Treat to goal: impact of clinical pharmacist referral service primarily in diabetes management.

Diabetes mellitus (DM) is associated with morbidity and mortality and significant costs to the health care system. It affects an estimated 25.8 million people, or 8.3% of the US population. Diabetes is the seventh leading cause of death and is the leading cause of blindness, kidney failure, and nontraumatic lower extremity amputations. Moreover, diabetes is associated with poorer prognosis in illnesses such as influenza and pneumonia, increased risk for stroke, death due to heart disease, and damage to the nervous system resulting in gastroparesis, neuropathies, and erectile dysfunction. In total, the disease costs the United States $174 billion dollars per year, including direct and indirect costs.1 The American Diabetes Association (ADA) publishes guidelines that are updated yearly with recommendations that are known or believed to favorably affect health outcomes in patients with diabetes. The ADA recommends targeting an A1c of <7% to prevent microvascular complications and, if implemented soon after diagnosis, for long-term reduction in macrovascular disease. Blood pressure (BP) is recommended to be lower than 130/80 mm Hg to prevent microvascular and macrovascular outcomes. Lipids, specifically low-density lipoproteins (LDL), are recommended to be lowered to <100 mg/dL to prevent macrovascular outcomes.2 Most data in the prevention of diabetic complications are from utilization of HMG-CoA reductase inhibitors (statins), angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARBs), and aspirin. Although these drugs are not routinely indicated for all diabetes patients without compelling indications, they are a cornerstone of therapy due to the common frequency of concomitant comorbidities. Patients with type 1 or 2 diabetes who have overt cardiovascular disease or equivalent risk factors, hyperlipidemia, hypertension, varying degrees of albuminuria, who smoke, or who have other indications qualify for these medications.2 Smoking worsens macrovascular and microvascular outcomes in patients with diabetes. Thus, diabetes care should include routine counseling on smoking cessation and pharmacologic treatment options to aid in smoking cessation. Among its many detrimental effects, smoking significantly worsens peripheral arterial disease and greatly increases the risk of patients developing ulcers.2 Smoking inhibits ulcer healing, which may lead to amputation.3 Diabetics, especially those with cardiac and chronic kidney disease, are more prone to infections, such as influenza and pneumonia, due to abnormalities in immune system function.4,5 Vaccination with the annual influenza vaccine in diabetes patients 6 months of age and older is recommended to prevent hospitalization and complications from influenza. Studies have shown that vaccination can decrease hospital admissions by as much as 79% during flu epidemics.4 The pneumococcal polysaccharide vaccine is indicated for patients 2 years of age and older, and it is to be repeated when patients turn 65 (unless previous vaccine was ≤5 years ago) or in other conditions such as nephrotic syndrome or post organ transplantation.2,5 The booster dose of pneumococcal vaccine at age 65 is recommended due to increased risk of morbidity and mortality in patients older than 64 years.5 Screening for disease progression and prevention of complications is necessary for optimal diabetes management. Hemoglobin A1c should be obtained every 2 to 3 months for persons who have A1c >7% or are not at their personalized goal. Lipid panel, comprehensive foot check, and dilated eye exam should be completed annually. Annual spot urine albumin excretion tests are recommended by the ADA, but the test and treatment options based on extent of albumin per gram of creatinine are now under controversy.6 BP should be checked at every routine diabetes visit.2 These measures can result in earlier detection of diabetes complications at a time when intervention may prevent further damage.2 Despite the evidence, rates of accomplishing standards of care are low. National rates derived from data from 1999 to 2006 for diabetic patients who are at goal for A1c, BP, and cholesterol are just 57.1%, 45.5%, and 46.5%, respectively. Only 12.2% of patients achieve all 3 targets simultaneously.7 National data from 2009 reveal that annual foot exams and eye exams are performed in 67.3% and 62.7% of diabetics and that vaccination rates for influenza and pneumonia are 49.5% and 43.0%, respectively. Routine labwork, such as the minimum requirement of A1c tests twice a year (assuming controlled diabetes), is performed in only 72% of patients.8 Control of diabetes and other chronic disease states presents a major challenge to the indigent patient population. This population has difficulty accessing primary and specialized medical care, prescription drugs, and healthy food choices such as fresh fruits and vegetables. With health care costs on the rise, a physician shortage,9 and the limited time and resources physicians have to comprehensively manage chronic disease states, there is the need for increased efficiency in the health care system. There is also difficulty translating guidelines for diabetes into clinical practice in areas with a high prevalence of indigent patients.10 In 2005, a pharmacy resident–based clinic was established at an adult medicine outpatient clinic. Uncontrolled diabetes is the primary reason for referrals, and many of these patients have concurrent hypertension and hyperlipidemia. Other reasons for referrals are smoking cessation and medication reconciliation for complicated regimens. The objective of this study was to determine the effect of pharmacist interventions on adherence to the ADA guidelines for diabetes and on control of diabetes, hypertension, and hyperlipidemia.