Reducing economic burden through split-shared care model for people living with uncontrolled type 2 diabetes and polypharmacy: a multi-center randomized controlled trial.

BACKGROUND: Interprofessional collaborative care such as a split-shared care model involving family physicians and community pharmacists can reduce the economic burden of diabetes management. This study aimed to evaluate the economic outcome of a split-shared care model between family physicians and community pharmacists within a pharmacy chain in managing people with uncontrolled type 2 diabetes and polypharmacy. METHOD: This was a multi-center, parallel arm, open label, randomized controlled trial comparing the direct and indirect economic outcomes of people who received collaborative care involving community pharmacists (intervention) versus those who received usual care without community pharmacist involvement (control). People with uncontrolled type 2 diabetes, defined as HbA1c > 7.0% and taking ≥ 5 chronic medications were included while people with missing baseline economic data (such as consultation costs, medication costs) were excluded. Direct medical costs were extracted from the institution's financial database while indirect costs were calculated from self-reported gross income and productivity loss, using Work Productivity Activity Impairment Global Health questionnaire. Separate generalized linear models with log link function and gamma distribution were used to analyze changes in direct and indirect medical costs. RESULTS: A total of 175 patients (intervention = 70, control = 105) completed the trial and were included for analysis. The mean age of the participants was 66.9 (9.2) years, with majority being male and Chinese. The direct medical costs were significantly lower in the intervention than the control group over 6 months (intervention: -US$70.51, control: -US$47.66, p < 0.001). Medication cost was the main driver in both groups. There were no significant changes in productivity loss and indirect costs in both groups. CONCLUSION: Implementation of split-shared visits with frontline community partners may reduce economic burden for patient with uncontrolled type 2 diabetes and polypharmacy. TRIAL REGISTRATION: Clinicaltrials.gov Reference Number: NCT03531944 (Date of registration: June 6, 2018).

Enhancing diabetes care with community pharmacist-involved collaborative care model: A multi-centre randomised controlled trial.

AIM: To evaluate the clinical and humanistic outcomes of a community pharmacist-involved collaborative care model in diabetes management. METHODS: This was a parallel arm, open-label, multi-centre randomized controlled trial conducted over 6 months. Subjects with type 2 diabetes, HbA1c ≥ 7.0% (53 mmol/mol) and taking ≥ 5 medications were included. Participants were randomized into intervention (collaborative care) and control groups (physician-centric care). The intervention included medication therapy management and telephonic follow-up with visits to family physicians, nurses, and dietitians. Clinical outcomes included changes in HbA1c, systolic blood pressure (SBP), lipids, and hypoglycaemic incidences. Humanistic outcomes included self-care capabilities and quality of life. Linear mixed models were constructed. Intention-to-treat analyses, with sensitivity analyses, were conducted. RESULTS: A total of 264 participants were randomized (intervention: 131, control: 133). Significantly greater reduction in HbA1c was observed in the intervention group (intervention: -0.32% (-3.52 mmol/mol) vs. control: -0.06% (-0.66 mmol/mol), p = 0.038). Changes in SBP, lipids, and incidences of hypoglycaemia were not significant over 6 months between both groups. Significantly greater improvements in self-management (p < 0.001) and quality of life (p = 0.003) were observed within the intervention group. CONCLUSION: Partnering community pharmacists in a collaborative care team improved glycaemic control, quality of life and self-care capabilities of patients with diabetes and polypharmacy.

Long-term clinical and cost-effectiveness of collaborative care in people with uncontrolled type 2 diabetes mellitus and polypharmacy: A multicenter randomized controlled trial.

AIMS: This study examined the effectiveness of a collaborative care model on clinical and humanistic outcomes, medical cost, productivity loss, and its cost-effectiveness in managing uncontrolled Type 2 Diabetes Mellitus (T2DM). METHODS: A randomized controlled study was conducted in two outpatient health institutions in Singapore. Patients aged above 21 years with HbA1c > 7% and polypharmacy were included. Eligible patients were randomized into the intervention (collaborative care) and control (usual care) arms. RESULTS: A total of 255 patients were included in the analysis. Compared to the control arm, the intervention arm achieved significantly greater glycated hemoglobin (HbA1c) reduction (mean difference: 0.25, 95%CI: [0.001, 0.50], p = 0.049) and quality-adjusted life year (QALY) (+0.011, 95%CI: [0.003, 0.019], p = 0.011) at 12 months. The costs per additional HbA1c and QALY improvements over one year were $40.52 and $920.91 respectively. Activity impairment was lower in the intervention group both at 6 months (12.7% vs 19.0%; p = 0.022) and at 12 months (6.7% vs 14.0%; p = 0.008). CONCLUSIONS: The collaborative care model achieved earlier HbA1c reduction and reduced patients' activity impairment without decreasing work productivity or increasing medical costs. This intervention is cost-effective for improving glycemic control and quality of life in patients with T2DM.

Efficacy and Safety of Use of the Fasting Algorithm for Singaporeans With Type 2 Diabetes (FAST) During Ramadan: A Prospective, Multicenter, Randomized Controlled Trial.

PURPOSE: We aimed to evaluate the efficacy and safety of use of the Fasting Algorithm for Singaporeans with Type 2 Diabetes (FAST) during Ramadan. METHODS: We performed a prospective, multicenter, randomized controlled trial. The inclusion criteria were age ≥21 years, baseline glycated hemoglobin (HbA1c) level ≤9.5%, and intention to fast for ≥10 days during Ramadan. Exclusion criteria included baseline estimated glomerular filtration rate <30 mL/min, diabetes-related hospitalization, and short-term corticosteroid therapy. Participants were randomized to intervention (use of FAST) or control (usual care without FAST) groups. Efficacy outcomes were HbA1c level and fasting blood glucose and postprandial glucose changes, and the safety outcome was incidence of major or minor hypoglycemia during the Ramadan period. Glycemic variability and diabetes distress were also investigated. Linear mixed models were constructed to assess changes. RESULTS: A total of 97 participants were randomized (intervention: n = 46, control: n = 51). The HbA1c improvement during Ramadan was 4 times greater in the intervention group (-0.4%) than in the control group (-0.1%) (P = .049). The mean fasting blood glucose level decreased in the intervention group (-3.6 mg/dL) and increased in the control group (+20.9 mg/dL) (P = .034). The mean postprandial glucose level showed greater improvement in the intervention group (-16.4 mg/dL) compared to the control group (-2.3 mg/dL). There were more minor hypoglycemic events based on self-monitered blood glucose readings in the control group (intervention: 4, control: 6; P = .744). Glycemic variability was not significantly different between the 2 groups (P = .284). No between-group differences in diabetes distress were observed (P = .479). CONCLUSIONS: Our findings emphasize the importance of efficacious, safe, and culturally tailored epistemic tools for diabetes management.

Risk factors and quality of life of patients with high diabetes-related distress in primary care: a cross-sectional, multicenter study.

PURPOSE: This study aimed to examine risk factors and quality of life of patients with high diabetes-related distress (DRD) in primary care. METHODS: A cross-sectional, multicenter study was conducted in four primary healthcare institutions. Patients aged ≥ 21 years with T2DM were included; patients who were pregnant or unable to communicate independently were excluded from this study. The problem area in diabetes (PAID) measuring DRD, European quality of life-5 dimensions (EQ-5D), and audit of diabetes-dependent quality of life (ADDQoL) measuring quality of life were administered by trained research assistants. RESULTS: A total of 525 patients were eligible for this study. The mean PAID score was 26.90 ± 20.23, with 27.8% of patients reporting having high DRD (PAID score ≥ 40). Patients who were younger than 50 years (OR 4.577, 95% CI 1.977-10.600) and patients with HbA1c greater than 9% (OR 1.720, 95% CI 1.064-2.779) were at higher risk of having high DRD (p < 0.05). Patients with high DRD have a lower EQ-5D index value (B = - 0.141) and ADDQoL AWI (B = - 1.276) than patients with little/no DRD (p < 0.001). CONCLUSION: High DRD was more common among younger patients and patients with poorer glycemic control. High DRD was associated with poorer quality of life and early screening and management of DRD is recommended.

Development of a Collaborative Algorithm for the Management of Type 2 Diabetes during Ramadan: An Anchor on Empowerment.

Empowerment plays significant roles in the complex management of type 2 diabetes. International guidelines have provided recommendations on management of Muslims who fast during Ramadan. However, there remains a lack of patient-centered epistemic tool to empower healthcare providers and patients in managing diabetes during Ramadan. This study discussed the development and evaluation of such tool. The collaborative algorithm was developed with reference to the nominal group technique by a board-certified clinical pharmacist and discussed with endocrinologists, nurses, and family physicians. The empowerment component of the algorithm was developed based on the Basic Psychological Needs Theory. The algorithm was evaluated through a randomized controlled trial. Glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and postprandial glucose (PPG) levels and safety profiles in terms of hypoglycemic events were assessed. The collaborative algorithm was developed with four components: screening, education, dose modification by healthcare provider, and dose adjustment by patient. A total of 62 individuals were recruited, with 30 and 32 randomized into the intervention and control groups, respectively. The mean age was 58.4 years, with majority being females (67.7%). There was a reduction in mean HbA1c from 7.9% ± 0.9% to 7.5% ± 0.8% (P < 0.001) in the intervention group, while no significant difference was observed in the control group (P = 0.270). FPG (P < 0.001) and PPG (P = 0.002) also improved significantly in the intervention group. There were no major hypoglycemic events and minor hypoglycemia comparable between both groups (P = 0.465). The collaborative algorithm incorporated empowerment and promoted shared decision-making in diabetes management, hence promoting safe and effective fasting.

Feasibility and acceptability of the informant AD8 for cognitive screening in primary healthcare: a pilot study.

OBJECTIVES: The utility of informant AD8 for case finding of cognitive impairment at primary healthcare settings is unknown and therefore its feasibility and acceptability for targeted screening at a primary healthcare clinic should be investigated. METHODS: The informants of older adult patients attending a primary healthcare clinic in Singapore were administered the AD8. Positive screening findings were provided to patients' primary care physicians for referrals to specialist memory clinics. The acceptability of AD8 was evaluated by collecting feedbacks from the informants and primary care physicians. RESULTS: 205 patients and their informants were recruited. However, 6 (2.9%) informants were uncontactable, while the majority of the remaining 199 patients with completed AD8 (96.5%, n=192) found it acceptable where 59 (29.6%) patients were deemed cognitively impaired (AD8≥2). Clinicians (100%, n=5) found the AD8 helpful in facilitating referrals to memory clinics. However, most referral recommendations (81.4%, n=48) were declined by patients and/or informant due to limited insight of implications of cognitive impairment. CONCLUSIONS: The AD8 can be easily administered and is well tolerated. It detected cognitive impairment in one-third of older adult patients and therefore may be useful for case finding of cognitive impairment in the primary healthcare.