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Diabetes care management: Comparative effectiveness of clinical decision support vs. additional pharmacist-led self-management support
Methods: EMR CDS rules risk stratify diabetics by disease control (A1C<7 vs. 8-9 vs. >9). Primary care providers (PCPs) receive CDS alerts which indicate chronic/preventive services that are overdue and patient eligibility for PharmD care management (A1C>8). Clinic staff also uses the registry to notify patients that they are eligible for PharmD visits for disease self-management. During PharmD visits, the pharmacist monitors status of disease control and health prevention; adjusts medications; provides counseling on lifestyle modifications and self-monitoring goals; and provides written care plans. Patients referred to care management follow up with the pharmacist in 4-6 week intervals until treatment goals are achieved (A1C<8). Using a difference-in-difference longitudinal linear model, we examined changes in A1C among patients who received PharmD care management (intervention) compared to patients who received care from the PCPs whose disease management is only prompted by EMR CDS reminders (control).
Results: Among 608 diabetics seen from 2012-2013, 191 had A1C>8 (121 control; 70 intervention). The intervention group had a higher A1C reduction than the control group (-1.08 [SD=0.40]; p<0.01) after adjusting for gender, race, ethnicity, marital status and age. However, this difference was no longer significant (-0.076 [SD=0.34]; p>0.05) after adjusting for baseline A1C which was higher in the intervention group compared to the control group (11.15 [SD=2.0] vs 9.78[SD= 1.9]). To determine the effects of the intervention we will need more than 1140 patients to detect a clinically significant A1C change of 0.5.
Conclusion: PCMH care team expansion to include clinical pharmacists holds promise for improving clinical outcomes among diabetics receiving care in safety-net community health centers. Larger studies in this vulnerable population are needed to determine the intervention's effectiveness. Future studies should also examine the dose effect of pharmacy visits (e.g. number and/or frequency of follow up) compared to PCP visits for diabetes control.
Learning Areas:
Chronic disease management and preventionLearning Objectives:
Compare the effectiveness of electronic medical record generated clinical decision support alone versus additional pharmacist-led care management to improve disease control among poorly diabetics.
Keyword(s): Chronic Disease Management and Care, Community Health Centers
Qualified on the content I am responsible for because: I am a General Internist and health services researcher with a focus on disease risk reduction, patient-centered medical home models of care, and use of health information technology to optimize care and reduce health disparities. I have eight years of experience in health administration and health service delivery re-design. I am principal investigator or co-investigator on a number of private foundation and federally funded research grants
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.