Pharmacist-Endocrinologist Clinic Saves on Diabetes Care Costs

Miriam E Tucker

March 06, 2017

A specialized endocrinologist-pharmacist collaborative clinic for complex patients with type 2 diabetes is cost-effective, new research indicates.

Located within the Veterans Affairs San Diego Health System, the Diabetes Intense Medical Management (DIMM) "tune-up" clinic model combines pharmacist-provided medication therapy management with patient-specific diabetes education. It is delivered in three 60-minute visits over a 6-month period — more time than patients typically receive in primary care — before patients are discharged back to their primary-care physicians.

"This is a good example of 'team-based care' — an approach that's becoming more common in healthcare systems today," said lead author Jan D Hirsch, PhD, professor of clinical pharmacy at the University of California, San Diego, in a statement from his institution.

"No matter how we looked at the data, the cost for the DIMM clinic group was always lower, while their predicted quality-adjusted life-years were always higher," Dr Hirsch said.

The new findings are published online February 27 in the Journal of Managed Care & Specialty Pharmacy.

Collaborative Model Improves HbA1c

The retrospective nonrandomized cohort study involved 155 adult patients with type 2 diabetes and an HbA1c level of 8% or higher who also had an average of eight comorbidities — including mental-health diagnoses in half of the patients — and who were taking an average of 12 to 14 medications. Most were male and white.

The controls were demographically similar and observed for the same 6-month time period but received only their usual primary care.

Within the DIMM clinic, the endocrinologist reviewed care plans for new patients and was available for acute symptom evaluation or a new diagnosis.

Otherwise, the pharmacist delivered the interventions. "In addition to medication management, we're also teaching lifelong skills for diabetes management that patients can continue doing long after they've completed 6 months with the clinic," noted study coauthor Candis M Morello, PharmD, in the statement.

The authors previously reported that the 99 patients referred to the DIMM experienced a significantly greater mean improvement in HbA1c than the 56 in the primary-care group at 6 months (-2.4 vs -0.8 percentage points, P < .001) and were more likely to meet HbA1c goals of <9%, <8%, and <7%. (Ann Pharmacother. 2016;50: 8-16 ).

These latest results demonstrate cost benefits from the clinic, health system, and payer perspectives.

Return on Investment of Almost $10 per Dollar Invested in Clinic

From the clinic perspective, the HbA1c benefit gained in the DIMM vs primary-care control group cost $21 per additional percentage point of HbA1c improvement, and the cost per additional patient treated to goal at 6 months ranged from $115 to $164, depending on the target goal.

From the health-system perspective, estimated 3-year cost per patient based on baseline and 6-month HbA1c values in each group were $44,733 and $35,940 (P < .001) for the DIMM group vs $42,367 and $38,861 (P = .01) for the primary-care group.

The estimated mean 3-year cost avoidance per patient in the DIMM group due to improved HbA1c levels — a gain of $5287per patient — was more than twice that of the primary-care group and resulted in a return on investment of $9.01 per dollar invested in the DIMM clinic.

And from the payer perspective, estimated medical costs were lower and quality-adjusted life-years gained were greater for the DIMM vs primary-care group at every time frame assessed up to 10 years.

Pharmacists Are a New Type of Primary Health Care Provider

"Over a 10-year period, the DIMM patients were projected to experience absolute risk reductions in the incidence of several diabetes-related complications and all-cause death when compared with the [primary-care] group," the authors note.

A series of sensitivity analyses did not change the overall conclusions.

"Despite the complex nature of DIMM clinic patients, significant glycemic control was achieved in a 6-month period and, most important, minimal costs were incurred per additional clinical and economic benefit gained," they conclude.

Dr Hirsch added: "Pharmacists are no longer simply pill dispensers — they're becoming a new type of primary healthcare provider.…And as we found in this study, this new approach may help us improve healthcare on many fronts."

The authors have no relevant financial relationships.

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J Manag Care Spec Pharm. Published online February 27, 2017. Abstract

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