Improving diabetes care through an interdisciplinary, patient-incentivized model in a public health department population

Methods: Patients with uncontrolled type 2 diabetes were identified using the electronic medical record and enrolled between August 2011 and January 2012.  Eligible patients were 18 years or older with a hemoglobin A1C (A1C) > 7% completing a minimum of two visits with the health department physician during the previous year.  Exclusion criteria included inability for self-care, Limited English Proficiency, pregnancy, or no longer being under care of a health department provider.  Patients were scheduled for pharmacist-provided blood glucose meter training, diabetes education and medication management every 4-6 weeks. Patients enrolled in the program were given a glucose meter and testing strips as well as a limited formulary of medications as incentives. The primary outcome measure was change in A1C from baseline. Secondary measures included change from baseline in blood pressure (BP), body mass index (BMI), cholesterol levels, and completion of an eye exam, foot exam, and indicated immunizations. 

Results: Eighty- eight patients were enrolled in the study. Mean age was 49.4 years.   The majority of patients were African- American (85%) and female (80%).  Most were uninsured (76%), with an income below poverty level (59%). Baseline means were: A1C of 9.7%, BMI of 37.0, Low density lipoprotein of 97, and BP of 130.2/82.9. Twenty patients were removed from the study cohort as they never attended clinic beyond the enrollment visit.  Sixty-five patients were included in final results.  At study end, a mean A1C reduction of 0.7% (p=0.010) and BMI reduction of 1 kg/m2 (p=0.005) had been achieved. BP and cholesterol measures were not changed significantly from baseline.  Pharmacist intervention resulted in a 75% improvement in number of eye exams and a 92.3% improvement in foot exams. Of the patients who had not received an annual influenza vaccine at baseline, two of three accepted pharmacist recommendation and received vaccination. Further analysis of the patient cohort by number of visits revealed that patients who attended > 30% of visits achieved a mean A1C reduction of 1.2%.  In contrast, patients who attended < 30% of visits experienced a mean A1C decrease of 0.3%.

Conclusion: While multiple care barriers exist within a public health population due to limited income, inadequate or no insurance and/or transportation, a patient-incentivized, pharmacist-led diabetes clinic, as part of an interdisciplinary care model, facilitates reduction of patient blood glucose and achievement of quality measures for diabetes care.  The amount of impact, however, is predicated by the patient’s ability to regularly attend visits.