About 30.3 million Americans (9.4%) have diabetes mellitus (DM).1 Veterans are disproportionately affected—about 1 in 4 of those who receive US Department of Veterans Affairs (VA) care have DM.2 The consequences of uncontrolled DM include microvascular complications (eg, retinopathy, neuropathy, and nephropathy) and macrovascular complications (eg, cardiovascular disease).
The American Diabetes Association (ADA) recommends achieving a goal hemoglobin A1c (HbA1c) level of < 7% to prevent these complications. However, a goal of < 8% HbA1c may be more appropriate for certain patients when a more strict goal may be impractical or have the potential to cause harm.3 Furthermore, guidelines developed by the VA and the US Department of Defense suggest a target HbA1c range of 7.0% to 8.5% for patients with established microvascular or macrovascular disease, comorbid conditions, or a life expectancy of 5 to 10 years.4
Despite the existence of evidence showing the importance of glycemic control in preventing morbidity and mortality associated with DM, many patients have inadequate glycemic control. Diabetes mellitus is the seventh leading cause of death in the US. Moreover, DM is a known risk factor for heart disease, stroke, and kidney disease, which are the first, fifth, and ninth leading causes of death in the US, respectively.5
Because DM management requires ongoing and comprehensive maintenance and monitoring, the ADA supports a collaborative, multidisciplinary, and patient-centered approach to delivery of care.3 Collaborative teams involving pharmacists have been shown to improve outcomes and cost savings for chronic diseases, including DM.6-12 In 1995, the VA launched a national policy providing clinical pharmacists with prescribing privileges that would aid in the provision of coordinated medication management for patients with chronic illnesses.13 The policy created a framework for collaborative drug therapy management (CDTM) models, which grants pharmacists the ability to perform patient assessments, order laboratory tests, and modify medications within a scope of practice.
Since the initiation of these services, several examples of successful DM management services using clinical pharmacists within the VA exist in the literature.14-16 However, even with intensive chronic disease and drug therapy management, not all patients who enroll in these services successfully reach clinical goals. Although these pharmacist-driven services seem to demonstrate overall benefit and cost savings to veteran patients and the VA system, little published data exist to help determine patient behaviors that are associated with glycemic goal attainment when using these services.
At the Corporal Michael J. Crescenz VA Medical Center in (CMCVAMC) Philadelphia, Pennsylvania, where this study was performed, primary care providers may refer patients with uncontrolled DM to the pharmacist disease state management (DSM) clinic. The clinic is a form of a CDTM and receives numerous referrals per year, with many patients discharged for successfully meeting glycemic targets.
However, a percentage of patients fail to attain glycemic goals despite involvement in this clinic. We observed specific patient behaviors that delayed glycemic goal attainment. This study examined whether these behaviors correlated with prolonged glycemic goal attainment. The purpose of this study was to identify patient behaviors that led to glycemic goal attainment in insulin-treated patients referred to this pharmacist DSM clinic.