPIES, JAN/FEB 2015 VOL. 21, 1

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diabetic patients at 2 independent community pharmacies in Richmond, Virgina. Patients received diabetic medication counseling, printed educational material, and instructions on dietary regulation, exercise, and lifestyle modifications from the community pharmacist. Average morning bloodglucose levels decreased by 19.3 mg/dL at the end of 6 months (P = .07) and 29.3 mg/dL at the end of 12 months (P < .05). The frequency of symptomatic episodes of hyperglycemia and hypoglycemia was significantly reduced in the intervention group. The data analysis indicated that diabetic patients had very good glycemic control, good health, and a good understanding of disease and its management at the end of study.59 Effects on Health-related Quality of Life Health-related quality of life (HRQoL) is defined as “a person’s perceived quality of life, representing satisfaction in those areas of life likely to be affected by health status.”60 Diabetes is a chronic disease with serious short-term and long-term consequences for the afflicted. In the long term, diabetes causes microvascular complications (eg, retinopathy and neuropathy) and macrovascular complications (eg, myocardial infarction, angina pectoris, and stroke). In addition to diabetes-related complications, episodes of hypoglycemia, fear of hypoglycemia, changes in lifestyle, and fear of long-term consequences may lead to issues of HRQoL. In fact, individuals with diabetes have reduced HRQoL compared with those without diabetes in the same age group,61-62 and their HRQoL decreases with disease progression and complications.63-64 In a 9-month study at Siouxland Community Health Center (SCHC) located in Sioux City, Iowa, 149 patients were randomized to the intervention group (n = 76) or control group (n = 73). The intervention group received services were scheduled every 2 weeks for 3 months to review therapy, nutrition, and exercise. The control group received SCHC standard approach to diabetes care. Scott et al demonstrated that patients enrolled in a pharmacist intervention group had improved in their glucose control and quality of life more than those receiving customary care. Mean HbA1c levels fell significantly (P < .05) from baseline to 9 months. Quality of life was measured by SF-12 and diabetes quality of life (DQOL) questionnaires. Using SF-12, the mental component score improved in the intervention group from 43.1 to 46.2 and decreased in the control group from 42.1 to 38.5, and difference between the groups was significant (P < .05). Using DQOL, satisfaction level in the intervention group improved from 63.7 to 77.4 and improved in the contorl group from 57.0 to 63.4, resulting in a significant difference (P < .05) during a 9-month period.65 CONCLUSIONS This review indicates that pharmacist interventions offer a potential benefit to improve medication adherence in diabetes and to reduce levels of HbA1c, BP, LDL, and diabetes-related complications significantly. This review also 34

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Figure 4. Effect of pharmacist’s integration program on clinical and humanistic outcome. Adherence Increase

Medication and Disease-related Knowledge Increase

Pharmacist’s Integration

Medication and Disease-related Problems Decrease

Improvement in Health-related Quality of Life

finds evidence that metabolic control of diabetes can be affected by a patient’s knowledge of the disease. As studies reviewed in this article have indicated, individuals with diabetes have reduced HRQoL compared with those without diabetes. A pharmacist can greatly improve not only adherence but also patients’ satisfaction and quality of life. This review also emphasizes that medication management or intervention programs by pharmacists provide improvements in clinical, humanistic, and financial outcomes for patients with a chronic disease (ie, diabetes). Reviewed studies showed that drug costs increased as a result of improved adherence to a prescribed therapy. Pharmacist integration into a health care team has been shown to be effective in improving a number of clinical health outcomes. Unfortunately, this review could not make conclusions as to the economic impact of pharmacists due to the paucity of high-quality economic studies. Future investments should be made on research into this area to address the limitations of the current literature. REFERENCES

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