A collaborative care approach for diabetes

Assoc Prof Lee (left) with Madam Poh, a Type 2 diabetes patient

NUS Pharmacy Associate Professor Joyce Lee is on a mission to bring pharmacists to the fore in the war against diabetes. She led two studies investigating the impact of involving pharmacists in diabetes care, focusing on a holistic range of outcomes — clinical, cost and quality of life. The studies revealed that Type 2 diabetes patients who received input from Ambulatory Care pharmacists — who are trained in chronic disease management — have better controlled diseases, spend less on healthcare and were more satisfied with their treatment. The first study involved 400 Type 2 diabetes patients and was conducted in four outpatient health institutions.

These patients were divided into two groups — intervention and control. Both groups were given the usual care of physicians, nurse educators and dieticians as needed over a six month period, while the intervention group had additional follow-up face-to-face visits or phone calls with Ambulatory Care pharmacists every four to six weeks.

A second study saw Assoc Prof Lee and her team looking into the effectiveness of a pharmacist-managed risk factor management clinic, compared with usual care in an acute care setting. A total of 140 patients under the cardiology service of a tertiary care hospital were randomly assigned into control and intervention groups. Both groups were given standard cardiologist care over 12 months but the intervention group additionally received three to six months of drug optimisation by trained Ambulatory Care pharmacists, where their medication was adjusted for better efficiency and they were given detailed information on their medication and how it could help them.

Patients in the intervention groups of both studies reported better clinical outcomes in terms of blood sugar, cholesterol and blood pressure levels. Cost-wise, healthcare and medical spending for the intervention group in the first study was about 15 per cent less than the usual care group over the course of the study, and in the second study was up to seven times less.

“Medication costs may be higher in usual care setting due to a lack of thorough medication use assessment. Without drug optimisation, patients who fail to reach recommended clinical targets may be switched to, or additionally given, a more expensive drug unnecessarily,” Assoc Prof Lee explained.

Our two studies illustrate the positive impact of multidisciplinary collaborative care involving pharmacists, hence supporting the effectiveness of this approach in managing chronic diseases.

Patients in the intervention group also reported more satisfaction and less distress associated with their treatment and disease. In addition, due to the close follow-up by the pharmacists, the diseases were better controlled, resulting in a decrease of about 2.5 times in physician workload for patients in the intervention group.

The second study additionally revealed that high-risk acute care patients in the intervention group had a significantly lower risk of diabetes and cardiovascular disease-related hospital admissions — about three times less — over the 12 months.

Patients in the intervention group were educated by the pharmacists on how to manage hypoglyemic (low blood sugar) events and heart failure symptoms, shared Assoc Prof Lee. “These patients could have been more informed and empowered to perform self-management, which may have resulted in the reduced need for urgent care,” she added.

“With the increasing prevalence of diabetes, the physician-centred model is challenged to deliver holistic care in Asia. Diabetes and its associated chronic diseases may be managed effectively within a multidisciplinary collaborative care model. However, evidence on its effectiveness in Asian patients is lacking. Our two studies illustrate the positive impact of multidisciplinary collaborative care involving pharmacists, hence supporting the effectiveness of this approach in managing chronic diseases,” said Assoc Prof Lee.

The services implemented were not just for research purposes and are currently still available, as the “Hypertension, Diabetes, Lipids Clinic” at seven polyclinics, and the “Risk Factor Management Pharmacist Clinic” at Tan Tock Seng Hospital.

“We know that patients will go from the hospital to the polyclinic and then from the polyclinic will become community-dwelling patients, where they may need easy access to healthcare professionals. So we have also engaged our retail community pharmacists and there are currently about four retail pharmacy chain stores that also conduct this type of diabetes-related service,” she said.

Seventy-five year old Madam Poh Kim Choo, a diabetes patient at Tan Tock Seng Hospital who is currently receiving the pharmacist services shared that the regular visits have helped her to better understand her medication and what it is for. She added that she feels her illness has become more stable and manageable. Madam Poh’s experiences are not unique; feedback revealed that patients valued their time with the pharmacists, attributing the sessions to their lifestyle changes and feeling empowered to manage their disease better.

Looking towards the future, Assoc Prof Lee hopes that pharmacists’ role in healthcare can be expanded. “Pharmacist services can certainly help to overcome challenges in managing diabetes. A review of existing health policy to involve pharmacists in every care team could help ensure optimal patient care,” she said.

See press release.