Detailed Treatment Algorithms for Effective Nurse- and Pharmacist-Directed Diabetes Care

Casey Murphy PharmD candidate 2010 

University of Florida College of Pharmacy

Dave Joffe, BSPharm, CDE, FACA Preceptor

The American Diabetes Association (ADA) declared that evidence-based treatment recommendations would greatly reverse the destructive outcomes caused by diabetes.  Most diabetic patients do not meet ADA goals for glycemia, low-density lipoprotein (LDL) cholesterol, or blood pressure (BP).  21 to 46% of patients have HbA1c >9.5, 22% to 46% meet LDL goals, 29% to 33% meet BP goal, and only 2% to 10% of diabetic patients meet all three treatment goals.  Current treatment approaches including appointment reminders, feedback information provided to physician, case management (when the case manager can not make independent treatment decisions), and education of physicians have not been found to be effective.

There are two very important barriers to good diabetes care; lack of time the physician sees the patient, and lack of timely and appropriate clinical decision making.  On average, a primary care physician spends 10 to 15 minutes with a patient.  That is not sufficient time to ensure that all process measures within the guidelines are evaluated, and often diabetics are asymptomatic, so patient’s other symptoms may take priority.  Furthermore, patients are seen on average every 3 months and thus allowing for the diabetic treatment goals to be out of range and out of control for longer periods.  However, it’s not just the long period of time between visits that accounts for a majority of patient to be above treatment goals, it is also the lack of appropriate treatment decisions when the patient’s clinical situation indicates a treatment adjustment or intensification.  Therapy is intensified only 20% of the time when an HbA1c is >8.0 and intensification takes on average 3 months to occur.  

Specially trained pharmacists and nurses have used treatment algorithms to make independent therapeutic decisions for diabetic patients in a variety of clinical settings.  Recently a Los Angeles County community health center implemented a nurse-led diabetes care trial.  The trial enrolled 361 randomized diabetes patients with a mean HbA1c of 8.8%.  Seventeen percent met the ADA goal of HbA1c <7% and 50% met the ADA LDL cholesterol goal.  After 1 year the mean HbA1c was 7%, 60% met the ADA glycemic goal, and 82% met the LDL goal.  This was done with a limited formulary of metformin, sulfonylureas, regular and NPH insulin, gemfibrozil, and statins (pravastatin and simvastatin, or 80mg of atorvastatin if still not to goal). 

In the same trial in a Los Angeles community care clinic patient’s blood pressure was evaluated.  Upon implementation of the nurse-led trial, patients met the ADA systolic and diastolic blood pressure goals 60% and 90% of the time respectively.  

Based on the improvement of ADA goals, independent clinical decisions by pharmacists or nurses based on an approved algorithm is demonstrably beneficial.  Physicians’ busier schedules impede their ability to assess whether the appropriate care is being delivered.  Assessment entails ensuring patient’s medication compliance, lifestyle modifications education, and teaching proper blood glucose testing techniques.  Considering all that goes into treating diabetic patients, it is not surprising the outcomes from specialized pharmacist- and nurse-directed care have shown significant improvement.  

Reference:

Davidson, Mayer. “Detailed Treatment Algorithms for Effective Nurse- and Pharmacist-Directed Diabetes Care”. The Diabetes Educator January/February 2009: 61-71.