Sherrill Christina H, Pentecost Angela, Wood Emily E
1 Assistant Professor of Ambulatory Care, Department of Clinical Sciences, High Point University School of Pharmacy, High Point, North Carolina.
2 Clinical Pharmacy Specialist, Department of Pharmacy, Charles George Veterans Affairs Medical Center, Asheville, North Carolina.
J Manag Care Spec Pharm. 2016 Jan;22(1):14-20. doi: 10.18553/jmcp.2016.22.1.14.
Diabetes, dyslipidemia, and hypertension are complex chronic disease states that often require close monitoring and frequent follow-up to achieve and maintain therapeutic control as determined by hemoglobin A1c (A1c), low-density lipoprotein (LDL), and blood pressure (BP). At the Charles George Veterans Affairs Medical Center (CGVAMC), physicians may refer their patients to the on-site pharmacist-managed Risk Reduction Clinic (RRC). Patients are discharged from the RRC once patient-specific therapeutic goals have been met for diabetes, dyslipidemia, and/or hypertension. This study investigated the change in A1c, LDL, and systolic blood pressure (SBP) after discharge from the CGVAMC RRC.
To investigate (a) how clinical endpoints for diabetes, dyslipidemia, and hypertension change after discharge from the pharmacist-managed RRC at the CGVAMC; (b) the factors associated with worsening of monitoring parameters; and (c) the frequency of reconsultation to the RRC.
In this single-center retrospective quality management study, patients were included if they had a completed consultation to the CGVAMC RRC between August 11, 2008, and January 1, 2011, for the management of type 2 diabetes, dyslipidemia, and/or hypertension. Patients were included if they were discharged from the RRC prior to October 1, 2011, due to goal attainment. Furthermore, it was required that patients have A1c, LDL, and SBP measurements, as applicable based on diagnoses, at least yearly during the first 2 years following discharge. Patients were excluded if they were discharged for any reason other than goal attainment or if they were followed by a specialty clinic related to the RRC, including the Diabetes PharmD, Diabetes MD, MIDAS (group diabetes), or MAGIC (group dyslipidemia) clinics. Data collection included patient demographics; date of and indication for consultation to the RRC; date of first RRC visit; date of discharge from the RRC; number of visits to the RRC; A1c, LDL, SBP, and weight at consultation to the RRC, at discharge, and during the 2 years following discharge from the RRC; and date of and indication for reconsultation to the RRC, as applicable. Two-tailed paired t-tests were used to compare A1c, LDL, and SBP at discharge from the RRC to A1c, LDL, and SBP during the follow-up period. Two-tailed unpaired t-tests were performed to determine which variables were associated with changes in the monitoring parameters after discharge from the RRC.
One hundred forty-nine patients were included in this study. For all patients with a diagnosis of diabetes (N = 82), A1c rose from 6.49% to 6.79% (P < 0.001) during the first year and to 7.04% (P < 0.001) during the second year following discharge. For patients diagnosed with dyslipidemia (N = 137), LDL rose after discharge from 81.5 mg/dL to 90.8 mg/dL (P < 0.001) and to 90.9 mg/dL (P < 0.001), respectively. For patients diagnosed with hypertension (N = 132), SBP rose from 126.2 mm Hg to 131.5 mm Hg (P < 0.001) and to 133.9 mm Hg (P < 0.001), respectively. An increase in A1c after discharge was associated with lower discharge A1c (P = 0.014), higher consultation weight (P = 0.009), and higher discharge weight (P = 0.042). A rise in LDL was correlated to higher consultation LDL (P = 0.006), while higher SBP was associated with lower discharge SBP (P < 0.001). Twelve percent of patients were reconsulted to the RRC.
A1c, LDL, and SBP rose after discharge from the pharmacist-managed risk reduction clinic, but these changes may not have been clinically significant based on the low reconsultation rate and values remaining close to generally accepted therapeutic goals. Patients likely to benefit from extending RRC services past goal attainment include those with higher A1c and LDL at the time of consultation and those with higher weight. As a result of this study, recommendations have been made to consider following up every 3-4 months for 2-3 additional visits for patients with baseline A1c > 8% and LDL > 115 mg/dL and those with weight > 220 pounds prior to discharging them from the CGVAMC RRC. Furthermore, we believe that all patients could benefit from extending follow-up to 6 months for 1-2 additional visits or as needed after their therapeutic goals have been reached.
糖尿病、血脂异常和高血压是复杂的慢性疾病状态，通常需要密切监测和频繁随访，以实现并维持糖化血红蛋白（A1c）、低密度脂蛋白（LDL）和血压（BP）所确定的治疗控制目标。在查尔斯·乔治退伍军人事务医疗中心（CGVAMC），医生可将患者转诊至现场由药剂师管理的风险降低诊所（RRC）。一旦针对糖尿病、血脂异常和/或高血压实现了患者特定的治疗目标，患者即可从RRC出院。本研究调查了从CGVAMC的RRC出院后A1c、LDL和收缩压（SBP）的变化。
调查（a）从CGVAMC药剂师管理的RRC出院后，糖尿病、血脂异常和高血压的临床终点如何变化；（b）与监测参数恶化相关的因素；（c）再次咨询RRC的频率。
在这项单中心回顾性质量管理研究中，纳入2008年8月11日至2011年1月1日期间因2型糖尿病、血脂异常和/或高血压管理而到CGVAMC的RRC完成咨询的患者。如果患者因达到目标于2011年10月1日前从RRC出院，则纳入研究。此外，要求患者在出院后的前2年中，根据诊断情况，每年至少测量一次A1c、LDL和SBP。如果患者因达到目标以外的任何原因出院，或由与RRC相关的专科诊所随访，包括糖尿病药学博士诊所、糖尿病医学博士诊所、MIDAS（糖尿病小组）或MAGIC（血脂异常小组）诊所，则排除该患者。数据收集包括患者人口统计学信息；咨询RRC的日期和指征；首次就诊RRC的日期；从RRC出院的日期；就诊RRC的次数；咨询RRC时、出院时以及从RRC出院后的2年期间的A1c、LDL、SBP和体重；以及再次咨询RRC的日期和指征（如适用）。采用双侧配对t检验比较从RRC出院时的A1c、LDL和SBP与随访期间的A1c、LDL和SBP。进行双侧非配对t检验以确定哪些变量与从RRC出院后监测参数的变化相关。
本研究纳入了149例患者。对于所有诊断为糖尿病的患者（N = 82），出院后第一年A1c从6.49%升至6.79%（P < 0.001），第二年升至7.04%（P < 0.001）。对于诊断为血脂异常的患者（N = 137），出院后LDL分别从81.5 mg/dL升至90.8 mg/dL（P < 0.001）和90.9 mg/dL（P < 0.001）。对于诊断为高血压的患者（N = 132），SBP分别从126.2 mmHg升至131.5 mmHg（P < 0.001）和133.9 mmHg（P < 0.001）。出院后A1c升高与出院时较低的A1c（P = 0.014）、咨询时较高的体重（P = 0.009）和出院时较高的体重（P = 0.042）相关。LDL升高与咨询时较高的LDL相关（P = 0.006），而较高的SBP与出院时较低的SBP相关（P < 0.001）。12%的患者再次咨询了RRC。
从药剂师管理的风险降低诊所出院后，A1c、LDL和SBP有所升高，但基于低再次咨询率以及数值仍接近普遍接受的治疗目标，这些变化可能在临床上并不显著。咨询时A1c和LDL较高以及体重较高的患者可能会从RRC服务在达到目标后延长中获益。基于本研究结果，已建议对于基线A1c > 8%、LDL > 115 mg/dL以及体重 > 220磅的患者，在从CGVAMC的RRC出院前，考虑每3 - 4个月进行2 - 3次额外随访。此外，我们认为所有患者在达到治疗目标后，延长随访至6个月进行1 - 2次额外随访或根据需要进行随访均可能获益。
