Original Research

Predictors of HA1c Goal Attainment in Patients Treated With Insulin at a VA Pharmacist-Managed Insulin Clinic

Fed Pract. 2018 November;35(6):S18-S22

References

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4. US Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of type 2 diabetes mellitus in primary care. https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoDDMCPGFinal508.pdf. Published April 2017. Accessed September 7, 2018.

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Results

Five hundred eighty-four patient records were reviewed, and 207 patients met inclusion criteria: 102 patient records were reviewed for the goal-attained arm, and 105 patient records for the goal-not-attained arm. Most patients were excluded from the analysis due to not having 3 consecutive visits during the specified period or having an HbA_1c of < 8% at the time of referral to the pharmacist DSM clinic.

The patients in this study had type 2 diabetes for about 11 years, were overwhelmingly male (99%), were aged about 61 years, and were taking on average 13 medications at the time of referral to the pharmacist DSM clinic. Mean HbA_1c at time of enrollment was slightly higher in the goal-not-attained arm vs goal-attained arm (10.7% vs 10.2%, respectively), but the difference was not statistically significant (P = .066). A little more than half the patients in both study arms were on basal + prandial insulin regimens (Table 2).

Patients who attained their goal HbA_1cwere more likely to bring their glucose meter/glucose log book to at least 80% of their appointments (P < .001). Additionally, this same cohort followed insulin dosing instructions at least 80% of the time (P < .001).

Frequency of glucose testing was not significantly different between goal-attained and goal-not-attained groups (P = .375). Moreover, our analysis showed that, on average, patients who met goal did so within 6 months of referral to the pharmacist-managed clinic (P < .001) (Table 3).

Five variables were included in the multivariate analysis because they had a P value ≤ .2 in univariate analyses: (1) patient adherence to instructions (P < .001); (2) duration in clinic (P < .001); (3) patient bringingglucose meter or glucose log to appointments (P < .001); (4) percentage of scheduled appointments patient attended (P = .015); and (5) baseline HbA_1c (P = .066).

Following instructions at least 80% of the time and duration in clinic were the only significant contributing factors when entered into the multivariate analysis. Longer duration in the pharmacist-managed clinic was inversely related to goal attainment; in other words, patients in clinic for longer periods were less likely to attain glycemic goals (odds ratio [OR] = 0.895, 95% CI: 0.830-0.964). Following instructions at least 80% of the time increased the likelihood of glycemic goal achievement (OR 17.3; 95% CI: 8.0-37.4).

Discussion

The development and constant modification of clinical practicing guidelines has made DM treatment a focus and priority.^3,4 Additionally, the collaborative approach to health care and creation of VA pharmacist-driven services have demonstrated successful patient outcomes.^6-16 Despite these efforts, further insight is needed to improve the management of DM. Our study identified specific behavioral factors that correlated to veteran patients to attaining their HbA_1cgoal of < 8% within a VA pharmacist DSM clinic. Additionally, it highlighted factors that contributed to patients not achieving their glycemic goals.

Our univariate analysis showed behaviors such as showing up for appointments and following directions regimens to correlate with glycemic goal attainment. However, following directions was the only behavioral factor that correlated to glycemic goal attainment in our multivariate analysis. Additionally, our findings indicated that factors for HbA_1cgoal attainment included patients who brought their glucose meter/glucose log book and attended clinic appointments at least 80% of the time, respectively.

These findings can help further refine the process for identifying patients who are most likely to achieve glycemic goals when referred to pharmacist DSM clinics or to any DM treatment program. Assessment of a patient’s motivation and ability to attend clinic appointments, bring their glucose meter/glucose log book, and to follow instructions provided at these appointments are reasonable screening questions to ask before referring that patient to a diabetes care program or service. Currently, this is not performed during the consult process to the pharmacist DSM clinic at the respective VA.

Additionally, our findings show that patients who met goal did so, on average, within 6 months of referral to the pharmacist DSM clinic. This finding may have occurred because patients who successfully reach HbA_1cgoal in 2 consecutive checks are discharged from the clinic. Patients who do not meet this goal continue with the clinic, thus increasing their duration of enrollment in this service. This finding could help clinical pharmacists estimate how long patients will be followed by the service, thus allowing for a more accurate estimation of workload and clinic capacity. Additionally, this finding provides insight if the patient should remain in clinic or be transferred to another program. Our findings aligned with previous studies showing the link between patient behaviors and glycemic goal attainment.^17-19