Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus

Study objective: To compare the effect of medication therapy management by a clinical pharmacy specialist who used the Care Coordination Home Telehealth (CCHT) program with the effect of medication therapy management by a clinical pharmacy specialist who did not use the CCHT program in a cohort of patients with poorly controlled type 2 diabetes mellitus.

Design: Nonrandomized, parallel, control group study.

Setting: Four outpatient primary care clinics within a Veterans Affairs health care system in which diabetes management services were provided by three clinical pharmacy specialists.

Patients: One hundred three patients with type 2 diabetes and a hemoglobin A(1c) (A1C) of greater than 7% who were receiving insulin therapy between October 1, 2008, and April 1, 2010; 36 patients were enrolled in the CCHT group, and 67 patients were in the non-CCHT group. Patients enrolled in the CCHT group were initially seen by a clinical pharmacy specialist and had two follow-up visits within a 6-month period. The CCHT program predominantly used a messaging device as a means of communication between providers and clinical pharmacy specialists and patients in the time intervals between their face-to-face visits. The clinical pharmacy specialist evaluated the transmitted data and made clinical decisions with respect to medication therapy management and diabetes management; a registered nurse communicated this information to the patients by telephone.

Measurements and main results: Data from medical records were reviewed for both groups. Baseline demographics were similar between the groups, with an initial A1C of 9% and 9.1% in the CCHT and non-CCHT groups, respectively (p=0.6201). The primary outcome was the change in A1C from baseline to 6 months. Secondary outcomes included the percentage of patients meeting American Diabetes Association (ADA) treatment goals for A1C, total amount of time spent/patient, and number of antidiabetic drug changes. A statistically significant difference in mean A1C was noted in the CCHT versus the non-CCHT group at 3 months (7.2% vs 8.0%, p=0.0002) and 6 months (6.9% vs 7.5%, p=0.0066); however, the mean reduction in A1C from baseline to 6 months was not significant between groups (p=0.1987). Sixty-nine percent of the CCHT group versus 36% in the non-CCHT group achieved the ADA A1C goal of less than 7% (p=0.0011). More time was spent (p<0.001) and more antidiabetic drug changes were made (p<0.0001) in the CCHT group.

Conclusion: Management of patients with diabetes who are receiving insulin may be optimized by clinical pharmacy specialist use of the CCHT program. Although no statistically significant difference was demonstrated with respect to change in A1C from baseline to 6 months, the CCHT group did show significantly greater differences than the non-CCHT group in A1C at 3 and 6 months, coupled with higher achievement of ADA A1C goals after 6 months.