Patient Care

Serious Mental Illness and Its Impact on Diabetes Care in a VA Nurse/Pharmacist-Managed Population

Fed Pract. 2017 October;34(suppl 8):S32-S37

References

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7. Desai MM, Rosenheck RA, Druss BG, Perlin JB. Mental disorders and quality of diabetes care in the veterans health administration. Am J Psychiatry. 2002;159(9):1584-1590.

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10. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-2620.

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13. James A, Leciejewski K, Pascuzzi K. Effect on diabetes care by a nurse certified diabetes educator with pharmacist support within a primary care clinic in a Veterans Affairs hospital. Abstract presented at: Ohio College of Clinical Pharmacy Spring Meeting; May 29, 2015; Cleveland, Ohio.

Results

A total of 134 veterans who were referred to the RN CDE/PharmD clinic were reviewed from January 1, 2011 to December 31, 2014 with 50 veterans in the SMI group and 50 veterans in the non-SMI group. The mean age, gender, number of clinic visits, number of HbA_1c tests, and mean initial HbA_1c were similar between groups (Table 1). Veterans in the SMI group were followed by the clinic longer than veterans without SMI (298 d vs 239 d, respectively) and had a slightly higher baseline HbA_1c (10.9% vs 10.3%). The majority of veterans in the SMI group had MDD (88%), and the mean number of mental health-related visits was 8 visits per veteran. Most veterans were prescribed antidepressants during the study period (70%), with fewer veterans prescribed antipsychotics (20%). Concurrent antidepressant and antipsychotic medications used during the study period are detailed in Tables 2 and 3.

Overall, there was a significant decrease in mean HbA_1c of 2.8% (10.6% to 7.8%; P < .001) for the entire study population (Figure 1). Veterans with SMI had a greater reduction in HbA_1c (SMI 3.0% vs non-SMI 2.6%, P = .271) (Figure 2).

Secondary objectives are listed in Table 4. The mean HbA_1c nadir was similar between groups (SMI 7.8% +/- 1.39% vs non-SMI 7.7 +/- 1.03%); however, the mean highest postnadir HbA_1c was higher in the SMI group compared with that of non-SMI (9.3% +/- 1.62% vs 10.1% +/- 2.36%), with a difference of 1.6% vs 2.3% (P < .005). Eighty-four percent of veterans in the SMI group relapsed compared with 72% of veterans without SMI, which was not a significant difference. Of the veterans who relapsed, the mean time to relapse was longer in the veterans without SMI compared with that of veterans with SMI, but the difference was not significant (372 +/- 204.6 d vs 336 +/- 241.6 d, P = .772). The most common documented reason for glycemic relapse was nonadherence to medications or diet (Table 5).

Discussion

Collaborative interventions have improved glycemic control in patients with concurrent SMI and DM. Although there was not a significant difference in mean HbA_1c from the initial HbA_1c to the nadir HbA_1cbetween study groups, this study provided valuable insight for the RN CDE/PharmD clinic. The mean HbA_1cdecreased over time in both study groups, demonstrating that the collaborative intervention was effective in improving glycemic control in veterans with SMI and veterans without SMI. The mean HbA_1c decrease in the SMI group was slightly higher compared with that of the non-SMI group, but the difference was not significant. The decrease in mean HbA_1c also demonstrated that the RN CDE/PharmD interventions were effective in each group. Contrary to this study’s hypothesis that veterans with SMI would have worse glycemic control compared with that of veterans without SMI, this study demonstrated that there was no difference in glycemic control between groups.

Veterans in the SMI group had a significantly greater percentage increase in mean HbA_1c postnadir, indicating that their glycemic control worsened postnadir compared with that of the non-SMI group. If veterans with SMI relapsed, they tended to relapse to a greater extent compared with veterans without SMI, as indicated by a larger percentage increase in mean HbA_1c. Time to relapse was shorter in veterans with SMI compared with that of veterans without SMI, but the difference was not significant. Using the information gathered, if veterans with SMI relapsed, they tended to relapse sooner and with a greater percentage increase in HbA_1c compared with that of veterans without SMI.

Limitations

As a retrospective study, data collection was limited to the information found in the veteran’s EMR: Data collected were dependent on accurate and comprehensive documentation in the veteran’s problem list and progress notes. Additionally, the time between HbA_1ctests was not analyzed when determining the differences in mean HbA_1c. These data may be helpful in identifying reasons for glycemic relapse. Glycemic relapse depended on the number of HbA_1ctests that the veteran completed. Time to glycemic relapse may occur sooner in veterans who completed more frequent HbA_1c testing.

Conclusion

There was a significant decrease in mean HbA_1c for the entire group over time. In comparing the percentage change in mean HbA_1c between groups, there was not a significant difference in the decrease in mean HbA_1cfrom initial to nadir HbA_1cin veterans with SMI compared with that of veterans without SMI. However, veterans with SMI had a significantly larger increase in HbA_1cpostnadir compared with that of veterans without SMI, indicating that support would likely be needed after the veteran achieves his or her HbA_1c target. Strategies such as extending the follow-up time in the RN CDE/PharmD clinic, expanding collaborative services with behavioral medicine and psychiatry, additional shared medical appointments or support groups for veterans with DM and SMI, and health literacy assessments may need to be adapted to assist in maintaining glycemic control in veterans with concurrent SMI and DM.

Serious Mental Illness and Its Impact on Diabetes Care in a VA Nurse/Pharmacist-Managed Population

References

Results

Discussion

Limitations

Conclusion

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