Impact of a Pharmacist-Managed TOC Clinic on Diabetes Outcomes Following Hospitalization

Focusing on patients with diabetes, an evaluation of a pharmacist-managed transitions of care (TOC) clinic revealed no difference in hospital readmission rates for these patients compared with patients in a non-TOC setting. However, the TOC clinic was able to decrease the time to follow-up and improve long-term diabetes outcomes for patients.

These findings were published in The Science of Diabetes Self-Management and Care, where researchers looked at the pharmacist-managed TOC clinic at the University of Kentucky Center for Clinical and Translational Science and its impact on outcomes among patients with diabetes following hospitalization.

Diabetes prevalence in the US has been steadily increasing, surpassing 11% of the total population in 2019, and patients with diabetes hospitalized for acute illnesses often face challenges in maintaining optimal glycemic control due to various factors such as stress, illness, nutrition, and changes in activity and schedule. Managing diabetes during hospitalization and after discharge becomes complicated due to the diverse nature of diabetes care regimens, including multiple medications, dosage forms, and instructions.

Notably, patients with diabetes demonstrate a high 30-day readmission rate of 20.3%, resulting in substantial health care costs exceeding $251 million. Factors such as higher blood glucose levels and variability, male sex, longer hospitalization duration, comorbidities, and lower socioeconomic or educational status have been shown to contribute to increased readmission rates. Both acute and ambulatory care facilities have a vested interest in preventing poor glycemic outcomes and readmissions, creating an opportunity for TOC programs to address these challenges and improve diabetes-related outcomes while reducing costs.

Pharmacists conversing | Image credit: Gorodenkoff – stock.adobe.com

The authors of the single-center study utilized electronic health records to identify discharged patients who were followed by the inpatient endocrinology team. The primary focus was on 30-day readmission rates, with secondary outcomes including 90-day readmission rates, time to first follow-up, emergency department/urgent care encounters, change in hemoglobin A_1c (HbA_1c) levels, retention with endocrinology, referrals for diabetes education, and types of interventions.

Upon initial inpatient admission, a higher percentage of patients in the TOC cohort were prescribed insulin (75% vs 59.1%; P = .025) and steroids (19% vs 8.6%; P = .043) compared with the non-TOC cohort. This trend persisted at the time of discharge, with a greater proportion of patients in the TOC cohort being discharged on insulin (91.7% vs 80.6%) and steroids (36.9% vs 19.4%; P = .009).

For the primary outcome, there was no statistically significant difference in 30-day readmission rates between the TOC cohort and non-TOC cohort, although the TOC cohort had a slightly higher rate (24% vs 18%; P = .150). There were also no significant differences regarding 90-day readmission rates, rates of 30-day or 90-day emergency department (ED) or urgent care visits, or the overall frequency of hospital readmissions and ED or urgent care visits. Additionally, among patients readmitted to the hospital, there was no significant difference in readmissions attributable to diabetes, although numerically fewer were observed in the TOC cohort compared with the non-TOC cohort.

“This difference may be attributable to the small sample size and patients in the TOC cohort being of older age; being on more complex medications, such as insulin and steroids; or having more concomitant comorbidities, such as chronic kidney disease (CKD), dialysis, chronic obstructive pulmonary disease (COPD), and transplant,” the authors noted.

When evaluating repeat HbA_1c within 120 days of discharge, the authors found that 60.7% of patients in the TOC cohort and 38.7% in the non-TOC cohort had HbA_1c values analyzed within this time frame, and the TOC cohort exhibited significantly lower HbA_1c values compared with the non-TOC cohort (7.5% vs 9.2%, P = .024). Additionally, patients in the TOC cohort were more likely to have a follow-up appointment (84% vs 45%, P < .001) and had closer follow-up after discharge, with a median of 10 days compared with 32 days (P < .001). While there was no difference in time to follow-up with a primary care provider, patients in the TOC cohort had longer time to follow-up with their endocrinology provider specifically, with a median of 78 days vs 42 days (P = .004). Further, there were no significant differences between the cohorts in terms of prior appointments with an endocrinology provider at the diabetes center or referrals for outpatient diabetes education.

Pharmacist interventions during the TOC visit were evaluated, revealing significant involvement in patient care. Using a credentialed and privileged protocol, the pharmacist adjusted doses of current diabetes medications for 66.7% of patients, initiated new medications for 7.1%, and discontinued medications for 2.4% of patients. Additionally, prescriptions for hypoglycemia treatments were provided to 3.6% of patients, while evaluations for diabetes technology were conducted for 45.2%, resulting in prescriptions for continuous glucose monitors for 14.3%.

The pharmacist addressed preventive care gaps by prescribing or adjusting medications for hypertension and dyslipidemia, discussing vaccine recommendations with 72.6% of patients, and arranging ophthalmology referrals for 2.4% of patients. Additionally, 6% of patients were identified as needing additional diabetes education, leading to referrals to certified diabetes care specialists, and laboratory tests were ordered for 3.6% of patients. Collaboration with providers outside of endocrinology occurred for 10.7% of patients, and medication access concerns were addressed for 7.1% of patients. Overall, 94% of patients benefited from multiple interventions during their TOC appointment with the pharmacist.

“This study supports that pharmacists can serve as an integral part of the health care team to improve diabetes outcomes during the transitional period,” the authors said.

Reference

Hall HM, Ashley KC, Schadler AD, Naseman KW. Evaluation of a pharmacist-managed diabetes transitions of care medication management clinic. Sci Diabetes Self Manag Care. Published online January 20, 2024. doi:10.1177/26350106231221463