Interim report shows clinical improvements for diabetes initiative

Pharmacists, VBID keys to program

The Diabetes Ten City Challenge (DTCC), which uses pharmacist coaches and a value-based insurance design (VBID) to help patients manage chronic disease, demonstrated improvements in all key clinical indicators in the first year, according to an interim report by the American Pharmacists Association (APhA) Foundation.

Through the DTCC, which the foundation is conducting in 10 U.S. cities with support from GlaxoSmithKline, employers establish a voluntary health benefit for insured members with diabetes and waive copayments for diabetes medications and supplies if they work with a pharmacist coach to manage their condition. The DTCC is modeled after other APhA Foundation programs that have proven to improve overall health, reduce absenteeism, shorten hospital stays, and reduce healthcare costs.

The interim report, published in the March/April Journal of the American Pharmacists Association, reviewed results of 914 patients who were in the DTCC at least three months as of September 30, 2007. It documented improvements in all the recognized standards of diabetes care (see the chart on p. 3 of the PDF of this issue), including:

  • Clinical measures, such as A1c, LDL cholesterol, and blood pressure
  • Care measures, including current influenza vaccinations and foot and eye exams
  • Self-management goals for patients, such as nutrition, weight, and exercise
  • Patient satisfaction with their pharmacist and overall diabetes care

Coauthor of the report William M. Ellis, CEO of the APhA Foundation, which contracts with employers, helps establish local pharmacist networks, and provides software and data analysis for the DTCC, says the diabetes self-management program empowers patients and puts them at the center of care. “Too many times, patients really are not directly involved in their care. With this program, they become educated about their condition and work in partnership with their pharmacists, physicians, and other healthcare providers,” says Ellis.

Building upon the Asheville Project, a successful pharmacist-driven diabetes program implemented in Asheville, NC, the APhA Foundation is expanding the pharmacist coach model nationally to prove it can be replicated in diverse geographies and various employer types.

The project is the most recent initiative giving the pharmacist a greater role in healthcare. A study released earlier this year by the University of Oklahoma Health Sciences Center’s College of Pharmacy in Oklahoma City showed that pharmacists performing medication therapy management services improved diabetic patients’ A1c levels. (See the February DMA for more information on this study.)

Although many graduating pharmacy students have healthcare experience beyond dispensing pills, local pharmacists are a largely untapped resource by the healthcare system, says Ellis.

The DTCC creates a system in which pharmacists play a larger role. There is also greater communication among the physician, diabetes educator, and other healthcare professionals. The pharmacist coach combines teaching lifestyle factors, such as prevention, exercise, and reading labels, which are meant to empower the patient to take a greater role in his or her health, with a clinical component in which the pharmacist can review and suggest changes to medications and check blood sugar and A1c levels. Jan Park, RN, a wellness coordinator for the city of Charleston, SC, says the pharmacist plays the role of patient advocate and collaborates with the physician and other members of the care team.

Pharmacists are also able to spend more time with patients than PCPs, who are often stretched for time. “They feel like their pharmacist coach is someone they can definitely call at any time and is a little bit easier to get in touch with at a moment’s notice and get their questions answered rather than waiting for their physician,” says Park, adding that one-third of the city’s diabetic employees (89 people) took advantage of the program.

Charleston doesn’t have the clinical outcomes for its DTCC patients, but Cecily V. DiPiro, RPh, PharmD, a pharmacist at The Prescription Center in Charleston, says, overall, her patients have started exercising more, reduced blood sugar and A1c levels, and are feeling better.

The city hasn’t received the insurance claims data yet to review the potential program savings, but Park hopes to save at least $1,000 per year per participant, which she bases on the Asheville Project. “It’s really an amazing thing to see. It really makes you feel like we’re doing something to help change healthcare,” says Park.

The preventive nature of the program is what prompted Charleston officials to get involved. The U.S. healthcare industry is great at “fixing things after they’re broken,” but DTCC is a shift to prevention focus, Park says.

“We need to shift [healthcare] over to more prevention and putting people in control of their disease and educating them and giving them the tools they need to prevent complications,” Park says. That shift to prevention appears to be working in the DTCC. After one year, the report noted, the program showed the following improvements:

A 21% increase in the number of participants achieving the American Diabetes Association goal of A1c levels of less than 7%

An increase from 43.8% to 57.7% of those who achieved National Cholesterol Education program goals for LDL cholesterol

A 15.7% increase in the number of people who achieved recognized goals for systolic blood pressure

The study’s authors say programs such as the DTCC could affect how healthcare is delivered in the United States.

“Successful implementation of such a model on a broad scale would have the capacity to transform the healthcare system by improving outcomes and controlling costs,” according to the interim report.

The ten DTCC sites are:

  • Charleston, SC
  • Chicago
  • Colorado Springs, CO
  • Cumberland, MD
  • Honolulu
  • Milwaukee
  • Northwest Georgia
  • Pittsburgh
  • Los Angeles
  • Tampa Bay, FL


Pharmacists participating in the DTCC completed a diabetes certificate program offered by the APhA. This program reviewed diabetes and its complications, offering management, monitoring, and educational strategies for diabetes care, as well as information on exercise and nutrition.

DiPiro assists in the care of 30 patients in the DTCC and says her role is to keep the patient focused. “The majority of these people know what they need to do. They know that they should be eating better, that they should be exercising more, but they need that one more person to keep them focused on actually doing it and someone to be accountable to,” she says.

Pharmacists meet with diabetic patients four times in the first six months. The first visit includes collecting information about medication, disease history, exercise regimens, sugar levels, and other specifics so the pharmacist knows where to focus. After that, visits range from 30 to 60 minutes and vary in regularity, depending on the status of the disease. For the patient who is in control of his or her diabetes, a meeting every three months might be sufficient, but someone with more education needs may have a monthly visit.According to the report, the participants studied visited the DTCC pharmacist an average of 4.6 times in the first year. During those appointments, pharmacists reviewed patients’ medications and blood glucose self-monitoring skills. A1c and cholesterol test results were discussed, when available, and pharmacists taught patients about nutrition and helped them create clinical, fitness, and nutritional goals.

Patients are weighed at every visit and the pharmacist also takes their blood pressure. The pharmacists are reimbursed by employers for patient visits depending on the fee schedules negotiated by the local pharmacy network.

DiPiro says part of her role is empowering patients to take greater control of their healthcare, such as suggesting what questions to ask a physician. For example, many of DiPiro’s patients did not understand or request copies of their blood work before the DTCC.

“It has been very gratifying to see people now ask, ‘What was my A1c?’ or ‘How do my cholesterol values look?’ ” says DiPiro.

After each visit, the pharmacist sends a note to the patient’s physician with a summary of the visit. The pharmacist might also call the patient’s physician if there is a concern. Clinical information obtained at each visit is documented by the pharmacist at a secure Web site.

Some physicians have been leery of programs in which other healthcare professionals assist in patient care, but DiPiro says she has not received any pushback from physicians.

She adds that she is careful not to compromise the physician-patient relationship. When communicating with physicians, she says she stays focused on the issue at hand and lets physicians know she is there to work with them.

“I want my patients to have the best relationship they can with everyone on the team because we are all working toward the same goal,” says DiPiro.

Park says physicians in the Charleston area have been receptive to the DTCC and have even encouraged some of their diabetic patients to take part. The pharmacist coaches’ participation has increased doctor visits because of prevention.

“Visits with the pharmacist coaches are not in place of their doctor visits. The nice part of the physician visit is they are becoming more preventive,” says Park, adding that physician visits before the DTCC were related mostly to sickness rather than prevention.

Ellis says the process of care is changing with more acceptance of pharmacists as members of a collaborative healthcare team.

“The pharmacist coach is central to this model, but not at the exclusion of other healthcare providers. This program involves a lot more communication and referrals to physicians, diabetic education centers, and other healthcare professionals than typically is found in the care process,” says Ellis.

DiPiro says the DTCC has allowed her to collaborate with other pharmacists on matters such as patient interviewing techniques. She takes a greater role in a patient’s care in the DTCC, asking personal, open-ended questions about general health, caregivers, and whether the patients have received eye and foot exams. Although pharmacist coaches are not the norm for community pharmacy, DiPiro says pharmacists in institutional practice have had more opportunity for involvement in direct patient care as members of the healthcare team.

“The opportunities at the community level can only expand. There are so many chronic diseases, and I believe pharmacists can have an impact in improving a patient’s daily health,” says DiPiro.

Researchers will review the economic analysis for the DTCC (which has expanded to more than 1,000 participants and 31 employers since the interim report research was conducted), and Ellis hopes to release that information in the first quarter of 2009.

Business leader: The DTCC involves best practice strategies

Not only are patients, their families, and the healthcare system struggling with the $174 billion spent annually on caring for the 17.5 million diabetic Americans, but businesses grapple with an estimated $58 billion in reduced productivity and absenteeism each year.

The authors of the Diabetes Ten City Challenge (DTCC) believe that the program, which couples a pharmacy program with a value-based insurance design (VBID) model that reduces or eliminates copays on specific drugs—in the DTCC’s case, diabetes drugs and tests—could be the cure for what’s ailing diabetic care.

“By implementing this standardized model, employers in a variety of markets can improve health outcomes for their health plan beneficiaries with diabetes,” according to the interim report published in the March/April Journal of the American Pharmacists Association.

Andrew Webber, president and CEO of the National Business Coalition on Health in Washington, DC, says his organization supports the DTCC and also backed the Asheville model, which was the launching point for the DTCC.

Webber’s organization believes that the idea of empowering patients through greater pharmacist involvement coupled with VBID combines best practice strategies. “There is a very good chance that this chronic condition can be managed, and individuals can live with diabetes and be very productive members in an employer’s work force,” says Webber.

Beyond a moral obligation, Webber says employers have a “huge business imperative” to tackle the issue of diabetes-related costs. Webber, a VBID proponent, says cutting copays gives employees an incentive to join the DTCC and shows that businesses support prevention and chronic care DM. The VBID model has been gaining popularity as studies have shown the benefits of reducing or eliminating copays for lifesaving medications. One study, released in January and led by a team of University of Michigan and Harvard University researchers, echoed other studies that reported that incorporating a VBID can increase medication compliance. That study of a large private employer showed significantly increased employee use of chronic-disease medicines by reducing or eliminating copays.

Another recent study by Brown University and Harvard Medical School researchers published in the New England Journal of Medicine showed that significantly fewer women received mammograms if a copay was charged for the potentially lifesaving screenings.

VBID supporters say the model works well with a DM program. In a regular DM program, coaches impart knowledge, but patients may not follow it because they can’t afford prescriptions. “Here’s an area where some short-term investment has longer-term payoffs on the two outcomes most important to employers: It improves their health and productivity and controls overall costs,” says Webber.

In the DTCC project, Cecily V. DiPiro, RPh, PharmD, a pharmacist at The Prescription Center in Charleston, SC, says the waived copays have increased diabetes medications and testing, which she believes will improve outcomes and reduce long-range costs.

“We see the wisdom in spending that money on prevention versus later having to spend that on a complication of diabetes,” says Jan Park, RN, a wellness coordinator for the city of Charleston.

Webber says he hopes the DTCC model of proactive community pharmacist coaches is the future of healthcare, adding that he would like to see the notion of the community pharmacy transformed from a place to pick up drugs and buy groceries to one of a community health center.

Community pharmacies should welcome these kinds of programs, and pharmacist coaches could work well as a business model, Webber says. Community pharmacies often compete with mail order companies, and pharmacy benefit managers often bypass the local pharmacist. By taking a larger coaching role, community pharmacists can create their own niche, he says.

“I would even argue that there is a business imperative to rethink their role at the community level,” says Webber.




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