Sandra Leal|M. Fernández Soto
Chronic Kidney Disease Risk Reduction in a Hispanic Population Through Pharmacist-Based Disease-State Management
Arizona Science Center|Community Health Center|University of Arizona|Arizona Science Center|Community Health Center|University of Arizona
purpose study evaluate ability pharmacistbased diseasestate management service improve care indigent predominately spanishspeaking patients diabetes mellitus common comorbid conditions high risk development chronic kidney disease ckd patients high risk developing ckd diabetes community health center placed pharmacistbased disease state management service ckd risk reduction residencytrained bilingual certified diabetes educator pharmd served patients provider using diagnostic educational therapeutic management services medical staff approved collaborative practice agreement outcomes assessed using national standards care disease control prevention screening impact ckd shown mean a1c decrease 2 improvement proportion patients target goals blood pressure a1c cholesterol levels receiving aspirin angiotensinconverting enzyme inhibitorangiotensin receptor blocker pharmacistbased diseasestate management service ckd risk reduction care diabetes frequently associated comorbid conditions improved compliance national standards diabetes care highrisk population purpose study evaluate ability pharmacistbased diseasestate management service improve care indigent predominately spanishspeaking patients diabetes mellitus common comorbid conditions high risk development chronic kidney disease ckd patients high risk developing ckd diabetes community health center placed pharmacistbased disease state management service ckd risk reduction residencytrained bilingual certified diabetes educator pharmd served patients provider using diagnostic educational therapeutic management services medical staff approved collaborative practice agreement outcomes assessed using national standards care disease control prevention screening impact ckd shown mean a1c decrease 2 improvement proportion patients target goals blood pressure a1c cholesterol levels receiving aspirin angiotensinconverting enzyme inhibitorangiotensin receptor blocker pharmacistbased diseasestate management service ckd risk reduction care diabetes frequently associated comorbid conditions improved compliance national standards diabetes care highrisk population estimated 20 million americans chronic kidney disease ckd another 20 million hypertension diabetes increased risk hypertension uncontrolled diabetes linked development progression ckd endstage kidney disease blacks hispanics pacific islanders american indians seniors groups considered increased risk according statistics provided end stage renal disease esrd network 15 end 2006 2071 esrd patients arizona 1055 esrd diagnosis diabetes 469 diagnosis hypertension1intermountain endstage renal disease network inc esrd network organization 15 annual report 2006 centers medicare medicaid services january 1 2006december 31 2006google scholar 208 million children adults united states 7 population diabetes total annual economic cost diabetes 2002 estimated 132 billion one every 10 health care dollars spent united states spent diabetes complications2american diabetes association economic costs diabetes us 2002diabetes care 2003 26 917932crossref pubmed scopus 1374 google scholar unfortunately large percentage patients receive suboptimal care diabetes comorbid conditions may result increased burden ckd addition poor control blood glucose hypertension dyslipidemia many patients fail receive recommended assessments aimed early detection reduction complications measurement estimated glomerular filtration rate egfr ckd dilated eye examinations retinopathy annual foot examinations neuropathy diabetic foot infections3saaddine jb engelgau mm beckles gl et ala diabetes report card united states quality care 1990sann intern med 2002 136 565574crossref pubmed scopus 530 google scholar multiple interventions proven successful improving disease control preventing disease complications4maljanian r grey n staff et alimproved diabetes control providerbased disease management programdis manage health outcomes 2002 10 18crossref scopus 10 google scholar 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nichols pj casperson cj et althe effectiveness disease case management people diabetes systemic reviewam j prev med 2002 22 1538abstract full text full text pdf pubmed scopus 395 google scholar one way address gap care focus disease state management using highly trained licensed professionals nurses clinical pharmacists6bessman comparison medical care nurse clinician physician clinics medical school affiliated hospitalsj chronic dis 1974 27 115125abstract full text pdf pubmed scopus 34 google scholar 7stein gh use nurse practitioner management patients diabetes mellitusmed care 1974 12 885890crossref pubmed scopus 14 google scholar 8coastsenior ea kroner ba kelley cl et almanagement patients type 2 diabetes pharmacists primary care clinicsann pharmacother 1998 32 636640crossref pubmed scopus 163 google scholar context clinical pharmacist makes recommendations changes patient regimens helps promote maintain restore good health patients involvement clinical pharmacist improves patients quality life medication adherence avoidance medicationrelated complications8coastsenior ea kroner ba kelley cl et almanagement patients type 2 diabetes pharmacists primary care clinicsann pharmacother 1998 32 636640crossref pubmed scopus 163 google scholar interventions save health care dollars recent figures estimate cost drugrelated morbidity mortality exceeds 1774 billion per year9american diabetes association national diabetes fact sheet ada alexandria va2003google scholar 10hogan p dall nikolov p economic costs diabetes us 2002diabetes care 2003 26 917932crossref pubmed scopus 1080 google scholar pharmacists expanded role management patients chronic diseases originally developed indian health service ihs 1970s11anderson po taryle da pharmacist management ambulatory patients using formalized standards caream j hosp pharm 1974 31 254257pubmed google scholar 12johnson tuchler rj role pharmacist primary health caream j hosp pharm 1975 32 162164pubmed google scholar 13erickson sh primary care pharmacist outpatient clinicam j hosp pharm 1977 34 10861090pubmed google scholar 14copeland gp apgar da pharmacist practitioner training programdrug intell clin pharm 1980 14 114119pubmed google scholar 15church rm pharmacy practice indian health serviceam j hosp pharm 1987 44 771775pubmed google scholar 16herrier rn boyce rw apgar da pharmacistmanaged patient care services prescriptive authority us public health servicehosp formul 1990 25 7678 80 6768pubmed google scholar next 3 decades expanded practice roles spread areas ambulatory pharmacy practice including veterans administration health maintenance organizations community pharmacies17solomon dk portner ts bass ge et alclinical economic outcomes hypertension copd arms multicenter outcomes studyj pharm assoc 1998 38 574585abstract full text pdf scopus 110 google scholar 18okamoto mp nakahiro rk pharmacoeconomic evaluation pharmacistmanaged hypertension clinicpharmacotherapy 2001 21 13371344crossref pubmed scopus 80 google scholar 19bluml bm mckenney jm cziraky mj pharmaceutical care services results project impact hyperlipidemiaj pharm assoc 2000 40 157165abstract full text pdf scopus 209 google scholar pharmacistbased diseasestate management services shown improve outcomes andor disease control patients variety chronic conditions11anderson po taryle da pharmacist management ambulatory patients using formalized standards caream j hosp pharm 1974 31 254257pubmed google scholar 12johnson tuchler rj role pharmacist primary health caream j hosp pharm 1975 32 162164pubmed google scholar 13erickson sh primary care pharmacist outpatient clinicam j hosp pharm 1977 34 10861090pubmed google scholar 17solomon dk portner ts bass ge et alclinical economic outcomes hypertension copd arms multicenter outcomes studyj pharm assoc 1998 38 574585abstract full text pdf scopus 110 google scholar 18okamoto mp nakahiro rk pharmacoeconomic evaluation pharmacistmanaged hypertension clinicpharmacotherapy 2001 21 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636640crossref pubmed scopus 163 google scholar 23kelley c rodgers pt implementation evaluation pharmacistmanaged diabetes servicej manage care pharm 2000 6 488493google scholar 24nau dp blevins jd neal se collaborating community pharmacists improve quality diabetes care ipa model hmoj manage care pharm 2001 7 292296google scholar 25anon collaborative drug therapy agreements lead improved diabetes managementformulary 2001 36 538539google scholar 26yanchick jk implementation drug therapy monitoring clinic primary care settingam j health syst pharm 2000 57 s30s37pubmed google scholar 27baran rw crumlish k patterson h et alimproving outcomes communitydwelling older patients diabetes pharmacist counselingam j health syst pharm 1999 56 15351539pubmed google scholar 28nau dp ponte cd effects community pharmacybased diabetes patientmanagement program intermediate clinical outcome measuresj manag care pharm 2002 8 4853google scholar 29cranor cw christensen db ashville project shortterm outcomes community pharmacybased diabetes care programj pharm assoc 2003 43 149159abstract full text full text pdf google scholar although many studies examined various parameters glycosylated hemoglobin a1c a1c none examined extensive number parameters including kidney function based measurement egfr metabolic cardiovascular preventive services pharmacistbased diseasestate management model care successfully implemented replicated community health center located tucson az el rio federally qualified health care center 35 years service tucson largest community health center arizona 70000 patients depend el rio regular source medical care patients approximately 72 hispaniclatino 15 white 10 american indian 2 black 1 classified primary goal el rio provide lowincome patients comprehensive health care benefits breakdown based payer source patients 50 medicaid 24 uninsured 12 private insurance 6 medicare 8 arizona law passed allows qualified pharmacists specified health care settings community health centers chcs implement monitor modify drug therapy described written protocols collaboration participating physicians practice model referred collaborative drug therapy management cdtm health care programs administered us public health service eg ihs department defense veterans health administration well independent practice settings approximately 43 states across united states support pharmacist participation cdtm require drugspecific diseasespecific collaborative practice agreements drug therapymanagement plans approved physicians participating andor supervising programs11anderson po taryle da pharmacist management ambulatory patients using formalized standards caream j hosp pharm 1974 31 254257pubmed google scholar 12johnson tuchler rj role pharmacist primary health caream j hosp pharm 1975 32 162164pubmed google scholar 13erickson sh primary care pharmacist outpatient clinicam j hosp pharm 1977 34 10861090pubmed google scholar 16herrier rn boyce rw apgar da pharmacistmanaged patient care services prescriptive authority us public health servicehosp formul 1990 25 7678 80 6768pubmed google scholar 18okamoto mp nakahiro rk pharmacoeconomic evaluation pharmacistmanaged hypertension clinicpharmacotherapy 2001 21 13371344crossref pubmed scopus 80 google scholar 19bluml bm mckenney jm cziraky mj pharmaceutical care services results project impact hyperlipidemiaj pharm assoc 2000 40 157165abstract full text pdf scopus 209 google scholar 30kelley c rodgers pt implementation evaluation pharmacistmanaged diabetes servicej manag care pharm 2000 6 488493google scholar 31shanemcwhorter l oderda gm providing diabetes education care underserved patients collaborative practice utah community health centerpharmacotherapy 2005 25 96109crossref pubmed scopus 41 google scholar 32knapp kk okamota mp black bl ashp survey ambulatory care pharmacy practice health systems 2004am j health syst pharm 2005 62 274284pubmed google scholar 33leal herrier rn glover jj felix improving quality care diabetes comprehensive pharmacistbased disease management programdiabetes care 2004 27 29832984crossref pubmed scopus 74 google scholar format modeled original ihs programs limits pharmacists clinical activities found physicianapproved guidelines program el rio health center described later falls category project initially funded clinical pharmacy demonstration project office pharmacy affairs component health resources services administrations healthcare systems bureau el rio clinical pharmacybased demonstration projects main objective provide comprehensive pharmacy services medically underserved community included increasing access affordable pharmaceuticals promoting efficient management services focusing improved patient outcomes addition project promoted concepts pharmacists members collaborative health care team critical model diseasestate management services outcomes research assessed impact pharmacists appropriate optimal use technology track impact made pharmacist clinical pharmacist discussion medical administrative team el rio reached consensus diabetesfocused diseasestate management clinic would best serve needs members table 1 el rio serves approximately 8000 diabetic patients highrisk populations predominantly hispaniclatino american indiantable 1demographics past medical historycharacteristicnumbertotal number patients601age average577 yearssd 135gender female37963 male22237ethnicity black163 white6511 hispanic46477 american indian529 other41past medical history dm type 1244 dm type 257395 htn38364 cad11018 smoker8214note numbers except age rounded nearest whole numberabbreviations dm diabetes htn hypertension cad coronary artery disease sd standard deviation open table new tab note numbers except age rounded nearest whole number abbreviations dm diabetes htn hypertension cad coronary artery disease sd standard deviation initially clinical pharmacists responsibilities focused coordination care patients diabetes common comorbid disease states hypertension dyslipidemia could contribute progression ckd pharmacist responsible modification drug therapy ordering laboratory work blood glucose a1c egfr education patients regarding various disease states addition identificationresolution compliance therapyrelated problems uncovered addressed visits including avoidance nephrotoxic medication use renoprotective agents angiotensinconverting enzyme inhibitors aceis angiotensin receptor blockers arbs effective management blood pressure blood glucose control diabetes management interventions aggressive target current stringent guidelines continuous laboratory monitoring improvement patient outcomes monitoring actual potential adverse drug reactions included pharmacists duties interventions pertinent laboratory data patient demographics records routine preventative therapy ie monofilament examinations vaccinations eye referrals podiatry referrals tracked via access database microsoft corporation redmond wa database developed practicing pharmacist consultant developed track clearly easily patients progress consistent manner report clinic statistics timely fashion produce progress note could included patents permanent medical record database proved one key components success program data collected since initial implementation august 2001 shows statistically significant improvement monitored clinical parameters33leal herrier rn glover jj felix improving quality care diabetes comprehensive pharmacistbased disease management programdiabetes care 2004 27 29832984crossref pubmed scopus 74 google scholar parameters include blood pressure control goal 13080 mm hg 12575 mm hg patients known ckd goal glycemic control a1c improvement minimum 2 versus standard care patients showed 6 decline table 2 use renoprotective agents blocking reninangiotensin system eg aceis arbs nearly doubled patients candidates therapy smoking cessation continually addressed encouraged aspirin use high cardiovascular risk group neared 100 table 3 limited somewhat patient allergies contraindications use also drugs known accelerate decline kidney function avoided identified pharmacist alternatives suggested primary care providers examples included recommending less use alternate nonsteroidal antiinflammatory agents things pain arthritis longitudinal studies necessary confirm reduction cardiovascular renal outcomes retinopathy neuropathy oral health decline improved quality lifetable 2comparison baseline followup metabolic parametersparameterbaseline meanfollowup meandifference sd95 cip valuetotal cholesterol mgdl198170282332001triglycerides mgdl247187603485001hdlc mgdl4543212001ldlc mgdl10791161319001bg mgdl209163473755001a1c 10821720001sbp mm hg124117759001dbp mm hg7570546001bmi kgm2327338112 0104abbrevations sd standard deviation hdl highdensity lipoproteins cholesterol ldl lowdensity lipoprotein cholesterol bg blood glucose a1c hemoglobin a1c sbp systolic blood pressure dbp diastolic blood pressure bmi body mass index ci confidence interval open table new tab table 3patients asaaceis arbsstatins baseline followuppatients contraindications listed included 89 patients asa contraindication 75 patients contraindication 1 listing aceiarb 8 patients contraindication listed statin medications 155 patients contraindications listed three categoriesparameter blbl fu fu diff 95 cip valueasa n 5122104150098525261001aceiarb n 5262905545987322737001statin n 5932153641870342940001all 3 agents n 4461272828163352841001abbreviations asa aspirin acei angiotensinconverting enzyme inhibitor arb angiotensin receptor blocker fu follow patients contraindications listed included 89 patients asa contraindication 75 patients contraindication 1 listing aceiarb 8 patients contraindication listed statin medications 155 patients contraindications listed three categories open table new tab abbrevations sd standard deviation hdl highdensity lipoproteins cholesterol ldl lowdensity lipoprotein cholesterol bg blood glucose a1c hemoglobin a1c sbp systolic blood pressure dbp diastolic blood pressure bmi body mass index ci confidence interval abbreviations asa aspirin acei angiotensinconverting enzyme inhibitor arb angiotensin receptor blocker fu follow beyond direct patient care pharmacists expanded role includes evaluating clinical improvement statistical data analysis feedback patients providers orienting training el rio staff pharmacists physicians reviewing current formulary management identifying opportunities improvement pricing distribution medications result combined effort health center able integrate 2 clinical pharmacists el rios current treatment team resulted improvements clinical outcomes highrisk diabetic patients33leal herrier rn glover jj felix improving quality care diabetes comprehensive pharmacistbased disease management programdiabetes care 2004 27 29832984crossref pubmed scopus 74 google scholar implementation collaborative practice highlighted national state meetings media thus resulting increased interest training pharmacists chcs southern arizona wish work clinical transient capacity local college pharmacy chosen integrate lecture designed specifically address type collaborative practice result efforts changing patient care throughout state fall 2004 pharmacy practice residency created el rio serve training opportunity future practitioners challenges successful development program el rio included following lack insurance language barriers health literacy issues reimbursement clinical pharmacist interventions one third el rios patient population uninsured creates difficult challenge trying deliver comprehensive care average patient diabetes takes multiple medications treat prevent diabetesrelated complications along comorbidities hypertension dyslipidemia ckd34leichter sb faulkner camp j cost diabetic patient variables physician prescribing behaviorclin diabetes 2000 18 4244google scholar additional costs include specialty eye referrals foot care vaccinations testing supplies even individuals health insurance expenses exceed financial resources important role pharmacist plays design affordable regimens effective safe provide desired results prevent disease progression even limited resources pharmacist works closely patient identify resources works ensure treatment uninterrupted things connecting patients medicationassistance programs assisting correct medication selection based prescription formulary barriers improving care include language differences health literacy 2 components critical working health disparities el rio many settings serving ethnic minorities enough health care providers speak language represent culture people serving health literacy degree individuals capacity obtain process understand basic health information services needed make appropriate health decisions nearly 90 million americans 1 2 adults understand basic health information according institute medicine report35insuring americas health principles recommendations committee consequences uninsurance board health care services institute medicine washington dc2004google scholar patients el rio exception 87 el rios population hispanic american indian many speak spanish primary language requiring use translators spanishspeaking pharmacist although primary care providers el rio speak spanish use bilingual hispaniclatino pharmacist main provider may contributed services success clearer communication attention cultural nuances contribute patient adherence allows comprehensive evaluation continuous dialog patient provider visit fragmented use translator cultural issues often easier pharmacist relate anticipate issues sensitive easier patient discuss directly pharmacist rather forgoing conversation fear embarrassment another individual involved one additional barrier includes reimbursement clinical services provided pharmacist pharmacists provider status medicare therefore reimbursement services provided occur level documented state medicaid private insurance groups reimbursed pharmacists clinical services uniformly majority thirdparty payers follow medicares lead setting reimbursement policies currently pharmacists primarily reimbursed products dispensed services rendered issue addressed local state federal levels pharmacistbased diseasestate management service care diabetes frequently associated comorbid conditions ckd improved compliance national standards diabetes care use preventative agent aceisarbs avoidance nephrotoxic agents accomplished chc treating primarily indigent highly mobile hispanic american indian populations