Can community retail pharmacist and diabetes expert support facilitate insulin initiation by family physicians? Results of the AIM@GP randomized controlled trial

Stewart B Harris, Hertzel C Gerstein, Jean-François Yale, Lori Berard, John Stewart, Susan Webster-Bogaert, Jordan W Tompkins, Stewart B Harris, Hertzel C Gerstein, Jean-François Yale, Lori Berard, John Stewart, Susan Webster-Bogaert, Jordan W Tompkins

Abstract

Background: Limited evidence exists on the effectiveness of external diabetes support provided by diabetes specialists and community retail pharmacists to facilitate insulin-prescribing in family practice.

Methods: A stratified, parallel group, randomized control study was conducted in 15 sites across Canada. Family physicians received insulin initiation/titration education, a physician-specific 'report card' on the characteristics of their type 2 diabetes (T2DM) population, and a registry of insulin-eligible patients at a workshop. Intervention physicians in addition received: (1) diabetes specialist/educator consultation support (active diabetes specialist/educator consultation support for 2 months [the educator initiated contact every 2 weeks] and passive consultation support for 10 months [family physician initiated as needed]); and (2) community retail pharmacist support (option to refer patients to the pharmacist(s) for a 1-hour insulin-initiation session). The primary outcome was the insulin prescribing rate (IPR) per physician defined as the number of insulin starts of insulin-eligible patients during the 12-month strategy.

Results: Consenting, eligible physicians (n = 151) participated with 15 specialist sites and 107 community pharmacists providing the intervention. Most physicians were male (74%), and had an average of 81 patients with T2DM. Few (9%) routinely initiated patients on insulin. Physicians were randomly allocated to usual care (n = 78) or the intervention (n = 73). Intervention physicians had a mean (SE) IPR of 2.28 (0.27) compared to 2.29 (0.25) for control physicians, with an estimated adjusted RR (95% CI) of 0.99 (0.80 to 1.24), p = 0.96.

Conclusions: An insulin support program utilizing diabetes experts and community retail pharmacists to enhance insulin prescribing in family practice was not successful. Too few physicians are appropriately intensifying diabetes management through insulin initiation, and aggressive therapeutic treatment is lacking.

Trial registration: ClinicalTrials.gov NCT00593489.

Figures

Figure 1
Figure 1
CONSORT diagram - disposition of physician subjects.

References

    1. Jaakkimainen L, Baiju RS, Kopp A. In: Diabetes in Ontario. Hux JE, Booth G, Slaughter PM, Laupacis A, editor. 2003. Sources of physician care for people with diabetes; pp. 9.181–9.192. (Institute for clinical evaulative sciences (ICES)).
    1. Harris SB, Ekoe J, Zdanowicz Y, Webster-Bogaert S. Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada evaluation study) Diabetes Res Clin Pract. 2005;70(1):90–97. doi: 10.1016/j.diabres.2005.03.024.
    1. Braga M, Casanova A, Teoh H, Dawson KC, Gerstein HC, Fitchett DH, Harris SB, Honos G, McFarlane PA, Steele A, Ur E, Yale JF, Langer A, Goodman SG, Leiter LA. Diabetes Registry to Improve Vascular Events (DRIVE) Investigators. Treatment gaps in the management of cardiovascular risk factors in patients with type 2 diabetes in Canada. Can J Cardiol. 2010;26(6):297–302. doi: 10.1016/S0828-282X(10)70393-7.
    1. Canadian Diabetes Association. Canadian diabetes association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2003;27(Supplement 2):S1–S140.
    1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian diabetes association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008;32(Suppl 1):S1–S201.
    1. Wright A, Burden ACF, Paisey RB, Cull CA, Holman RR. Sulfonylurea inadequacy: Efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the U.K. Prospective Diabetes Study (UKPDS 57) Diabetes Care. 2002;25(2):330–336. doi: 10.2337/diacare.25.2.330.
    1. Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, Landgraf R, Kleinebreil L. Resistance to insulin therapy among patients and providers: Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care. 2005;28(11):2673–2679. doi: 10.2337/diacare.28.11.2673.
    1. Brown JB, Harris SB, Webster-Bogaert MS, Wetmore S, Faulds C, Stewart M. The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus. Fam Pract. 2002;19:344–349. doi: 10.1093/fampra/19.4.344.
    1. Larme AC, Pugh JA. Evidence-based guidelines meet the real world: the case of diabetes care. Diabetes Care. 2001;24(10):1728–1733. doi: 10.2337/diacare.24.10.1728.
    1. Francke AL, Smit MC, de Veer AJ, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak. 2008;8:38. doi: 10.1186/1472-6947-8-38.
    1. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997;157(4):408–416.
    1. Riddle MC. The underuse of insulin therapy in North America. Diabetes Metab Res Rev. 2002;18(Suppl 3):S42–S49.
    1. Kirkman MS, Williams SR, Caffrey HH, Marrero DG. Impact of a program to improve adherence to diabetes guidelines by primary care physicians. Diabetes Care. 2002;25(11):1946–1951. doi: 10.2337/diacare.25.11.1946.
    1. Walker EA, Wylie-Rosett J, Shamoon H, Engel S, Basch CE, Zybert P, Cypress M. Program development to prevent complications of diabetes. Assessment of barriers in an urban clinic. Diabetes Care. 1995;18(9):1291–1293.
    1. Stolar MW. Clinical management of the NIDDM patient. Impact of the American Diabetes Association practice guidelines, 1985–1993. Endocrine Fellows Foundation Study Group. Diabetes Care. 1995;18(5):701–707. doi: 10.2337/diacare.18.5.701.
    1. Phillips LS, Branch WT, Cook CB, Doyle JP, el Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical inertia. Ann Intern Med. 2001;135(9):825–834.
    1. Roumie CL, Elasy TA, Wallston KA, Pratt S, Greevy RA, Liu X, Alvarez V, Dittus RS, Speroff T. Clinical inertia: a common barrier to changing provider prescribing behavior. Jt Comm J Qual Patient Saf. 2007;33(5):277–285.
    1. Pearson GJ. Evolution in the practice of pharmacy - not a revolution! CMAJ. 2007;176(9):1295–1296.
    1. Berenguer B, La Casa C, de la Matta MJ, Martin-Calero MJ. Pharmaceutical care: past, present and future. Curr Pharm Des. 2004;10(31):3931–3946. doi: 10.2174/1381612043382521.
    1. Farris KB, Fernandez-Llimos F, Benrimoj SI. Pharmaceutical care in community pharmacies: practice and research from around the world. Ann Pharmacother. 2005;39(9):1539–1541. doi: 10.1345/aph.1G049.
    1. Alliance for Pharmaceutical Care. Collaborative drug therapy management: a coordinated approach to patient care. 2013. Last accessed, 24January.
    1. Manitoba Society of Pharmacists. Bill 41 passed with pharmacists retaining voting rights. 2013. Last accessed, 24January.
    1. British Columbia Pharmacy Association. Pharmacist prescribing position statement. 2013. Last accessed, 24January.
    1. Priest A. Alberta pharmacists may get prescribing powers. CMAJ. 2006;175(5):463–464.
    1. Emmerton L, Marriott J, Bessell T, Nissen L, Dean L. Pharmacists and prescribing rights: review of international developments. J Pharm Pharm Sci. 2005;8(2):217–225.
    1. Roscoe RS. Role of the pharmacist in diabetes care. 2013. Last accessed, 24January.
    1. Freemantle N, Nazareth I, Eccles M, Wood J, Haines A. A randomised controlled trial of the effect of educational outreach by community pharmacists on prescribing in UK general practice. Br J Gen Pract. 2002;52(477):290–295.
    1. Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes. Cochrane Database Syst Rev. 2000;3:CD000336.
    1. Jaber LA, Halapy H, Fernet M, Tummalapalli S, Diwakaran H. Evaluation of a pharmaceutical care model on diabetes management 3. Ann Pharmacother. 1996;30(3):238–243.
    1. Coast-Senior EA, Kroner BA, Kelley CL, Trilli LE. Management of patients with type 2 diabetes by pharmacists in primary care clinics. Ann Pharmacother. 1998;32(6):636–641. doi: 10.1345/aph.17095.
    1. Bernsten C, Bjorkman I, Caramona M, Crealey G, Frokjaer B, Grundberger E, Gustafsson T, Henman M, Herborg H, Hughes C, McElnay J, Magner M, van Mil F, Schaeffer M, Silva S, Sondergaard B, Sturgess I, Tromp D, Vivero L, Winterstein A. Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care: a multicentre study in seven European countries 1. Drugs Aging. 2001;18(1):63–77. doi: 10.2165/00002512-200118010-00005.
    1. Villeneuve J, Genest J, Blais L, Vanier MC, Lamarre D, Fredette M, Lussier MT, Perreault S, Hudon E, Berbiche D, Lalonde L. A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study. CMAJ. 2010;182(5):447–455.
    1. Odegard PS, Goo A, Hummel J, Williams KL, Gray SL. Caring for poorly controlled diabetes mellitus: a randomized pharmacist intervention. Ann Pharmacother. 2005;39(3):433–440. doi: 10.1345/aph.1E438.
    1. Canadian medical directory 2006 edition. 2006. Toronto, Canada: Scott’s Directories; 2006.
    1. Gerstein HC, Yale JF, Harris SB, Issa M, Stewart JA, Dempsey E. A randomized trial of adding insulin glargine vs. avoidance of insulin in people with Type 2 diabetes on either no oral glucose-lowering agents or submaximal doses of metformin and/or sulphonylureas. The Canadian INSIGHT (Implementing New Strategies with Insulin Glargine for Hyperglycaemia Treatment) Study. Diabet Med. 2006;23(7):736–742. doi: 10.1111/j.1464-5491.2006.01881.x.
    1. Bandura A. Social Foundations of Thought and Action: A Cognitive Theory: Englewood Cliffs. NJ: Prentice Hall; 1986.
    1. Ozer EM, Adams SH, Gardner LR, Mailloux DE, Wibbelsman CJ, Irwin CE Jr. Provider self-efficacy and the screening of adolescents for risky health behaviors. J Adolesc Health. 2004;35(2):101–107.
    1. de Gier JJ. Clinical pharmacy in primary care and community pharmacy. Pharmacotherapy. 2000;20(10 Pt 2):278S–281S.
    1. Scott DM, Boyd ST, Stephan M, Augustine SC, Reardon TP. Outcomes of pharmacist-managed diabetes care services in a community health center. Am J Health Syst Pharm. 2006;63(21):2116–2122. doi: 10.2146/ajhp060040.
    1. Choe HM, Mitrovich S, Dubay D, Hayward RA, Krein SL, Vijan S. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005;11(4):253–260.
    1. Harris SB, Kapor J, Lank CN, Willan AR, Houston T. Clinical inertia in patients with T2DM requiring insulin in family practice. Can Fam Physician. 2010;56(12):e418–e424.
    1. Laubscher T, Evans C, Blackburn D, Taylor J, McKay S. Collaboration between family physicians and community pharmacists to enhance adherence to chronic medications: opinions of Saskatchewan family physicians. Can Fam Physician. 2009;55(12):e69–e75.
    1. McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M, Fisher P. The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol. 2007;7:30. doi: 10.1186/1471-2288-7-30.

Source: PubMed

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