Evaluative research on pharmacist managed diabetes care: focus on self-monitoring of blood glucose

Diabetes, especially Type 2 Diabetes (90%) is an ongoing problem for many nations. The world-wide prevalence of diabetes estimated by World Health Organization was approximately 175 million in 2000 and is predicted to be at least 366 million by 2030 among adults ≥ 20 years of age. The WHO estimate for Trinidad and Tobago in 2000 was 60,000 and is projected to increase to 125,000 if current trends prevail. Recent data (unpublished) from the Ministry of Health indicate that the Chronic Disease Assistance Programme, since its inception in 2003 to 2009, has provided medicines for approximately 226,435 diabetic patients. The National Insurance Property Development Company procures and manages the distribution of medicines for Chronic Disease Assistance Programme on behalf of the Ministry of Health. The total cost of diabetes treatment amounted to 285 million USD, representing approximately 38% of the total patient population receiving treatment through the progamme in this period. Objective: The primary objective was to demonstrate that pharmacists can assist patients to achieve at least a 1% decrease in HbA1c. Methods: A randomized controlled Pharmacist Evaluative Research Study compared the efficacy of pharmacist managed care (the intervention), and routine standard management (control) of poorly controlled (abnormal glycosylated haemoglobin, blood pressure, blood glucose and lipid panel) adult diabetic patients. Participants in the intervention group met with the pharmacist at their respective primary care sites on a regular basis for an assessment of adherence to medications, barriers to adherence and education. Control group participants consisted of patients receiving routine care by their primary physician but, with no direct intervention by the pharmacist except for the filling of prescriptions. Results: Seventy-five (75) patients were initially recruited, of these forty-eight (48) [20 interventions and 28 control] met the inclusion criteria. It was only possible to analyse the result from twenty (20) patients: 14 (70%) intervention and 6 (21.4%) control because of incomplete collected data. A minimum decrease of at least 1% HbA1c was obtained by eight (57%) intervention participants compared to two (33%) in the control group; while HbA1c remained unchanged for two participants each in the intervention and control groups (14% and 33%, respectively). The patient cohort was too small, therefore better methods for recruitment needed to be explored. The failure of patients to document key measurements (SMGB, BP), as requested by the pharmacist, was responsible for the exclusion of these patients in the statistical analysis. All of these factors reinforced the importance of preventing patients from absconding in order to reduce the high attrition rate. Conclusion: The data supports the hypothesis that the use of pharmacists as adjunctive healthcare practitioners achieves better patient outcomes than the non-use of pharmacists.

Practice-based buprenorphine maintenance treatment (BMT): how do French healthcare providers manage the opiate-addicted patients?

UNLABELLED: France was the first country to promote the extensive use of buprenorphine for the treatment of drug-addicted subjects through the primary care system. To assess both professional commitment and patients' characteristics, all the physicians and pharmacists of a French area having prescribed/dispensed buprenorphine from 2/12/96 (the official release date) to 1/31/98 were identified from data files of the Health Insurance and then interviewed. During the first 61 weeks of buprenorphine maintenance treatment (BMT), 27.5% of physicians and 51.2% of pharmacists of that area were involved; 142 patient records were documented. Features of the clinical routines spontaneously implemented for practice-based BMT were: a high level of on-site supervised dispensation by the pharmacist (71% at treatment induction and 23% thereafter); the absence of objective measurement of illicit drug use; and a low buprenorphine dosage. These features are consistent with the lack of physicians' experience and training, and also the relatively good status of the population treated (no HIV-positives, heroin use duration averaging 4.2 +/- 3.1 years, and 81.7% with stable accommodations). Despite liberal regulations guiding BMT, a negligible proportion of cases had a "nomadic" attitude (multiple buprenorphine prescribers/deliverers). The treatment outcomes (no deaths, three drug overdoses, improvement in occupational status) are encouraging. CONCLUSION: Practice-based BMT appears to be a safe and acceptable response to moderate heroin addiction, but further training of the professionals involved and longitudinal investigations of individual outcomes are needed.