Diabetes is an incredibly complex chronic illness to manage. The wide array of treatment strategies available, the importance of patient self-management, frequent presentation of comorbidities, and the number of healthcare providers often engaged in the care for one patient make diabetes one of the toughest chronic illnesses to handle. The result of this complexity is that, despite good intentions, oversight of a patient’s complete medication regimen may be incomplete and create opportunities for mistakes and suboptimal management. This is illustrated in the following case.
Bob is a 68-year-old patient with diabetes refereed for comprehensive medication management (CMM) services. Bob’s primary care physician (PCP) made the referral after noting he was not taking his insulin as directed, and his glycated hemoglobin (A1C) was now at 11.3%, up from a normal level of 8%. Bob’s PCP was particularly concerned that Bob had developed gangrene in one of his feet. From the CMM review, it was revealed that Bob was choosing to ration his insulin in order to save money, which was being used to afford medications for secondary stroke prevention and depression. Bob also revealed that he did not feel the desired effects from the medication prescribed for depression.
While Bob was referred specifically for support in taking his medication as prescribed, the result of a comprehensive evaluation of all his medication-related needs revealed the following medication-related problems: poor control of diabetes secondary to not following directions correctly with the prescribed insulin regimen, lack of control of depression secondary to the wrong and ineffective drug choice, and risk for stroke secondary to a medication regimen deemed unaffordable by the patient.
As part of developing a plan to address the three medication-related problems, the pharmacist collaborated with the three physicians involved in prescribing Bob’s medications to transition to a less expensive medication for stroke prevention, alter treatment for depression to a medication that was less expensive and expected to produce a more effective outcome, and help Bob understand the implication of rationing his insulin use.
As a result of these changes, Bob’s A1C improved to 8.5% within 6 months, his symptoms of depression improved and reached his treatment goals, and Bob was able to maintain an antiplatelet regimen that provided appropriate stroke prevention.
The Institute of Medicine has stated, “Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system.” The influence of medication use on the ability to achieve the Triple Aim is enormous.
This is evident in the case presented above, where Bob’s medication-related issues related to each component of the Triple Aim. First, Bob was not achieving the clinical goals associated with his medical conditions. Second, his healthcare experience was negatively influenced by his inability to afford his medications. Third, the cost associated with his care was higher than necessary, secondary to preventable complications from his diabetes.
In cases like Bob’s, division of healthcare often produces a scenario in which no medical provider is monitoring or responsible for all components of a patient’s medication-related treatment plan.
Unfortunately, thousands of patients every day across the United States encounter these situations. The frequency of lackluster medication use may occur even more often in seniors with diabetes because medication complexity increases in people with diabetes, and adverse drug events are more prevalent with increased age.
Comprehensive Medication Management (CMM) services are emerging as a solution to medication-related problems. CMM services involve application of a specific assessment process to ensure that all of a patient’s medication-related needs are met. This includes making sure their medications are achieving their intended effects, not producing adverse effects, and that the medication-related treatment plan aligns with the lifestyle and needs of the patient.
Pharmacists that collaborate with a primary care team typically provide CMM services. A care process is applied with each patient that begins with an assessment, followed by identification of problems, development of a care plan, and follow up. The manner in which the assessment is completed is distinct. When providing services, a pharmacist will systematically assess medication needs in the context of the individual patient, categorizing medication-related problems using a defined framework.
To resolve medication-related problems, the pharmacist collaborates with the patient’s other medical providers to confirm and implement a revised care plan that addresses all of the patient’s medication-related needs.
Application of this assessment process and problem categorization system reveals interesting findings regarding the prevalence of what factors are driving sub-optimal outcomes from medication use.
While a great deal of attention has recently been placed on ensuring patient adherence to medication regimens, the work of three large heath systems in Minnesota, that have consistently integrated CMM programs in their primary and specialty care clinics, demonstrates that non-adherence is only the third most common medication-related problems. More frequently, patients are not achieving therapeutic goals because they have not been prescribed a medication indicated for their medical situation, or medications are not prescribed at a dose high enough to achieve the desired goal.
The clinical and financial outcomes associated with patients with diabetes receiving CMM services have been positive. In one study, patients with diabetes referred for CMM services have experienced A1C reductions of 1.3% to 2.7%. Furthermore, CMM services have been associated with a positive impact on cardiovascular risk factors, such as blood pressure (BP) and low-density lipoprotein (LDL) cholesterol in patients with diabetes.
A trial that compared outcomes of patients enrolled in a pharmacist-managed diabetes service compared with those who were referred to this service, but never attended, found that not only were A1C reductions greater in the pharmacist-managed group, but more patients in this group achieved BP and LDL cholesterol goals, more frequently took aspirin as indicated, and has greater adherence to smoking-cessation measures. These outcomes occurred even though patients enrolled in the pharmacist service had a more complex medical history and medication regimens.
Seniors represent a group likely to benefit from CMM services because medication regimens often become more complex as one ages. Although seniors only comprise 13% of the US population, they receive 30% of all prescriptions dispensed. They also tend to have more prescribers than younger patient groups and also more frequently use multiple pharmacies. Both of those factors put seniors at greater risk of adverse drug reactions.
Although improved health outcomes and cost savings are associated with CMM, this service remains limited in its presence in healthcare settings. A reason for this is that typical fee-for-services, operated by payers, generally don’t recognize services provided by pharmacists as a covered benefit. Despite this, it is expected for CMM services to continue to expand based on its clear improvement of patient health.
The negative aspects of Bob’s healthcare are quite commonly observed in our healthcare system today but the positive experience derived from having CMM included in the spectrum of services provided by his primary care team can and should become the norm in the future. All members of Bob’s primary care team, and Bob, are very grateful for the CMM services that were provided to him and it is a hope for the future that this type of care will increase for patients everywhere.
Todd D. Sorensen, PharmD
Executive Director, AIMM