This study evaluated the outcomes of a pharmacist-provided diabetes medication therapy management program (MTMP) sponsored by an employer for its employees and dependents. The study found: 1) Patients experienced improved clinical outcomes including reductions in A1c, blood pressure, and hospitalizations/ER visits. 2) Economic outcomes improved with reductions in costs of physician visits, hospitalizations, and ER visits. 3) Humanistic outcomes were positive with high patient satisfaction and improved disease knowledge retention over 6 months. The MTMP resulted in overall improved health, quality of life and cost savings for participants.

1. EVALUATING ECONOMIC, CLINICAL, AND HUMANISTIC OUTCOMES OF AN EMPLOYER SPONSERED MULTI CENTER DIABETES MEDICATION THERAPY MANAGEMENT PROGRAM (MTMP)
Jinender Kumar, B. Pharm, PGDBM, Research Assistant1, Sharrel L. Pinto, B.S Pharm, Ph.D, Assistant Professor and Director2
1,2 The Pharmaceutical Care and Outcomes Research Laboratory, Department of Pharmacy Health Care Administration, College of Pharmacy, University of Toledo, Ohio, USA
Background Results Results Cont…..
Available data: Baseline - 97 Patients 3 Months – 72 Patients
In the era of ever increasing health care costs, there is a strong emphasis for employer assisted programs (EAPs) to develop across the Available Data: 92 Patients
Clinical, Social and Process Measures Economic Outcomes
6 Months – 50 Patients
country. Employer assisted programs involve employers contacting pharmacies to provide MTMPs to their employees. These EAPs
encourage employees to take advantage of MTMPs at the cost of their employer. Table1 : Changes in Clinical, Social, And Process Measures Table 5: Economic Outcomes
P – Value#
Outcomes/Measures Variables N Baseline Visit 3 Months Visit 6 Months Visit Variables Pre enrollment (Jan – Dec 2007) , N (%) Study Period (Jan – Dec 2008) , N (%)
Previous work in this area has demonstrated a positive impact of the pharmacist interventions but has lacked the foundation of a (Mean ± S.D) (Mean ± S.D) (Mean ± S.D) (Mean ± S.D) (Mean ± S.D )
conceptually coherent framework to track outcomes.1-4 This study has utilized a theoretical framework to examine effects of Clinical A1c* 45 7.77 ± 1.75 7.42 ± 1.54 7.59 ± 1.80 0.183 Number of Physician Office Visits 10.2 ± 7.91, 54 (58.70) 8.36 ± 5.83 , 81 (88.04)
pharmacists’ interventions on patient health outcomes using economic, clinical, and humanistic outcomes (ECHO) model. Baseline A1c ≥ 7* 27 8.74 ± 1.62 8.02 ± 1.68 8.27 ± 1.99 0.009 Cost of Physician Office Visits $488.00 ± $386.29 , 54 (58.70) $428.29 ± $318.88 , 81 (88.04)
Systolic BP* 45 135.53 ± 20.31 129.98 ± 17.59 132.02 ± 15.96 0.474 Number of ER Visits 1.87 ± 7.9 , 23 (25.00) 1.27 ± 0.45, 15 (15.96)
Objective Baseline SBP ≥ 140* 17 155.76 ± 15.62 143.18 ± 19.25 136.06 ± 17.71 0.014 Cost of ER Visits $2,451.038 ± $2,161.96 , 23 (25.00) $1,989.55 ± $1,196.26 , 5 (15.96)
Diastolic B.P* 45 84.09 ± 11.89 78.89 ± 10.40 82.09 ± 9.29 0.001
To measure the impact of a pharmacist-provided MTMP on the economic, clinical, and humanistic outcomes for the City of Toledo Number of hospitalizations 1.60 ± 1.07 , 10 (10.86) 1.33 ± 0.57, 3 (3.26)
employees and their dependents with diabetes. Baseline DBP ≥ 90* 12 99.42± 8.75 86.42 ± 8.80 84.92 ± 9.36 0.002 Length of stay per hospitalization 6.30 ± 5.96 , 10 (10.86) 7.67 ± 5.03 , 3 (3.26)
BMI 44 35.98 ± 7.84 35.79 ± 7.87 36.05 ± 7.74 0.359 Cost of hospitalizations $ 22,252.24 ± $19,260.34 , 10 (10.86) $ 17,016.19 ± $10,417.63 , 3 (3.26)
Methods Social Caffeine (bev/day)* 47 1.87 ± 1.74 1.67 ± 1.82 1.88 ± 1.98 0.244
Discussion and Study Implications
Alcohol (bev/day) 40 0.08 ± 0.32 0.06 ± 0.32 0.10 ± 0.44 0.368
Study Design: Prospective, pre-post longitudinal study design
Smoking (packs/day) 48 0.10 ± 0.32 0.09 ± 0.26 0.08 ± 0.25 0.936
City of Toledo employees who participated in the MTM program experienced improved economic, clinical, and humanistic outcomes.
Exercise (Hrs/week) 45 1.42 ± 2.29 1.26± 2.26 1.07 ± 1.99 0.714
Inclusion Criteria: The main inclusion criteria were as follows:
Patients who had a higher baseline A1c benefitted most from the program. About 26% of patient’s A1c values decreased by more
The study participants primary provider for medical insurance and prescription coverage must be the City of Toledo (includes Process Sick Days (past 3 Mo) 46 1.18 ± 4.52 0.28 ± 1.11 0.26 ± 0.83 0.109
than 1%. Additionally, these patients achieved ADA’s recommended level of less than 7. Furthermore, glycemic control was maintained
employees and dependents). Hypoglycemic 44 2.01 ± 2.97 1.35 ± 2.43 1.51 ± 2.26 0.113
in most patients who were at goal at baseline. Patients who had hypertension also saw a decrease in blood pressure reaching goal.
Episodes (past 3 mo)*
At the time of enrollment, participants must be taking medications or have a new prescription for the treatment of Type 2 diabetes.
These results are consistent with the results of similar pharmacist managed MTM programs for diabetes.1,3,8, and 9
Over 18 years of age, speak English and have transportation to one of the practicing sites. SMBG (times/day)* 47 1.79 ± 2.01 2.17± 1.87 2.05 ± 1.36 0.298
Improved glycemic control is associated with positive economic outcomes such as reduced rate of hospital admissions for selected
# - Friedman Test for Paired Data (significance at α = 0.05)
Exclusion Criteria: Participants not meeting the above stated inclusion criteria were excluded from the study. short term complications and reduced medical costs.9 This study found that patients had lesser diabetes related ER visits and
* - Wilcoxon Signed Rank Test for Paired Data (Baseline to 3 months) (significance at α = 0.05)
hospitalizations since enrolling in the program. Consequently, the average costs per ER visit and hospitalization also decreased. Total
Setting: Pharmacists from Toledo Area Coalition of Independent pharmacies (Program name PharmacistCareTM).. The Coalition consists costs decreased by 62.69%. From an employer perspective, these were significant cost savings resulting from participation in a
Humanistic Outcomes
of five independent pharmacies in Northwest Ohio: The Pharmacy Counter Pharmacy (three locations), Glenbyrne Pharmacy, Kahler pharmacist-conducted MTM program. This study adds to the existing literature demonstrating pharmacist-led EAPs lead to positive
Table 2: Quality of life (Using SF – 36 v.2)
Pharmacy, Erie Drugs, and Ryan Pharmacy. outcomes thereby increasing external validity for studies such as the Ashville Project, Diabetes Ten City Challenge etc. 1,3Based on the
results from this study, employers might be encouraged to invest in similar program for patients with other chronic conditions.
N Baseline Mean ± S.D 6 Months Visit ± S.D P- Value
Intervention: Enrolled patients were required to visit the pharmacy on six occasions during the one year period. The initial visit (baseline)
Physical Functioning 44 49.28 ± 9.15 49.19 ± 8.90 0.773 During 2008, there was a 30% increase in the number of patients visiting their physician’s office. This increase corresponded with the
was with the pharmacy technician for completing the consent forms and collecting enrollment information. This was followed by five
increase in the number of patients visiting specialty physicians such as podiatrists (27%), ophthalmologist etc. Pharmacists in this
Role Physical 44 48.39 ± 10.11 49.17 ± 8.56 0.646
counseling sessions with the pharmacist. Each visit was scheduled based on a program algorithm developed using national guidelines
program strongly encouraged patients to see their podiatrist, ophthalmologist and dentist. Patients who have annual exams are less
Bodily Pain 42 48.53 ± 9.12 45.39 ± 8.20 0.111
(ADA, JNC-VII, and NCEP) and published literature.
likely to incur long term costs associated with micro and macrovascular complications.
General Health 43 45.74 ± 5.66 44.85 ± 4.79 0.196
Vitality 42 51.31 ± 6.24 49.64 ± 5.83 0.160
Data Collection: Patient satisfaction with pharmacists, pharmacy and staff improved significantly by the 3 month visit. Patient satisfaction has been
Social Functioning 44 34.66 ± 4.31 35.28 ± 3.52 0.359
associated with improved quality of life, adherence to medication therapy, level of pharmaceutical care received, and patients’
Clinical Outcome Measures: A1c, systolic and diastolic blood pressure, and body mass index (BMI) Role-Emotional 44 48.81 ± 10.28 48.46 ± 10.12 0.748
perception of the pharmacist's ability to help them.10-12 Patients reported high levels of satisfaction with the pharmacist when the
Social Measures: Number of caffeine beverages consumed per day, alcohol beverages consumed per week, number of packs of Mental Health 43 44.08 ± 8.30 42.54 ± 6.76 0.455
pharmacist involved them in decisions about using their medications, explained what their medications were used for, and improved
cigarettes smoked per day and number of exercise hours per week Physical Component Summary 41 49.60 ± 7.83 48.72 ± 6.92 0.425
their knowledge and skills on lifestyle changes.
Process Measures: Podiatrist visits, eye exams, dentist visits, sick days, ER visits, self monitored blood glucose levels (SMBG), Mental Component Summary 41 42.84 ± 6.71 42.10 ± 6.19 0.693
hypoglycemic episodes, and flu shots Patients’ knowledge about their diabetes improved post counseling. Additionally, patients seemed to retain this gain in knowledge at
The mean norm based score for US general population with diabetes are 41.10 ± 11.16 for Physical component Summary and 47.75 ± 11.49 for Mental Component Summary.
their 6 month visit. This was a result of the pharmacist’s efforts to educate patients about their disease state. Better awareness is linked
These clinical, social, and process measures were measured at the baseline visit and every 3 months thereafter. Data was collected by the A higher score at follow up visit indicates improved quality of life. Each domain have separate minimum and maximum scores. The details about the meaning of each domain
with improved adherence and improved outcomes.13 Patients in this study reported better adherence at the end of 3 months.
pharmacist or the pharmacy staff at each visit. scores can be found in the User Manual for SF-36 v2 Survey by Quality Metrics.
No significant changes were observed in QoL. However, role physical and social functioning scores improved. Items on the role
Humanistic Outcome Measures: Quality of life (measured using SF-36v2), patient satisfaction, patient adherence (Morisky scale), and physical domain measure constraints/inability to perform at work as a result of the disease. It was interesting to note that patients
Table 3: Disease-Specific Knowledge Surveys
disease-specific knowledge (diabetes (DM), hypertension (HTM) and hyperlipidemia (HL)) performed better at work after participating in the program. These findings mimic those of a similar program for patients with
Tests N Mean ± S.D # of Correct Mean ± S.D# of Correct Mean ± S.D # of Correct P- Value
hypertension at the end of 6 months.14
Patient quality of life and disease specific knowledge was assessed at baseline visit, 6 months, and 1 year. Patient satisfaction was Responses (Baseline) Responses Responses
evaluated at the baseline visit, 3 and 9 months. Patients completed these surveys at the sites. (1 month) (6 Months Visit)
Conclusion
Diabetes Knowledge 37 7.95 ± 1.47 8.81 ± 1.33 8.91 ± 1.40 0.001
Knowledge Surveys: Three (one each for DM, HTM, HL) newly developed surveys containing 10 items each. Items correspond with
Hypertension Knowledge 21 8.52 ± 1.03 9.00 ± 0.84 9.00 ± 0.95 0.193
education provided. E.g.: What are common problems associated with type 2 diabetes? What is normal fasting blood glucose level?
The six month evaluation of this pharmacist-provided MTM program has shown to be successful in improving clinical, humanistic, and
Hyperlipidemia 24 7.46 ± 1.84 7.79 ± 1.79 8.21 ± 1.38 0.071
5- 7
Patient Satisfaction Survey: Developed based on 3 previously validated and reliable surveys. Total of 34 items measuring 3 domains economic outcomes of City of Toledo employees and their dependents with diabetes.
Knowledge
(experience with the pharmacist (18 items), experience with the pharmacy (12 items), and experience with pharmacy staff (4 items)). Knowledge tests are scored on a scale of 1-10 (1 – Low Knowledge, 10 – High Knowledge)
References
Table 4: Patient Satisfaction and Self-Reported Patient Adherence (Using Morisky Scale) 1. Cranor C.W., Christensen D.B. The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc.2003;43:149-59.
Economic Outcome Measures: Costs and number of physician office visits, ER visits, hospitalizations, and length of stay per 2. Cranor C.W., Bunting B.A., Christensen D.B. The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc.2003;43:173-84.
3. Fera T, Bluml B.M. et a., The Diabetes Ten City Challenge: Interim clinicaland humanistic outcomes of a multisite community pharmacy diabetes care program. J Am Pharm Assoc.2008;48:181-190.
hospitalization. These economic outcomes were measured for one year prior to baseline visit, and every 6 months thereafter and is 4. Garrett D.G, Bluml B.M, Patient Self-Management Program for Diabetes : First-Year Clinical, Humanistic, and Economic Outcomes. J Am Pharm Assoc.2005;45:130-137
Survey N Mean ± S.D Score (Baseline) Mean± S.D Score (3 Months Visit) P- Value 5. Larson, LN, Rovers, JP, MacKeigan, LD. Patient satisfaction with pharmaceutical care: update of a validated instrument. J Am Pharm Assoc. 2002; 42(1): 44-50.
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Experience with The Pharmacist 63 3.32 ± 0.75 4.24 ± 0.62 0.000 7. Hooker, RS, Potts, R, Ray, W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. The Permanente Journal. 1997; 1(1): 38-42.
8. Ragucci K.R., Fermo J.D. et al. Effectiveness of pharmacist-adminstered diabetes mellitus education and management services.Pharmacotherapy.2005;25(12):1809-1816.
Experience with The Pharmacy 63 3.59 ± 0.87 4.21 ± 0.60 9. Wagner e, Sandhu N, Newton K et al. Effect of improved glycemic control on health care cost ad utilization. JAMA.2001;285:182-9.
Data Analysis: Friedman test was used to compare variables at multiple time points. Wilcoxon-Signed rank test was used to compare 0.000 10. Kimmel PL, Patel SS. Quality of life in patients with chronic kidney disease: focus on end-stage renal disease treated with hemodialysis. Semin Nephrol. 2006; 26(1):68-79.
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variables at two time points. A priori level of 0.05 was used for the data analysis. 12. Ried LD, Wang F, Young H, Awiphan R. Patients' satisfaction and their perception of the pharmacist. J Am Pharm Assoc. 1999; 39(6):835-842.
Experience with The Pharmacy Staff 63 4.08 ± 0.89 4.48 ± 0.75 0.003 13. Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: the role of disease and medication beliefs J Behav Med. 2009 Jan 30. Epub ahead of print.
14. Viviam E.M., Improving Blood Pressure Control in a Pharmacists-Managed Hypertension Clinic. Pharmacotherapy.2002;22(12):1553-1540.
Overall Patient Satisfaction 63 3.50 ± 0.73 4.26 ± 0.58 0.000
A subgroup analysis was conducted for patient’s who had high A1c ≥ 7 at baseline. The subgroup analysis was also conducted for This study was funded by a seed grant from The National Business Coalition on Health
Patient Adherence 64 3.86 ± 0.99 4.20 ± 0.62 0.002
diabetes patient’s who were hypertensive (B.P ≥ 140/90) at baseline. Acknowledgements: City of Toledo, Front Path Coalition, Toledo Area Network of Independent Pharmacies
Patient satisfaction and patient adherence are scored on a scale of 1-5. The higher the score, the more improved was the satisfaction or adherence.