Pharmacists Improve Diabetes Control for Hispanic Patients

An intervention in which trained pharmacists assessed patients and made medication-adjustment recommendations to primary care physicians was associated with improved glycemic control in Hispanic patients with type 2 diabetes (T2D), researchers reported.

HbA1c fell by a mean of 0.46% (95% CI -0.84% to -0.07%) within a year of having at least one visit with a UCMyRx-trained pharmacist, researchers led by Kimberly Narain, MD, PhD, MPH, of the University of California Los Angeles, reported online in JAMA Network Open.

While the study found no significant difference in systolic blood pressure (SBP change -1.71 mm Hg, 95% CI -4.0 to 0.58), that coprimary endpoint measure started out relatively low among study participants to begin with (mean 136 mm Hg), Narain and colleagues said.

They pointed to a sensitivity analysis showing that a single pharmacist intervention visit was associated with significantly lower HbA1c, although more than the median number of visits didn’t appear to be better.

In general, Hispanic patients are more likely than whites to develop complications from their diabetes, the researchers noted, but the findings from the study “suggest that a pharmacist-led intervention may be a strategy for improving some outcomes among Hispanic patients with type 2 diabetes.”

The program carried similar benefits for Black patients, showing a 0.4% reduction in HbA1c without a significant blood pressure impact in a previous analysis.

An HbA1c reduction of 0.46% is consistent with what some studies have found for insulin, Narain’s team noted. “Economic models have predicted that a 0.4% decrease in HbA1c concentration would significantly reduce microvascular and macrovascular complications among patients with diabetes over 25 years, taking into account age, sex, risk factors, and preexisting complications,” they said.

The UCMyRx program began in 2012 at 38 primacy care clinics in the Los Angeles area. The program embeds clinical pharmacists trained in motivational interviewing into primary care practices to co-manage patients with complex needs, along with their primary care provider.

In the initial UCMyRx visit, the clinical pharmacist reviews vital signs and laboratory results, performs medication reconciliation, and assesses medication adherence using a standardized survey. Based on results of the visit, the pharmacist implements a personally-tailored intervention to improve medication adherence.

For example, if a patient indicates out-of-pocket costs as a barrier to adherence, the pharmacist will look for less expensive therapeutic options, patient-assistance programs, or generic substitutions. If the complexity of the regimen is a problem, the pharmacist will simplify the regimen by suggesting daily long-acting drug formulations or deleting unnecessary medications, Narain’s group said.

The results of the pharmacists’ assessments and recommendations are communicated to the primary care physician through electronic health records. Once the physician reviews the notes and then documents agreement with the recommendations, the pharmacist is able to directly prescribe or discontinue medications as needed. The pharmacist schedules follow-up visits as well as virtual visits, emails, and phone calls as needed.

The 931 study participants were adult Hispanic patients with uncontrolled T2D with HbA1c measurements of 8% or higher and hypertension as determined by an SBP of 140 mmHg or higher before the intervention. Their mean age was 64, and 59% were female. All participants had at least one visit with a UCMyRx pharmacist during the study period from March 2013 to December 2018.

“Since it is not possible to randomize patients to the UCMyRx program, we use propensity score matching to create comparable cohorts of UCMyRx-exposed and usual care patients,” the researchers noted.

The main outcomes were HbA1c measured within 365 days of the pharmacist visit and SBP measured within 450 days. The researchers performed difference-in-differences analyses, which they said would eliminate the influence of other potential interventions.

An internal review of all patients during the first 3 years of the UCMyRx program, which was conducted separately from the study, found 24% had an inaccurate medication list, 37% were not taking medications as directed, and 46% were nonadherent to medications. The most common reasons for nonadherence were intolerable adverse effects, memory issues, out-of-pocket cost concerns, and beliefs regarding the medications. The UCMyRx program is designed to address these issues, Narain and colleagues said.

Because the study focused on Hispanic patients being treated at academic health centers in southern California from 2013 through 2018, the results might not reflect current practice patterns or be generalizable to other patients, the study authors noted. Another limitation was the lack of detailed data on the specific interventions the pharmacists initiated, they said.

Nevertheless, they concluded: “Given the potential of pharmacist-led interventions like UCMyRx to help improve outcomes in T2D while simultaneously supporting primary care physicians, it is important to facilitate their broader uptake.”

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