Taveira TH (Providence VAMC), Cohen LB
(Providence VAMC), Pirraglia PA
(Providence VAMC), Friedmann PD
(Providence VAMC), Wu WC
Simultaneous control of multiple cardiovascular risk factors in diabetes mellitus (DM) is labor-intensive and often difficult to accomplish in traditional patient care settings. We tested the feasibility and efficacy of a pharmacist-led Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction (MEDIC) program that targets hypertension, hyperglycemia, smoking cessation, and dyslipidemia delivered as group medical visits for patients with DM.
We conducted a randomized controlled trial of MEDIC vs. usual care in DM veterans with a hemoglobin A1c (A1c) between 7% and 9% within the previous 6 months at the Providence VA medical center. A clinical pharmacist comprehensively intervened on the behavioral and pharmacotherapy aspects of DM and cardiovascular risk over 4 weekly sessions. Educators in nursing, physical therapy, and nutrition provided subject-specific education in this multidisciplinary model. We then compared the reduction in cardiovascular risk burden as estimated by the ratio of the United Kingdom Prospective Diabetes Study (UKPDS) risk score at 4 months to baseline between MEDIC and usual care.
Of 118 participants, 109 patients completed the study. Patients in MEDIC (n=58) were younger (62.3±10.4 vs. 65.4±10.2, p=0.03) and had greater tobacco use (smokers = 18.4 vs. 6.4%, p=0.01) at baseline than usual care; but were similar in other cardiovascular risk factors (SBP 131.0±18.8mmHg vs. 137.2±17.5mmHg, p=0.07; Cholesterol 173.5±42.4mg/dL vs. 165.3±39.8mg/dL, p=0.3; A1c = 8.1±1.6% vs. 7.9±1.1%, p= 0.4). After an average of 3.7 ± 0.6 weekly MEDIC visits, significant reductions from baseline values were found in cases vs. controls in SBP (-6.8±21.0 mmHg, p= < 0.01 vs. -1.8±19.6/ mmHg p=0.6; Cholesterol -20.7±40.9mg/dL, p=0.01 vs. -7.9±37.4mg/dL, p=0.32; A1c -0.9±1.6%, p < 0.05 vs. -0.2±0.9%, p=0.49) There was no significant difference in tobacco cessation rates between treatment groups. The UKPDS risk score decreased by 15% for MEDIC and increased by 3% for usual care (ratio 4 months/baseline = 0.85±0.29 vs. 1.03±0.21, p=0.004).
Pharmacist-led group medical visits are feasible and effective for improving cardiac risk factors in DM.
Our results demonstrate a potentially less costly, yet effective collaborative care approach to manage DM and associated cardiovascular risk.