Glycemic Control in Pharmacist-Managed Insulin Titration Versus Standard Care in an Indigent Population
Based on evidence of decreased microvascular and macrovascular complications, the current American Diabetes Association (ADA) guidelines recommend as goals an A1C of < 7%, blood pressure of < 130/80 mmHg, and LDL cholesterol of < 100 mg/dl. 1 It has been demonstrated that the recommended goals can be achieved with formal education, routine appointments, and close telephone follow-up. 2 However, in the current health care environment with time constraints on primary care providers and common
... ders and common patient follow-up intervals of every 3 months, these proven methods are impractical. Thus, attainment of glycemic control in the primary care setting has, historically, been suboptimal. 3, 4 It has been demonstrated that diabetes-focused pharmacist care can improve outcomes, including reductions in A1C, improvement in lipid parameters, and increased adherence to preventive care guidelines. 5-10 There are fewer data evaluating the impact of pharmacist-managed insulin titration. Achieving glycemic control presents additional unique challenges in low-income minority patient groups. Some barriers encountered in this population include misconceptions about health and food, inability to afford more healthful dietary options, and a low level of health literacy. A recent cross-sectional study 11 found that more than half of lowincome, minority patients surveyed believed that a normal glucose level Purpose. To assess the impact of a pharmacist-managed insulin titration program on achieving clinical goals in an underserved population with diabetes. Methods. The study included 35 subjects followed in a pharmacistmanaged insulin titration and 35 matched control subjects. Control subjects were followed under standard procedures within the same clinic and were matched for age, titration time frame, and insulin regimen. The primary outcome was change in A1C between the two groups at 6 months. Secondary outcomes included change in A1C within groups at 3, 6, 9, and 12 months, as well as the proportion of subjects attaining a goal A1C of < 7% and adhering to preventive care recommendations. Results. Between-group comparison demonstrated a significant absolute difference in mean change in A1C at 6 months favoring pharmacist management (0.9%, 95% CI 0.2-1.6, P = 0.009). Within-group comparisons demonstrated significant A1C reduction from baseline at 6 months (−1.1%, 95% CI −1.7 to −0.4, P = 0.002), 9 months (−1.4%, 95% CI −2.0 to −0.7, P < 0.001), and 12 months (−1.3%, 95% CI −2.0 to −0.5, P = 0.001) in the pharmacistmanaged group with no significant changes observed in the control group. Conclusion. Pharmacist-managed insulin titration resulted in significant improvement in glycemic control compared to standard care in an indigent population.