Serious Mental Illness and Its Impact on Diabetes Care in a VA Nurse/Pharmacist-Managed Population

Methods

The current study examines a novel service involving the collaboration of a registered nurse-certified DM educator (RN CDE) and clinical pharmacy specialist (PharmD) to improve access to care and maximize DM outcomes. The Louis Stokes Cleveland VAMC defines the PharmD scope of practice. One of the pharmacist’s clinical obligations includes serving as a preceptor for the RN CDE, a collaboration that has not been investigated in previous studies. A primary care provider (PCP) refers veterans to the RN CDE/PharmD clinic, with HbA_1c ≥ 8%.

The RN CDE/PharmD clinic tends to receive referrals for the most challenging veterans who may have very elevated HbA_1c readings, complex multidrug regimens, or basal/bolus insulin regimens. The RN CDE sees veterans in individual appointments and takes manual BP readings, checks point-of-care glucose/HbA_1c readings, downloads home glucometer results into the electronic medical record (EMR), and provides education on DM management specific to the veteran’s individual needs. Because there is no established treatment algorithm for the RN CDE to follow, all medication changes are determined by a preceptor in real time.

When the RN CDE clinic was established, the RN CDE presented veterans to their PCP who determined the veteran’s plan of care. However, this plan was frustrating for the RN CDE because the PCP was not always readily available, causing delays in the workflow of the RN CDE clinic. Since the PharmD has a scope of practice and is more frequently available to discuss veteran cases, RN CDE/PharmD collaboration was initiated. Based on information gathered during the appointment, medication additions, titrations, and changes are precepted with the PharmD. Veterans can be seen in clinic every 2 to 4 weeks, allowing for continued medication adjustments if warranted until their HbA_1c target is achieved. Veterans are discharged to their PCP once their HbA_1c is at target.

Within the primary care clinic, this service was compared with usual care by a PCP and was associated with a clinically significant reduction in HbA_1c by 2.5% compared with usual care after 1 year (P < .001).¹³ The same study population was investigated to determine whether there was a difference in glycemic control between veterans with SMI compared with veterans without SMI (non-SMI) to provide insight and better support for veterans with SMI and their DM care.

A retrospective review of the veterans referred to the RN CDE/PharmD clinic from January 1, 2011 to December 31, 2014 was performed with institutional review board approval. Veterans were identified using a pharmacy-generated list searching for clinic note titles from the Computerized Patient Record System (CPRS).

The primary objective of this study was to determine the percentage change in mean HbA_1c in veterans with SMI compared with that of veterans without SMI after referral to the RN CDE/PharmD clinic. The following secondary objectives also were investigated: the difference in the percentage of veterans with glycemic relapse after the intervention in veterans with SMI compared with that of veterans without SMI, and the difference in time to glycemic relapse between veterans with SMI compared with that of veterans without SMI. Serious mental illness was defined as schizophrenia, schizoaffective disorder, bipolar disorder, and MDD and identified in CPRS using ICD-9 and ICD-10 codes, medicine progress notes, and psychiatry progress notes. Glycemic relapse was defined as > 1% increase in HbA_1c from the lowest HbA_1c within 1 year of being followed by the RN CDE/PharmD clinic (nadir).

Veterans were included in the study if they were aged ≥ 18 years, referred to the RN CDE/PharmD clinic from January 1, 2011 to December 31, 2014, had at least 2 clinic visits, an HbA_1c > 8% at the date of the first clinic visit, and at least 1 HbA_1c test at baseline and 1 HbA_1c test at least 2 months after referral to the clinic. Veterans were excluded from the study if they met the following criteria: diagnosed with SMI during the study period, followed by the RN CDE or PharmD in other primary care clinics prior to referral, followed by the PharmD clinic within 365 days after the initial RN CDE/PharmD clinic visit, referred to or followed by endocrinology, or veterans enrolled in a VA DM research trial. Veterans continued to be enrolled until target enrollment was met.

Medical records were reviewed to capture the following information: demographics (age and gender), type of SMI, date diagnosed with SMI, number of mental health-related visits, antidepressant and antipsychotic use, HbA_1c prior to referral to the RN CDE/PharmD clinic (initial HbA_1c) and date, HbA_1c nadir and date, and highest postnadir HbA_1c (glycemic relapse) and date, number of clinic visits, time followed by the clinic, and reason for glycemic relapse.

A total sample size of 100 veterans was needed to determine a medium effect size of 0.25 for between-group treatment effect on veterans with SMI compared with that of veterans without SMI, using a 2-group by 2 time-point repeated measures analysis of variance (ANOVA) with a power of 80% and alpha of 0.05. Of the 100 veterans, 50 veterans in each group were necessary to meet power. The percentage change in mean HbA_1c from the initial time point to nadir was analyzed using a 2-time point by 2-group repeated measures ANOVA analysis. The secondary objectives were analyzed using descriptive statistics, a repeated measures ANOVA test to determine the percentage change in mean HbA_1c from nadir to relapse, and an independent samples Student t test to analyze time to glycemic relapse.