Pharmacists improving outcomes in patients with DiabetesAn argument for expansion of scope of practice

Outline

TheoryDiabetesPharmacistsLegislationThe Asheville projectRecommendationsAcknowledgements

Theory

The Health Belief ModelDeveloped by Irwin Rosenstock in 1966 to

explain why people used health services.The first version only had the first 3 pointsSubsequent versions have added 4 ,5 and 6

Health Belief Model

1. Perceived Susceptibility2.Perceived Seriousness3.Perceived benefits of taking action and

perceived barriers to such4.Perception that benefits outweigh risks5.Cues to action6.Perceived self efficacy

Health Belief Model

This theory is especially apt for diabetes The prognosis depends on the patients ability to do the

following things: Take their medication Change their behavior ( checking blood sugar

regularily) Change their diet and lifestyle Before they can make these changes they have to

believe in their susceptibility, the seriousness of the disease and have they must have self efficacy

Diabetes

346 million people worldwide have diabetes25.8 million people (8.3%) in the United

States have diabetesThe American Diabetes Association has

established goals for treatment Hemoglobin A1C <7%, blood pressure

<130/80 , total cholesterol <200mg/dL

Diabetes

By 2030 the estimate is that 1 in 3 people will have diabetes.

People do not die from diabetes they die from the complications of diabetes

Cardiovascular Disease, kidney disease, blindness ,nerve damage and amputations are complications of diabetes

It is the number one cause of adult onset blindness and end stage renal disease

Diabetes

Total costs for diabetes care were $124 billion nationally (ADA 2012)

Individual employers can spend up to $4410 more per year for each employee with diabetes (Cranor and Christensen 2003)

Costs for patients with diabetes are due to sick days, emergency department visits and hospitalizations for exacerbations and complications.

Diabetes

Only 57% of people with diabetes have met the A1c goal of less than 7%

Only 45% have met the goal of blood pressure less than130/80

Only 46.5% have a total cholesterol of less than 200mg/dL

Only 12.2% are meeting all 3 goals

Pharmacists

Pharmacists are among the most trusted and accessible professionals ( Survey 2012)

They are less expensive than physiciansThey are well versed in medication

requirements for diabetes

Pharmacists

Pharmacists have been managing patients with diabetes for years in Ambulatory care, Federal facilities and hospitals ( Giberson et al 2011)

Community pharmacists can do it too if given the tools ( Asheville Project 2012)

Currently in California community pharmacists can manage patients with diabetes if they have a Collaborative Practice agreement with a physician.

Legislation

Collaborative Practice Agreement between pharmacist and a physician.

This allows the pharmacist to perform routine drug therapy related assessment

It allows the pharmacists to order related laboratory tests,

It allows the pharmacist to administer drugs and biologicals by injection and initiate or adjust the drug regimen pursuant to physician order or following an established protocol. ( CA Board of Pharmacy 2012)

Legislation

SB1481 went into effect January 2013Allows the pharmacists to perform heretofore

restricted clinical duties without a physicians oversight

Pharmacists are now allowed to conduct certain lab tests as provided by the Clinical Laboratories Improvement Amendment (CLIA) of 1988

Legislation

As long as the pharmacy obtains the certificate of waiver.

The ability to check A1C, blood glucose and cholesterol in the pharmacy would allow the pharmacist to better manage the patients with diabetes

One could check to see if patients are at goal at their first visit and then periodically thereafter.

Legislation

Clinical Pharmacist Practitioner ( CPP)Established legislation in North Carolina July 1st 2000Allows for established pharmacists with

Collaborative Practice Agreements to order, change , substitute therapies or order tests according to an established protocol ( Dennis 2012)

Legislation

Pending legislationSB 493 introduced by Senator Ed HernadezAdvocates for provider status for pharmacists

in CaliforniaThe bill is intended to allow these highly

trained practitioners to practice to the full extent of their abilities and expand access to healthcare in light of the shortage of primary care physicians. ( Hernandez 2013)

Asheville project

A joint project in the city of Asheville, North Carolina

Between the City of Asheville ( the City), University of North Carolina ( UNC), Mission St John Healthcare (MSJ) and the North Carolina Pharmacists Association ( NCPhA)

The project has been running since 1997 and uses Pharmacists as health coaches.

Asheville Project

The patients meet with the pharmacists regularly

Pharmacists in the program have the ability to adjust/change medications as needed.

They also have the ability to order necessary laboratory tests to track patient progress.

The project has yielded marked improvements in A1C, cholesterol and blood pressure ( Mattson 2013)

Asheville Project

Cranor et al 2003

Medical claims/patient costs

$1,000

$3,000

$5,000

$7,000

$9,000

Prior toProgram

1997 1998 1999 2000 2001

Avge

rage

Dia

bete

s Pa

tient

Cos

ts P

er Y

ear

Medical Claims Diabetes Rx Other Rx

$7,042

$4,669 $4,288 $4,677$4,129

$4,371

Innovations in Quality patient care: The Asheville experience Webb, Michael2013

Compared to US Averages

U.S. Average $7,808 prior to start of program

U.S. Average $7,239 1997U.S. Average $7,485 1998U.S. Average $7.762 1999U.S. Average $8,088 2000U.S. Average $8,468 2001

Percentage of lab values in optimal range

C

Cranor et al 2003

Recomendations

Passage of SB 493 and introduction and passage of a similar federal bill.

Enhanced use of Collaborative Practice Agreements to allow pharmacists to start to help more patients with diabetes pending passage of this bill.

Recognition of Pharmacists as Non Physician Practitioners ( NPPs) by the Centers For Medicare and Medicaid Services (CMS).

Recommendations Implementation of the Asheville Project Model

( Healthmaprx) for Diabetes management in all employer and non-employer healthcare plans

Healthmaprx program can be bought and implemented by any organization it is a good value for money and well worth the investment

Funding should be allocated for community and state organizations that cannot afford the implementation fee.

It should be implemented on a federal level by CMS, VA services Indian Health Services and US Public Health Services.

Acknowledgements Sally Geisse Ramon Castelblanch Mickey Eliason Nina Wallerstein Jessica Wolin Judith Ottoson Sukdip Purewal The faculty and Staff of the MPH program Cohorts 2012, 2013 and 2014