Clinical Review

Efficacy of Patient Aligned Care Team Pharmacist Services in Reaching Diabetes and Hyperlipidemia Treatment Goals

Fed Pract. 2015 November;32(11):42-47

References

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The primary objectives of this QI analysis were to determine the efficacy of PACT CPSs in reducing LDL-C and/or A_1c levels in veterans enrolled in VAIHCS DSM clinics. The primary endpoints of this study were change from baseline LDL-C to first LDL-C drawn between 6 and 9 months and change from baseline A_1c to first A_1c drawn between 9 and 12 months after enrollment in DSM clinics.

The secondary objectives of this QI analysis were to determine the efficacy of PACT CPSs in improving high-density lipoprotein cholesterol (HDL-C), triglycerides (TGs), and total cholesterol (TC) levels in veterans enrolled in DSM clinics. The secondary hyperlipidemia endpoints were the change from baseline HDL-C, TG, and TC to first blood work results and percentage of patients who achieved National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) LDL-C goal between 6 and 9 months after clinic enrollment.²¹ The secondary DM endpoint was the percentage of patients who achieved the recommended American Diabetes Association A_1c goal between 9 and 12 months after enrollment. Mean percentage reduction of primary and relevant secondary endpoints were determined for each study subject.

Subjects selected for inclusion within this analysis were U.S.  veterans aged 18 to 75 years who were enrolled in DSM clinics for hyperlipidemia or type 2 DM (T2DM) between September 1, 2011, and September 1, 2013. These subjects did not meet VA performance measures for hyperlipidemia or T2DM at baseline. The key focus of these measures was to include disease prevention and management of diagnosed disease by clinical practice guideline standards. To be included in the analysis, subjects were required to attend DSM clinic appointments for a minimum of 3 months for hyperlipidemia or  6 months for T2DM.

Subjects were excluded from this study if they were nonadherent to clinic visits (defined as missing  > 50% of their appointments), were discharged from the clinic due to nonadherence to drug therapy and/or lifestyle interventions, met LDL-C or A_1c goals prior to the laboratory collection interval, or had a baseline LDL-C of < 110 mg/dL or baseline A_1cof < 8%. Subjects were also excluded if they failed to receive any antihyperlipidemic or antidiabetic agents through the course of their enrollment. Statistics were derived by averaging the percentage change of laboratory parameters per subject. The time frame used was from baseline to the time of primary and secondary endpoint collection. Due to the QI nature of this analysis, power was not targeted for attainment. A randomized sample of  49 subjects was pulled from the population for complete analysis, which was determined by using a random number generator and analyzing corresponding alphabetized patient charts.

Results

Two hundred ninety-five charts were reviewed to yield 49 subjects eligible for the analysis (Figure 1). One subject was eligible for both hyperlipidemia and T2DM. The primary reasons for exclusion were consults for DSM services not related to T2DM or hyperlipidemia (49.4%) and inadequate time of enrollment (30.2%). Less than 10% of exclusions were due to baseline LDL-C < 110 mg/dL or A_1c < 8%, unavailable blood work within the collection interval, nonadherence to clinic visits or medications, or other reasons.

Hyperlipidemia

Means and ranges for LDL-C, TG, and TC were all significantly reduced from baseline (Figure 2). The primary endpoint for hyperlipidemia included a 25.1% reduction in mean LDL-C (95% CI, 0.173-0.327). Secondary endpoints included a 12.9% reduction in mean TG from baseline (95% CI, 0.017-0.241) and a 22.5% reduction in mean TC from baseline (95% CI, 0.174-0.276). A 2.1% increase in mean HDL-C was considered nonsignificant (95% CI, -0.082 to -0.042). The percentage of subjects meeting LDL-C goal between 6 and  9 months after enrollment was 36.7% (Table 1).

Twenty-six subjects (63.4%) did not reach their LDL-C goal between 6 and 9 months after clinic enrollment. Of these subjects, an additional analysis was performed to determine potential contributing factors. Eleven of these subjects received moderate- to high-intensity statin therapy, 2 received low-intensity statin therapy, and  3 (without documented statin intolerance) received no statin therapy. Seven subjects had statin intolerance documented in their charts at baseline or during treatment in DSM clinics. Three subjects had documented nonadherence. Subjects receiving no statin therapy due to intolerance or other reasons were prescribed  fibrates, cholestyramine, psyllium, or therapeutic lifestyle changes.

Diabetes

Mean A_1c and A_1c range resulted in a significant reduction from baseline (Figure 3). The primary endpoint for T2DM included a 3.1% reduction in mean A_1c(95% CI, 1.45-5.52). The percentage meeting A_1cgoal between  9 and 12 months after enrollment was 44.4% (Table 2).