Search

Background:Type 2 diabetes (T2D) requires close collaboration between patients and their care management team, often including endocrinology. Primary care pharmacist impact on diabetes management in collaboration with endocrinology is not well established. Objective:To assess if pharmacy and endocrinology collaboration results in a greater A1c reduction in patients with T2D vs endocrinology alone. Methods:This retrospective, observational cohort study was conducted in adult outpatients with T2D and baseline A1c >9% who saw endocrinology within 1 year preceding the study period (January 1, 2021 to January 1, 2022). Patients were included if they had a follow-up A1c 6 months (±90 days) from index date and completed at least 1 endocrinology visit during the study period. Patients managed by endocrinology/primary care pharmacist collaboration (Endo/PharmD) were compared with those who received endocrinology care alone (Endo). Primary outcome was change in A1c from baseline to 6 months. Secondary outcomes included total number of completed visits and percentage of patients achieving A1c <6.5%, <7%, <8%, and <9% between groups at 6 months. Results:A total of 418 patients were included (22 Endo/PharmD, 396 Endo). The change in follow-up A1c was not significantly different between groups, −0.481% (standard error [SE] = 0.396); P= 0.6179. Endo/PharmD patients had significantly more provider visits during the study period (5.3 ± 2.3 vs 2.3 ± 1.2; P< 0.001). No significant difference was observed in odds of A1c goal attainment between groups at 6 months. Conclusion and Relevance:Endocrinology/primary care pharmacist collaboration occurred infrequently but was associated with a trend toward greater A1c reduction in patients with T2D and A1c >9%.

Background:Although randomized trials demonstrate the noninferiority of rivaroxaban compared with warfarin in the context of nonvalvular atrial fibrillation (AF), little is known about how these drugs compare in practice. Objective:To assess the relative effectiveness and safety of rivaroxaban versus warfarin in a large health system and to evaluate this association by time in therapeutic range (TTR). Methods:We conducted a retrospective cohort study with propensity matching in the Cleveland Clinic Health System. The study included patients initiated on warfarin or rivaroxaban for thromboembolic prevention in nonvalvular AF between January 2012 and July 2016. The main outcomes were thromboembolic events and major bleeds. Analyses were stratified by warfarin patients’ TTR. Results:The cohort consisted of 472 propensity-matched pairs. The mean age was 73.6 years (SD = 11.7), and the mean CHADS2score was 1.8. The median TTR for warfarin patients was 64%. In the propensity-matched analysis, there was no significant difference in thromboembolic or major bleeding events between groups. Among warfarin patients with a TTR <64% and their matched rivaroxaban pairs, there was also no significant difference in thromboembolic or major bleeding events. Conclusions:Under real-world conditions, warfarin and rivaroxaban were associated with similar safety and effectiveness, even among those with suboptimal therapeutic control. Individualized decision making, taking into account the nontherapeutic tradeoffs associated with these medications (eg, monitoring, half-life, cost) is warranted.

Background:Health care reform and the projected shortage of primary care physicians necessitate more efficient use of multidisciplinary collaboration. No studies, to date, have evaluated factors associated with treatment success among patients referred to a clinical pharmacist. Objective:To develop a prediction model using patient factors to assist in selecting patients with diabetes most likely to benefit from pharmacy interventions. Methods:A retrospective, nested case-control study was performed. A prediction model using multivariable logistic regression was developed, with model calibration and internal validation. Adult patients with diabetes who had a baseline hemoglobin A1C(A1C) ≥9%, who were consulted for collaborative pharmacy care between July 2009 and July 2014 were included. Success (cases) was defined as a decrease in A1C by 2% or a value of A1C <8% 1 year after the initial visit. Failures were those who did not achieve the A1C goal or were lost to follow-up. Results:A total of 544 unique patients were included, with 243 (44.7%) classified as clinical successes and 301 as clinical failures. Independent factors associated with success included past medical history of cerebrovascular accident and higher baseline A1C, whereas use of short-acting insulin and higher number of classes of diabetic medications at baseline corresponded with failure. A prediction model for success using these factors had an optimism-adjusted C-statistics of 0.629, with good calibration. Conclusion:Referred patients with diabetes have baseline characteristics that are predictive of clinical success. A predictive model based on those factors performed well and might be utilized to improve pharmacist efficiency in the face of constrained resources.

Few studies have examined the effect of pharmacist-led telemanagement on diabetes outcomes during the COVID-19 pandemic.