Reducing economic burden through split-shared care model for people living with uncontrolled type 2 diabetes and polypharmacy: a multi-center randomized controlled trial.

BACKGROUND: Interprofessional collaborative care such as a split-shared care model involving family physicians and community pharmacists can reduce the economic burden of diabetes management. This study aimed to evaluate the economic outcome of a split-shared care model between family physicians and community pharmacists within a pharmacy chain in managing people with uncontrolled type 2 diabetes and polypharmacy. METHOD: This was a multi-center, parallel arm, open label, randomized controlled trial comparing the direct and indirect economic outcomes of people who received collaborative care involving community pharmacists (intervention) versus those who received usual care without community pharmacist involvement (control). People with uncontrolled type 2 diabetes, defined as HbA1c > 7.0% and taking ≥ 5 chronic medications were included while people with missing baseline economic data (such as consultation costs, medication costs) were excluded. Direct medical costs were extracted from the institution's financial database while indirect costs were calculated from self-reported gross income and productivity loss, using Work Productivity Activity Impairment Global Health questionnaire. Separate generalized linear models with log link function and gamma distribution were used to analyze changes in direct and indirect medical costs. RESULTS: A total of 175 patients (intervention = 70, control = 105) completed the trial and were included for analysis. The mean age of the participants was 66.9 (9.2) years, with majority being male and Chinese. The direct medical costs were significantly lower in the intervention than the control group over 6 months (intervention: -US$70.51, control: -US$47.66, p < 0.001). Medication cost was the main driver in both groups. There were no significant changes in productivity loss and indirect costs in both groups. CONCLUSION: Implementation of split-shared visits with frontline community partners may reduce economic burden for patient with uncontrolled type 2 diabetes and polypharmacy. TRIAL REGISTRATION: Clinicaltrials.gov Reference Number: NCT03531944 (Date of registration: June 6, 2018).

Clinical activities that contributed to the effectiveness of a cardiologist-pharmacist collaborative care model in managing diabetes.

OBJECTIVES: The primary objectives of this study were to evaluate the change in glycated haemoglobin (HbA1c) and its association to clinical activities. The secondary objective was to elucidate moderators of the relationship between pharmacist-involved collaborative care (PCC) and change in HbA1c. METHODS: This study was a retrospective cohort study conducted in a tertiary hospital over 12 months. Individuals with Type 2 diabetes, aged ≥21 years with established cardiovascular diseases were included while individuals with incomplete care documentation or missing data related to cardiovascular diseases were excluded. Individuals under the care of PCC were matched 1:1 based on baseline HbA1c with an eligible person who received care from the cardiologists (CC). Changes in mean HbA1c were analysed using linear mixed model. Linear regression was used to determine clinical activities that associated with improvement in HbA1c. Moderation analyses were conducted using the MacArthur framework. KEY FINDINGS: A total of 420 participants (PCC:210, CC:210) were analysed. The mean age of the participants was 65.6 ± 11.1 years, with the majority being male and Chinese. The mean HbA1c among participants in the PCC group decreased significantly after 6 months (PCC: -0.4% versus CC: -0.1%, P = 0.016), with maintenance of improvement at 12 months (PCC: -0.4% versus CC: -0.2%, P < 0.001). Frequencies of lifestyle counselling, reinforcement of visits to healthcare providers, health education, resolution of drug-related problems, emphasis on medication adherence, dose adjustments and advice on self-care techniques were significantly higher in the intervention group (P < 0.001). CONCLUSION: Improvements in HbA1c were associated with the provision of health education and medication adjustments.

Enhancing diabetes care with community pharmacist-involved collaborative care model: A multi-centre randomised controlled trial.

AIM: To evaluate the clinical and humanistic outcomes of a community pharmacist-involved collaborative care model in diabetes management. METHODS: This was a parallel arm, open-label, multi-centre randomized controlled trial conducted over 6 months. Subjects with type 2 diabetes, HbA1c ≥ 7.0% (53 mmol/mol) and taking ≥ 5 medications were included. Participants were randomized into intervention (collaborative care) and control groups (physician-centric care). The intervention included medication therapy management and telephonic follow-up with visits to family physicians, nurses, and dietitians. Clinical outcomes included changes in HbA1c, systolic blood pressure (SBP), lipids, and hypoglycaemic incidences. Humanistic outcomes included self-care capabilities and quality of life. Linear mixed models were constructed. Intention-to-treat analyses, with sensitivity analyses, were conducted. RESULTS: A total of 264 participants were randomized (intervention: 131, control: 133). Significantly greater reduction in HbA1c was observed in the intervention group (intervention: -0.32% (-3.52 mmol/mol) vs. control: -0.06% (-0.66 mmol/mol), p = 0.038). Changes in SBP, lipids, and incidences of hypoglycaemia were not significant over 6 months between both groups. Significantly greater improvements in self-management (p < 0.001) and quality of life (p = 0.003) were observed within the intervention group. CONCLUSION: Partnering community pharmacists in a collaborative care team improved glycaemic control, quality of life and self-care capabilities of patients with diabetes and polypharmacy.

Spinning the globe from west to east: A mixed-method study to examine the impact of pharmacists on immunization advocacy and delivery in Asia Pacific.

BACKGROUND: Global effort is key to prevent and control infections effectively. Whereas pharmacists' involvement in the immunization neighborhood, collaborative effort to meet immunization needs of the public, has reduced burden of vaccine-preventable diseases in Western countries, the impact of pharmacist-involved vaccination advocacy and delivery in Asia Pacific remains unclear. OBJECTIVE: To examine the evidence for impact of pharmacists on immunization advocacy and delivery in Asia Pacific and to assess Singaporean pharmacists' experience in becoming immunizing pharmacists through the American Pharmacists Association's Pharmacy-based Immunization certificate training program. METHODS: A mixed-method study consisted of systematic review and survey was conducted. The systematic review was conducted by searching PubMed and Cumulative Index to Nursing and Allied Health databases from inception to March 2021. Randomized controlled trials and observational studies related to pharmacist-involved immunization advocacy and training conducted in Asia Pacific were included. Eligible studies were appraised for quality using CONsolidated Standards of Reporting Trials (CONSORT) and STrengthening the Reporting of OBservational checklists. In addition, a 20-item Likert-scale survey evaluated the pharmacists' experience in becoming immunizing pharmacists in Singapore. Frequencies of each response to the survey items were analyzed. RESULTS: Six studies were eligible for inclusion; 2 assessing impact of pharmacist as immunizer, 3 reporting outcomes of pharmacist-involved vaccine advocacy, and 1 evaluating the structure of pharmacist immunization training. Although study quality was minimal, all studies echoed positive findings as a result of pharmacist-provided immunization advocacy and delivery. Of the 23 pharmacists completing the survey, 91.3% strongly agreed that quality training was important to become immunizing pharmacists. CONCLUSION: Although limited in number, studies conducted in Asia Pacific reported increased vaccination rates when involving pharmacists. Coupled with the enthusiasm to be trained in immunization advocacy and delivery as elucidated by the Singaporean pharmacists, pharmacists in Asia Pacific should also be advocated for their role in the immunization neighborhood as part of the global effort against vaccine-preventable infectious diseases.

Efficacy and Safety of Use of the Fasting Algorithm for Singaporeans With Type 2 Diabetes (FAST) During Ramadan: A Prospective, Multicenter, Randomized Controlled Trial.

PURPOSE: We aimed to evaluate the efficacy and safety of use of the Fasting Algorithm for Singaporeans with Type 2 Diabetes (FAST) during Ramadan. METHODS: We performed a prospective, multicenter, randomized controlled trial. The inclusion criteria were age ≥21 years, baseline glycated hemoglobin (HbA1c) level ≤9.5%, and intention to fast for ≥10 days during Ramadan. Exclusion criteria included baseline estimated glomerular filtration rate <30 mL/min, diabetes-related hospitalization, and short-term corticosteroid therapy. Participants were randomized to intervention (use of FAST) or control (usual care without FAST) groups. Efficacy outcomes were HbA1c level and fasting blood glucose and postprandial glucose changes, and the safety outcome was incidence of major or minor hypoglycemia during the Ramadan period. Glycemic variability and diabetes distress were also investigated. Linear mixed models were constructed to assess changes. RESULTS: A total of 97 participants were randomized (intervention: n = 46, control: n = 51). The HbA1c improvement during Ramadan was 4 times greater in the intervention group (-0.4%) than in the control group (-0.1%) (P = .049). The mean fasting blood glucose level decreased in the intervention group (-3.6 mg/dL) and increased in the control group (+20.9 mg/dL) (P = .034). The mean postprandial glucose level showed greater improvement in the intervention group (-16.4 mg/dL) compared to the control group (-2.3 mg/dL). There were more minor hypoglycemic events based on self-monitered blood glucose readings in the control group (intervention: 4, control: 6; P = .744). Glycemic variability was not significantly different between the 2 groups (P = .284). No between-group differences in diabetes distress were observed (P = .479). CONCLUSIONS: Our findings emphasize the importance of efficacious, safe, and culturally tailored epistemic tools for diabetes management.

Impact of pharmaceutical care on mental well-being and perceived health among community-dwelling individuals with type 2 diabetes.

PURPOSE: Mental well-being among community-dwelling individuals with type 2 diabetes has not been well established. The primary objective was to evaluate the change in the mental well-being of individuals with diabetes. The secondary objective was to evaluate the association between changes in mental well-being and perceived health over 6 months, and any interacting factors in this association. METHODS: This was a prospective, multicenter study. Community-dwelling individuals aged ≥ 21 years with type 2 diabetes were invited to meet with community pharmacists monthly for 6 months. Individuals who were unable to converse independently were excluded. A 12-item General Health Questionnaire (GHQ), measuring mental well-being was administered at baseline, and after 3 and 6 months. Perception of health was measured using the visual analog scale (VAS) of the EuroQoL 5-Dimension tool. Linear mixed model was used to analyze the change in mean GHQ and VAS scores. Association between the changes in GHQ and VAS scores was determined, and moderation analysis was conducted to elucidate the interacting variables of this association. RESULTS: Ninety-six individuals (82.4%) were included for analysis. The mean age was 60.3 years with a baseline mean HbA1c of 7.6%. A mean GHQ score reduction of 1.36 (p = 0.022) was observed. This reduction of mean GHQ score was associated with the change in mean VAS score. Having a duration of diabetes diagnosis of < 3.2 years was identified as moderator of this association. CONCLUSION: Effective integrated pharmaceutical care with individualized counseling on lifestyle management appeared to improve the mental health of community-dwelling individuals with diabetes on top of glycemic control.

Medication compliance in Singaporean patients with Alzheimer's disease.

INTRODUCTION: Singapore has a rapidly ageing population and an increasing prevalence of Alzheimer's disease (AD). Compliance to AD medications is associated with treatment effectiveness. We investigated compliance to acetylcholinesterase inhibitors (AChEIs) and N-methyl-D-aspartate (NMDA) receptor antagonist and treatment persistence among patients seen at the General Memory Clinic of National University Hospital, Singapore. We also identified the reasons for non-compliance. METHODS: Patients seen at the General Memory Clinic between 1 January 2013 and 31 December 2014, who were prescribed AChEIs and NMDA receptor antagonist, were included in this retrospective cohort study. Non-compliance to medications was indirectly measured by failure to renew prescription within 60 days of the last day of medication supplied by the previous prescription. The reasons for non-compliance were identified. RESULTS: A total of 144 patients were included. At one year, 107 patients were compliant to AD medications, while 37 patients were non-compliant. Around 60% of the non-compliant patients discontinued the use of AD medications within the first six months, and the mean persistent treatment period among this group of patients was 10.3 ± 3.5 months. The main reason for non-compliance was patients' and caregivers' perception that memory loss was of lower priority than other coexisting illnesses. Other reasons for non-compliance included side effects of medications (18.9%), perceived ineffectiveness of treatment (16.2%), inability to attend clinic (5.4%) and high cost of medications (2.7%). CONCLUSION: Our findings suggest that the reasons for medication non-compliance can be identified early. Better compliance may be achieved through a multidisciplinary approach to patient education.

Development of a Collaborative Algorithm for the Management of Type 2 Diabetes during Ramadan: An Anchor on Empowerment.

Empowerment plays significant roles in the complex management of type 2 diabetes. International guidelines have provided recommendations on management of Muslims who fast during Ramadan. However, there remains a lack of patient-centered epistemic tool to empower healthcare providers and patients in managing diabetes during Ramadan. This study discussed the development and evaluation of such tool. The collaborative algorithm was developed with reference to the nominal group technique by a board-certified clinical pharmacist and discussed with endocrinologists, nurses, and family physicians. The empowerment component of the algorithm was developed based on the Basic Psychological Needs Theory. The algorithm was evaluated through a randomized controlled trial. Glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and postprandial glucose (PPG) levels and safety profiles in terms of hypoglycemic events were assessed. The collaborative algorithm was developed with four components: screening, education, dose modification by healthcare provider, and dose adjustment by patient. A total of 62 individuals were recruited, with 30 and 32 randomized into the intervention and control groups, respectively. The mean age was 58.4 years, with majority being females (67.7%). There was a reduction in mean HbA1c from 7.9% ± 0.9% to 7.5% ± 0.8% (P < 0.001) in the intervention group, while no significant difference was observed in the control group (P = 0.270). FPG (P < 0.001) and PPG (P = 0.002) also improved significantly in the intervention group. There were no major hypoglycemic events and minor hypoglycemia comparable between both groups (P = 0.465). The collaborative algorithm incorporated empowerment and promoted shared decision-making in diabetes management, hence promoting safe and effective fasting.

Perceptions and Barriers of Survivorship Care in Asia: Perceptions From Asian Breast Cancer Survivors.

PURPOSE: With the long-term goal to optimize post-treatment cancer care in Asia, we conducted a qualitative study to gather in-depth descriptions from multiethnic Asian breast cancer survivors on their perceptions and experiences of cancer survivorship and their perceived barriers to post-treatment follow-up. METHODS: Twenty-four breast cancer survivors in Singapore participated in six structured focus group discussions. The focus group discussions were voice recorded, transcribed verbatim, and analyzed by thematic analysis. RESULTS: Breast cancer survivors were unfamiliar with and disliked the term "survivorship," because it implies that survivors had undergone hardship during their treatment. Cognitive impairment and peripheral neuropathy were physical symptoms that bothered survivors the most, and many indicated that they experienced emotional distress during survivorship, for which they turned to religion and peers as coping strategies. Survivors indicated lack of consultation time and fear of unplanned hospitalization as main barriers to optimal survivorship care. Furthermore, survivors indicated that they preferred receipt of survivorship care at the specialty cancer center. CONCLUSION: Budding survivorship programs in Asia must take survivor perspectives into consideration to ensure that survivorship care is fully optimized within the community.