Transcript Slide 1

El Rio Community
Health Center
Clinical Pharmacy
Services
Arthur N. Martinez, M.D., MSHA
Chief Medical Officer
El Rio Community Health
Center 2009 Snapshot





73,651 patients were served
280,808 patient encounters
15% patients uninsured
22% patients on Medicaid
62% patients at or below
Federal poverty level
Clinical Pharmacy
Services
 Clinical Pharmacy Demonstration
Grant from the Office of Pharmacy
Affairs
 Arizona Revised Statute 32-1970
 First Clinical Pharmacist in Arizona
Services:
Physician Concerns
I don’t want:

to be forced to share patients

someone to take over “my” patients

someone to provide medical care
I do not agree with
Success:
Physician Support
 Volunteer
referral system
 Great formal and informal
communication and follow-up with
physicians
 Comprehensive evaluation and
treatment plan
 You knew and agreed with the clinical
guidelines/ADA Guidelines
Standards:
 Productivity
 Quality
HEDIS
Diabetes

Process
 A1C Testing
 Retinal Exam
 LDL-C Screening
 Monitoring for Nephropathy

Outcome
 Poor A1C Control
 LDL-C Level < 130mg/dL
Clinical Pharmacy
HEDIS Comparison
Provider
Without Sandra
Total
Process
With Sandra
Outcome
SL
Total
Process
Outcome
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 Visit
Day before appointment-thorough review of
chart for baseline
 Foot exam/monofilament test
 Review of diabetes, blood pressure, lipids
including goals and previous lab work
– Initiate self-testing
 Ophthalmology referral
 Smoking cessation counseling
 Aspirin
 Depression Screening
 Update vaccinations

Results
Changes in Recommended Annual Follow-up Screenings
Results
Changes in Metabolic and BP Measures: Baseline to Follow-Up
Parameter
# Pts
Baseline
(Mean)
FU
(Mean)
Diff.
P-value
168
184
28
<0.001
<0.001
0.004
<0.001
0.001
<0.001
<0.001
TC (mg/dL)
670
TG (mg/dL)
670
196
241
HDLc (mg/dL)
667
44.6
43.4
1.2
LDLc (mg/dL)
644
659
DBP (mm/Hg)
659
89
120
71
17
SBP (mm/Hg)
106
123
74
A1C (%)
671
10
8.2
1.8%
Gluc (mg/dL)
655
209
164
45
GFR
663
83
80
3
57
3
3
<0.001
0.001
Why do we try so hard?
Relative Risk of Progression of Diabetic Complications as a Function of Mean A1C*
Relative Risk
19
Diabetic retinopathy
17
Nephropathy
15
13
Severe nonproliferative or
proliferative retinopathy
Neuropathy
11
Microalbuminuria
9
7
5
3
1
6
7
8
9
A1C
*Based on DCCT data
Reprinted with permission from Skyler J. Endocrinol Metab Clin North Am. 1996;25:243-254.
10
11
12
Reduction in Risk of Diabetic Complications with 1%
Decline in Updated A1C (UKPDS)
DiabetesRelated Mortality
All-Cause
Mortality
Myocardial
Infarction
Peripheral
Vascular Disease
Microvascular
Disease
0
–10
–14%
–20
–14%
–21%
–30
–40
–37%
All P<.0001
–50
A1C = glycosylated hemoglobin; UKPDS = United Kingdom Prospective Diabetes Study.
Adapted from Stratton IM et al. BMJ. 2000;321:405-412.
–43%
The Patient Safety & Clinical Pharmacy
Services Collaborative (PSPC) Change
Package is organized into five colorcoded 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
Publications
Endsley 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):672-676
Leal 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 42 nd
American Society of Health-Systems Pharmacist (ASHP) Midyear Clinical Meeting and Exhibition, Las Vegas, NV,
December 2007
eghini 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 40th 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 2005
Leal 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 SepOct;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 Projects
Volume 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.pdf
November 30, 2004
Volume II: Case Studies
Presents 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.pdf
November 30, 2004
Results
Changes from Baseline to Follow-Up for Patients on ASA and ACEIs/ARBs
•102 patients with ASA contraindication
•91patients had contraindication to ACEI/ARB
•8 patients had a contraindication to statins
Studies
Conversation Maps
• Self Management
• Dental
• ROI
•
http://www.hrsa.gov/patientsafety/changepackage.htm