This project’s strengths included the large sample size, appropriate inclusion criteria that identified patients at risk for hypoglycemia, and the use of shared decision making. It was also beneficial to obtain HbA1c levels after a relaxation in therapy for objective outcomes. The increase in HbA1c levels showed a statistically significant gain, which led to more patients having an HbA1c closer to a CPG-recommended goal range, given their risk factors for hypoglycemia. This pharmacy initiative fostered increased communication between providers and CPS within the PACT team. The pharmacist was not consulted by the provider for management of these patients with DM, so therapy relaxation was documented in CPRS and was addressed at the patient’s next primary care appointment. Some changes also required discussion with the primary care provider prior to relaxation in therapy. By initiating these discussions with providers, opportunities arose for additional education on appropriate HbA1c goals and why therapy should be relaxed in select patient populations.
Limitations
Some limitations to this project were the use of telephone encounters and interpharmacist variability. Patients who were contacted via telephone by a pharmacist who was unknown to them were more hesitant to make changes. Patients managed for DM by non-VA providers or patients receiving medications at a non-VA pharmacy were also reluctant to implement changes. Education was the major intervention for these patients. Pharmacists were instructed to use their clinical judgment in addition to shared decision making with the patient when relaxing therapy. There was no protocol for medication changes. Although interpharmacist variability is identified as a weakness, it could be considered more representative of daily practice.
Additionally, despite a statistically significant increase in HbA1c, which would presumably lead to fewer episodes of hypoglycemia, patients were not contacted again after the intervention to inquire whether hypoglycemia had decreased. Studies targeted at the impact of less frequent hypoglycemia events, including fewer emergency department visits, hospital admissions, or primary care walk-in appointments, would improve the clinical significance of these data. As the HSI is implemented nationally within the VA, more data will be available to better evaluate the applicability of this clinical reminder. Locally, the criteria for the clinical reminder has proved to capture a significant number of patients experiencing hypoglycemia. Using national data will also help to guide the frequency of screening needed in this population.
Conclusion
The implementation of the HSI led to increased provider and patient awareness of hypoglycemia. The CPS interventions have resulted in statistically significant increases in HbA1c levels, which would seemingly decrease the patient’s risk of adverse outcomes as shown in the ACCORD and VADT trials.