Impact of pharmacist-involved collaborative care on the clinical, humanistic and cost outcomes of high-risk patients with type 2 diabetes (IMPACT): a randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: With the increasing prevalence of diabetes, the physician-centred model is challenged to deliver holistic care in Asia. Diabetes may be managed effectively within a multidisciplinary collaborative care model; however, evidence on its effectiveness in Asian patients is lacking. Therefore, the primary objective was to evaluate the clinical outcomes of multidisciplinary collaborative care vs physician-centred care in diabetes. The secondary objectives were to evaluate humanistic and economic outcomes among the two types of care. METHODS: This 6-month prospective, open-label, parallel-arm, randomized, controlled study was conducted at four outpatient healthcare institutions. High-risk patients aged ≥21 years with uncontrolled type 2 diabetes, polypharmacy and comorbidities were included. Patients with type 1 diabetes or those who were unable to communicate independently were excluded. The control arm received usual care with referrals to nurses and dietitians as needed. The intervention arm (multidisciplinary collaborative care) was followed up with pharmacists regularly, in addition to receiving the usual care. The primary outcomes included HbA1c, systolic blood pressure, low-density lipoprotein and triglycerides. The secondary outcomes included scores from the Problem Areas in Diabetes (PAID) and the Diabetes Treatment Satisfaction Questionnaires (DTSQ), and diabetes-related health service utilization rates and costs. RESULTS AND DISCUSSION: Of 411 eligible patients, 214 and 197 patients were randomized into the intervention and control arms, respectively. At 6 months, 141 patients in the intervention arm (65.9%) and 189 patients in the control arm (95.9%) completed the study. Mean HbA1c reduced from 8.6%±1.5% at baseline to 8.1%±1.3% at 6 months in the intervention arm (P=.04), with up to mean HbA1c improvement of 0.8% in patients with greater levels of uncontrolled glycemia. Whereas the mean HbA1c in the control arm remained unchanged (8.5%±1.4%) throughout the 6-month period. Improvements in PAID and DTSQ scores, reduction in physician workload and an average cost savings of US$91.01 per patient were observed in the intervention arm over 6 months. WHAT IS NEW AND CONCLUSIONS: The positive clinical, humanistic and economic outcomes highlighted the value of multidisciplinary collaborative care for Asian diabetic patients, thereby supporting the effectiveness of this approach in managing chronic diseases.

Knowledge that upper respiratory tract infection resolves on its own is associated with more appropriate health-seeking behaviour and antibiotic cognition.

INTRODUCTION: This study aims to study whether knowledge that upper respiratory tract infection (URTI) resolves on its own is associated with more appropriate antibiotic cognition and treatment-seeking behaviour in adult patients seeking consultation for upper respiratory tract symptoms in all nine polyclinics of the National Healthcare Group in Singapore. METHODS: A prospective study of 595 adult patients who attended for URTI symptoms of less than seven days duration was performed. We collected data using an interviewer-administered structured questionnaire eliciting the participant's personal and demographical data, his knowledge about URTI, past experience with URTI and treatment-seeking behaviour for this current episode of URTI. These variables were then regressed against the variable "URTI resolves on its own", adjusting for "antibiotics relieve URTI faster", "antibiotic used unnecessarily for URTI", "recovery faster with antibiotics" for antibiotic cognition; and "number of days with URTI", "first line of action: self-medicate", "reason for attendance: felt unwell", "reason for attendance: get well faster" and "used prescribed medication before current visit" for health-seeking behaviour. RESULTS: More than one-third of patients believed that URTI resolved on its own. Subjects who believed that URTI resolved on its own were not significantly different in terms of gender, ethnic group, educational status, age, knowledge of germs as causal, and number of days sick before attendance. However, such patients were 1.68 times (confidence interval [CI] 1.17, 2.41) more likely to agree that, nowadays, antibiotics are used unnecessarily for "flu", and 2.07 times (CI 1.32, 3.24) more likely to self-medicate. They were 0.51 (CI 0.35, 0.76) times more likely to be dependant on prescribed medication. CONCLUSION: Knowledge that URTI resolves on its own is associated with more appropriate antibiotic cognition and health-seeking behaviour.

Stroke disease management--a framework for comprehensive stroke care.

Disease management is an approach to patient care that coordinates medical resources for the patient across the entire healthcare delivery system throughout the lifetime of the patient with the disease. Stroke is suitable for disease management as it is a well-known disease with a high prevalence, high cost, variable practice pattern, poor clinical outcome, and managed by a non-integrated healthcare system. It has measurable and actionable outcomes, with available local expertise and support of the Ministry of Health. Developing the programme requires a multidisciplinary team, baseline data on target populations and healthcare services, identification of core components, collaboration with key stakeholders, development of evidence-based clinical practice guidelines and carepaths, institution of care coordinators, use of information technology and continuous quality improvement to produce an effective plan. Core components include public education, risk factor screening and management, primary care and specialist clinics, acute stroke units, inpatient and outpatient rehabilitation facilities, and supportive community services including medical, nursing, therapy, home help and support groups for patients and carers. The family physician plays a key role. Coordination of services is best done by a network of hospital and community-based care managers, and is enhanced by a coordinating call centre. Continuous quality improvement is required, with audit of processes and outcomes, facilitated by a disease registry. Pitfalls include inappropriate exclusion of deserving patients, misuse, loss of physician and patient independence, over-estimation of benefits, and care fragmentation. Collaboration and cooperative among all parties will help ensure a successful and sustainable programme.