title: The effect of a diabetes collaborative care management program on clinical and economic outcomes in patients with type 2 diabetes.
abstract: BACKGROUND
  Clinical pharmacy services (CPS) in the primary care setting have been shown to help patients attain treatment goals and improve outcomes. However, the availability of CPS in community-based primary care is not widespread. One reason is that current fee-for-service models offer limited reimbursement opportunities for CPS in the community setting. Furthermore, data demonstrating the value of CPS in this setting are limited, making it difficult for providers to determine the feasibility and sustainability of incorporating CPS into primary care practice.
  
  
  OBJECTIVE
  To (a) evaluate the association between a pharmacist-led, diabetes collaborative drug therapy management program and patient outcomes, including glycemic control and health care costs, and (b) assess short-term economic outcomes in a primary care setting.
  
  
  METHODS
  A retrospective cohort analysis was conducted using medical record data. This study was conducted using patients with uncontrolled type 2 diabetes (T2DM), defined as HbA1c ≥ 7.0%. Outcomes were compared between patients referred to a diabetes collaborative care management (DCCM) intervention from 2009-2012 and patients who did not participate in the DCCM program. To illustrate the difference in HbA1c between the 2 cohorts over the follow-up period, mean time adjusted HbA1c values were estimated using a panel-type random effects regression model, with results plotted at 90-day intervals from index date through the end of the study period. To help control for confounding by other factors, multivariate regression models were run. A difference-in-difference model was employed to estimate the effect of the program on resource utilization and all-cause charges.
  
  
  RESULTS
  A total of 303 DCCM and 394 comparison patients were included. Mean (95% CI) age was 57.4 years (55.963, 58.902) versus 59.9 years (58.613, 61.276; P < 0.001) with 48% and 44% female for DCCM and comparison patients, respectively (P = 0.49). Mean baseline HbA1c was higher for DCCM (10.3%; 10.10, 10.53) than comparison patients (8.4%; 8.26, 8.61; P < 0.001). The greatest reduction in HbA1c was seen for both groups at 9 and 12 months post-index date. At these time points, the mean time adjusted difference in HbA1c between groups was no longer significant. Multivariate modeling identified that the DCCM program was associated with a -0.44% (-0.64, -0.25; P < 0.001) lower HbA1c at follow-up relative to the comparison group controlling for potential confounders, including baseline HbA1c. Change in resource utilization from pre- to post-index date did not differ between groups. However, in the difference-in-difference multivariate analysis the difference in mean all-cause charges from the 12-month pre- to post-index periods DCCM patients experienced a smaller average increase in charges ($250) than comparison patients ($1,341; coefficient = -0.423; 95% CI = -0.779, -0.068).
  
  
  CONCLUSIONS
  A pharmacist-led diabetes collaborative care management program in a patient-centered primary care setting was associated with significantly better follow-up glycemic control relative to comparison patients. Further, the data suggest that the DCCM program was associated with a less substantial increase in all-cause total costs in patients with uncontrolled T2DM relative to comparison patients, which could translate into reduced costs and improved outcomes to managed care payers.
authors.affiliation: University of Utah, 30 S. 2000 E., Salt Lake City, UT 84112. carrie.mcadam-marx@pharm.utah.edu.
authors.forename: Carrie
authors.initials: C
authors.lastname: McAdam-Marx
authors.forename: Arati
authors.initials: A
authors.lastname: Dahal
authors.forename: Brandon
authors.initials: B
authors.lastname: Jennings
authors.forename: Mukul
authors.initials: M
authors.lastname: Singhal
authors.forename: Karen
authors.initials: K
authors.lastname: Gunning
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003299:Cooperative Behavior; D003924:Diabetes Mellitus, Type 2 / Q000191:economics / Q000628:therapy*; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000191:economics / Q000458:organization & administration; D054539:Medication Therapy Management / Q000191:economics / Q000458:organization & administration; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010593:Pharmaceutical Services / Q000191:economics / Q000458:organization & administration*; D010595:Pharmacists / Q000191:economics / Q000458:organization & administration; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*; D012189:Retrospective Studies; D055815:Young Adult