A Novel Pharmacist-led Virtual Endocrinology Consult Program in Collaboration with Primary Care Physicians Reduces A1C in Persons with Type 2 Diabetes

A1C is a standard CMS diabetes outcome quality metric for accountable care organizations (ACO) with financial implications.  Our goal was to improve A1C in our healthcare system’s ACO using a novel program of pharmacist-led Virtual Endocrinology Consult Program (VECP) to provide expert, individualized interventions for management of type 2 diabetes (T2D) in collaboration with an ACO Primary Care Physician (PCP) network.  

Methods:

Patients with an A1C > 9% as defined by CMS for Medicare/Medicaid or A1C ≥ 8% for commercial payors were identified.  Exclusion criteria included type 1 diabetes, currently managed by an endocrinologist, last PCP visit ≥ 6 months, labs ≥ 6 months ago, patient was unreachable or declined participation.  A clinical pharmacist performed an in-depth telephonic assessment focused on lifestyle behaviors, glucose monitoring, diabetes medication history, diabetes self-management skills, and social determinants of health, including depression screening.  Barriers were identified including financial, medication compliance, side effects and psychological challenges. Education was performed by a clinical pharmacist and supplemented by a certified diabetes care and education specialist (CDCES). Labs and information from recent PCP visits were extracted from the electronic health record (EHR). Each case was then reviewed in detail with an endocrinologist. A summary of the VECP recommendations including pharmacotherapeutic changes were communicated to the PCP for implementation.

Results:

From 2019 to 2020, 89 patients were screened for participation and 37 were excluded. Of the 52 eligible,  37 completed the program with pre- and post-A1C outcomes. The mean age was 69 years (SD±10), with 59% female, 65% white and 92% Medicare and 8% commercial insurance. Patients had T2D for a mean of 12.9 years (SD±7.1), mean BMI of 34 kg/m2 (SD±6.8). Comorbidities included hypertension (92%), hyperlipidemia (95%), chronic kidney disease (41%) and cardiovascular disease (32%). At completion of the VECP, the mean A1C decreased from 9.82% ( SD ± 1.5) to 8.06% (SD ± 1.4) with 94% of patients showing an improvement.   

Discussion/Conclusion:

This VECP is an innovative solution for a growing epidemic with increasing complexity and comorbidity in the setting of a shortage of endocrinologists and increase in value based payment for diabetes outcomes. A clinical pharmacist led multidisciplinary team successfully identified and addressed patients’ needs and barriers, and in collaboration with a PCP, implemented changes and follow-up to the treatment plan to reduce A1C by 1.76% to avoid future diabetes complications. Further studies should track sustainability with continued education and follow-up.