El Rio CommunityEl Rio CommunityHealth Center Health Center

Clinical Pharmacy Clinical Pharmacy ServicesServices

Arthur N. Martinez, M.D., MSHAArthur N. Martinez, M.D., MSHAChief Medical OfficerChief Medical Officer

73,651 patients were served73,651 patients were served 280,808 patient encounters280,808 patient encounters 15% patients uninsured15% patients uninsured 22% patients on Medicaid22% patients on Medicaid 62% patients at or below 62% patients at or below Federal poverty levelFederal poverty level

El Rio Community Health El Rio Community Health Center 2009 SnapshotCenter 2009 Snapshot

Clinical Pharmacy Clinical Pharmacy ServicesServices

Clinical Pharmacy Demonstration Grant from the Office of Pharmacy Affairs

Arizona Revised Statute 32-1970 First Clinical Pharmacist in Arizona

I don’t want:I don’t want: to be forced to share patientsto be forced to share patients someone to take over “my” someone to take over “my”

patientspatients someone to provide medical care someone to provide medical care

I do not agree withI do not agree with

Services:Services:Physician ConcernsPhysician Concerns

Volunteer referral systemVolunteer referral system Great formal and informal Great formal and informal

communication and follow-up with communication and follow-up with physiciansphysicians

Comprehensive evaluation and Comprehensive evaluation and treatment plantreatment plan

You knew and agreed with the clinical You knew and agreed with the clinical guidelines/ADA Guidelinesguidelines/ADA Guidelines

Success:Success:Physician SupportPhysician Support

Standards:

Productivity

Quality

ProcessProcess A1C TestingA1C Testing Retinal ExamRetinal Exam LDL-C ScreeningLDL-C Screening Monitoring for NephropathyMonitoring for Nephropathy

OutcomeOutcome Poor A1C ControlPoor A1C Control LDL-C Level < 130mg/dLLDL-C Level < 130mg/dL

HEDISHEDISDiabetesDiabetes

Clinical Pharmacy Clinical Pharmacy HEDIS ComparisonHEDIS Comparison

Provider Without Sandra   With Sandra

  Total Process Outcome   Total Process Outcome

SL         5.17 3.33 1.83

               

JV 4.45 3.14 1.32   5.5 3.5 2

JE 4.09 2.65 1.43   5 3.75 1.25

DS 4.18 2.82 1.35   5 3 2

NF 4.2 2.67 1.53   6 4 2

Typical VisitTypical Visit Day before appointment-thorough review of Day before appointment-thorough review of

chart for baseline chart for baseline Foot exam/monofilament testFoot exam/monofilament test Review of diabetes, blood pressure, lipids Review of diabetes, blood pressure, lipids

including goals and previous lab work including goals and previous lab work – Initiate self-testingInitiate self-testing

Ophthalmology referralOphthalmology referral Smoking cessation counselingSmoking cessation counseling Aspirin Aspirin Depression ScreeningDepression Screening Update vaccinationsUpdate vaccinations

ResultsResults

Changes in Recommended Annual Follow-up ScreeningsChanges in Recommended Annual Follow-up Screenings

ResultsResultsChanges in Metabolic and BP Measures: Baseline to Follow-UpChanges in Metabolic and BP Measures: Baseline to Follow-Up

Parameter # PtsBaseline (Mean)

FU (Mean) Diff. P-value

TC (mg/dL) 670 196 168 28 <0.001TG (mg/dL) 670 241 184 57 <0.001HDLc (mg/dL) 667 44.6 43.4 1.2 0.004LDLc (mg/dL) 644 106 89 17 <0.001SBP (mm/Hg) 659 123 120 3 0.001DBP (mm/Hg) 659 74 71 3 <0.001A1C (%) 671 10 8.2 1.8% <0.001Gluc (mg/dL) 655 209 164 45 <0.001GFR 663 83 80 3 0.001

Why do we try so hard?Why do we try so hard?Relative Risk of Progression of Diabetic Complications as a

Function of Mean A1C*

13579

111315

6 7 8 9 10 11 12

Diabetic retinopathyNephropathy

Severe nonproliferative or proliferative retinopathy

NeuropathyMicroalbuminuria

Rela

tive

Ris

k

A1C

1719

*Based on DCCT dataReprinted with permission from Skyler J. Endocrinol Metab Clin North Am. 1996;25:243-254.

Reduction in Risk of Diabetic Complications with 1% Reduction in Risk of Diabetic Complications with 1% Decline in Updated A1C (UKPDS)Decline in Updated A1C (UKPDS)

A1C = glycosylated hemoglobin; UKPDS = United Kingdom Prospective Diabetes Study.Adapted from Stratton IM et al. BMJ. 2000;321:405-412.

Diabetes-Related Mortality

All-CauseMortality

MyocardialInfarction

PeripheralVascular Disease

MicrovascularDisease

All P<.0001

–21%

–14% –14%

–43%–37%

0

–10

–20

–30

–40

–50

The Patient Safety & Clinical Pharmacy Services Collaborative (PSPC) Change Package is organized into five color-coded strategies to achieve accountability for results:

• Leadership Commitment• Measurable Improvement• Integrated Care Delivery• Safe Medication Use Systems• Patient Centered Care

http://www.hrsa.gov/patientsafety/changepackage.htm

PublicationsPublicationsEndsley S, Leal S, Choi J, Martinez AN. An Office Based Physician Education Program to Enhance the Earlier Initiation of Insulin: An Evaluation of an Academic Detailing Intervention in the US. Accepted for oral presentation at the American Diabetes Association's 70th Scientific Sessions, Orlando, FL, June, 2010. Pending publication in the Scientific Sessions Abstract Book June 2010 supplement to the journal Diabetes.Rust G, Leal S. Cost-Effective Prescribing vs. Moments of Compromise: An educational tool designed for prescribers in the Community and Migrant Health Center environment free of pharmaceutical influence. National Center for Farmworker Health, Inc. (NCFH). CD-ROM. 2009.Leal S, Soto-Rowen M. Usefulness of Point-of-Care Testing in the Treatment of Diabetes in an Underserved Population. Journal of Diabetes Science and Technology 2009;3(4):672-676Leal S. Cost Effective Prescribing versus Moments of Compromise. Migrant Health Newsline Vol. 26, No. 2. March/April 2009. Dingham J, Glenn ZM, Leal S. Improving Patient Safety-Improving Lives: A Patient’s Story. Journal of Health Care for the Poor and Underserved 20(1):1-3, February 2009. Patel N, Lee AA, Warholak T, Leal S. A Consumer Assessment of Pharmaceutical Care Services in a Diabetes Ambulatory Clinic. Poster presentation at the 43rd American Society of Health-Systems Pharmacist (ASHP) Midyear Clinical Meeting and Exhibition, Orlando, FL, December 2008. Leal S. Long-Acting Insulins for the Treatment of Type 2 Diabetes. Pharmacy Times, October 2008: pp 38-40.http://www.pharmacytimes.com/issues/articles/2008-10_005.asp Leal S. Increasing Patient Access and Improving Patient Outcomes in Diabetes through Pharmacy-Based Disease Management Services. Poster presentation at the Community Health Institute (CHI) & EXPO for the National Association of Community Health Centers (NACHC), New Orleans, LA, September 2008.Leal S, Leal K. Back to basics: helping patients pick ‘real’ food. 2008 Diabetes Educators’ Handbook, A Supplement to Endocrine today, Vol 6, No 14 (August 10), 2008: p 6.Leal S, Soto ML. Chronic Kidney Disease Risk Reduction in a Hispanic Population Through Pharmacist-Based Disease-State Management. Advances in Chronic Kidney Disease, Vol 15, No 2 (April), 2008: pp 162-167.Armin J, Shaw S, Schaecher A, Leal S, Petruski J. Nobody took time to tell me watch out for this: understanding risk and social support among people living with type 2 diabetes. Presentation for the Society for Applied Anthropology/Society for Medical Anthropology Meeting, Memphis, TN, March 2008. Strickland C, Armstrong EP, Leal S. Pharmacist Knowledge of Inhaled Insulin. Poster presentation at the 42nd American Society of Health-Systems Pharmacist (ASHP) Midyear Clinical Meeting and Exhibition, Las Vegas, NV, December 2007eghini L, Kennedy L, Koff R, Kuritzky L, Leal S, Peterson K, Zamudio V. Appropriate Advancement of Type 2 Diabetes Therapy. Current Clinical Practice 1(1): 19a-30a, October 2007.http://www.jfponline.com/pdf/5610/5610ACCP_Supplement1.pdf Leal S, Public Health Institute/Medpin’s Low Literacy Questions and Answers about Diabetes Treatment (English and Spanish), 2007. Leal S, Herrier RN, Soto M. The Role of Rapid-Acting Insulin Analogues and Inhaled Insulin in Type 2 Diabetes Mellitus. Insulin 2(2):61-67, April 2007. Hogan E, Leal S, Slack M, Apgar D. Pharmacist-Led vs Physician Diabetes Drug Management. Hospital Pharmacy Europe May/June 2006. Leal S, Soto M, Felix A. Pharmacist-Based Diabetes Management through a Collaborative Practice Model. Poster presentation at the 40 th American Society of Health-Systems Pharmacist (ASHP) Midyear Clinical Meeting and Exhibition, Las Vegas, NV, December 2005.

.

Men Hogan, EG, Leal S, Slack M, Apgar M. Comparison of pharmacist led collaborative drug therapy management to standard physician provided therapy for type 2 diabetes mellitus. Poster presentation at the 40 th American Society of Health-Systems Pharmacist (ASHP) Midyear Clinical Meeting and Exhibition, Las Vegas, Nevada, December 2005. Leal, S. Medications, Rationing, and Health Care: The Role of Pharmacists in Bridging the Gap. Journal of Health Care for the Poor and Underserved 16(3): 418-420, August 2005. Leal, S. Changing the Face of Pharmacy. Rx for Access Volume 2 Issues 5 p.2, MedPin (Medicine for People in Need), July/August 2005. Leal, S. Cambiando la Cara de la Farmacia. Rx for Access Volume 2 Issues 5 p.2, MedPin (Medicine for People in Need), Julio/Agosto 2005. Burgos I, Westpheling K, Leal S, Levy R, Frazier E. Access to Medications by Underserved Populations: Recommendations for Process Improvement. Association of Clinicians for the Underserved (ACU), June 2005. Leal S, Soto ML. Pharmacists Disease State Management Through a Collaborative Practice Model. Journal of Health Care for the Poor and Underserved 16(2):220-224, May 2005Leal S, Herrier RN, Glover JJ, Felix A. Improving Quality of Care in Diabetes Through a Comprehensive Pharmacist-Based Disease Management Program (Brief Report). Diabetes Care 27:2983–2984, 2004. Understanding Medicare Reform. What Pharmacists Need to Know, Monograph 2: Medication Therapy Management Services and Chronic Care Improvement Programs. American Pharmacists Association (APhA) Resources, 2004. Leal, S. Clinicians & Community: Primary Health Care, A Fellowship, and Change. Association of Clinicians for the Underserved (ACU), Summer 2004. Goyette D, Disco ME, Leal S, Schwed DH. The pharmacist as a primary care provider for the medically underserved. Journal of the American Pharmacist Association (Wash DC). 2003 Sep-Oct;43(5 Suppl 1):S52-3. Leal S, Ford M. A Retrospective Evaluation of the Clinical Use of Glycosylated Hemoglobin Levels in Diabetic Patients, Southern Arizona VA Health Care System. Tucson, AZ, 2000. Brandt, T. L., Fraser, D. J., Leal, S., Halandras, P. M., Nelson, A. R., and Kroll, D. J. c-Myb trans-activates the human DNA topoisomerase II gene promoter. Journal of Biological Chemistry, 272:6278 –6284,1997. c-Myb transactivates the human topisomerase II-alpha gene promoter in HL-60 cells. Proc AM Assoc. Cancer Research. 36:451 (Abstract 2691). Evaluation of HRSA's Clinical Pharmacy Demonstration ProjectsVolume 1: Synthesis Report Final evaluation report of the Clinical Pharmacy Demonstration Projects (CPDP) managed by OPA. The purpose of these projects was to examine the effects of expanded access to clinical pharmacists and comprehensive pharmacy services on the health outcomes of medically underserved populations. This report is an evaluation of expanded access and improved outcomes due to the Clinical Pharmacy Demonstration Projects. ftp://ftp.hrsa.gov/bphc/pdf/opa/CPDPvolume1finalreport.pdfNovember 30, 2004 Volume II: Case StudiesPresents five case studies of Clinical Pharmacy Demonstration Project networks whose experience may prove beneficial to other Community Health Centers and providers exploring the potential for clinical pharmacy service. El Rio’s Demonstration Project is highlighted. ftp://ftp.hrsa.gov/bphc/pdf/opa/CPDPvolume2finalreport.pdfNovember 30, 2004

ResultsResults

•102 patients with ASA contraindication•91patients had contraindication to ACEI/ARB•8 patients had a contraindication to statins

Changes from Baseline to Follow-Up for Patients on ASA and ACEIs/ARBs

StudiesStudies

• Conversation Maps• Self Management• Dental• ROI

http://www.hrsa.gov/patientsafety/changepackage.htm