Diabetes Medication Assistance Service: The pharmacist's role in supporting patient self-management of type 2 diabetes (T2DM) in Australia

Abstract

Objective

To evaluate the capacity and effectiveness of trained community pharmacists in delivering the Diabetes Medication Assistance Service (DMAS) via (1) number and types of self-management support interventions (SMSIs); (2) number of goals set and attained by patients and (3) patient outcomes (glycaemic control, medication adherence and satisfaction).

Methods

Pharmacists (n = 109) from 90 community pharmacies in Australia were trained and credentialed to deliver the DMAS. The training focused on developing pharmacists’ knowledge and skills in supporting patients’ diabetes self-management.

Results

A total of 387 patients completed the trial. The mean number of SMSIs per patient was 35 (SD ±31) and the majority (87%) had at least one documented goal that was fully or partially attained. There were significant health benefits for patients including improved glycaemic control and a reduced risk of non-adherence to medications. Over 90% of DMAS patients reported improvements in their knowledge about diabetes self-management.

Conclusion

The DMAS provides self management support in the community pharmacy for people with T2DM which may result in improved clinical outcomes.

Practice implication

Given appropriate training in diabetes care and behavior change strategies, community pharmacists can offer programs which provide self-management support to their patients with T2DM and improve their health outcomes.

Introduction

Worldwide, type 2 diabetes mellitus (T2DM) has been described as a major epidemic which imposes a huge cost burden on families, communities and health care systems. In Australia, according to recent national estimates, 7.2% of the population have T2DM [1], half of whom have not yet been diagnosed [2]. The prevalence is expected to escalate in line with the continuing rise of risk factors that contribute to the development of T2DM. There is now conclusive evidence that intensive glycaemic control can reduce the risk and delay the onset of complications, and therefore improve the overall quality of life for people with T2DM [3], [4], [5], [6], [7]. However, the achievement of strict glycaemic control is highly dependent on the extent to which an individual is able to self-manage their condition. Successful self-management of T2DM requires individuals to engage in various cognitive and behavioural processes on a daily basis to maintain blood glucose levels within the normal range, including lifestyle modifications, adherence to medications, self-monitoring of blood glucose (SMBG) and regular visits to health care professionals (HCPs). For many people with T2DM, self-management is challenging as they do not possess adequate knowledge, skills and motivation to initiate and maintain behavioural changes to help them control their illness [8], [9], [10].

A critical strategy to address this is to educate HCPs to empower patients to be proactive in the self-management of their condition. The use of motivational interviewing and collaborative goal setting to facilitate self-management support interventions (SMSIs) delivered by HCPs, has been shown to improve health outcomes for a range of chronic diseases including T2DM [11], [12], [13], [14], [15]. Motivational interviewing is a patient centered counseling approach designed to enhance the patient's intrinsic motivation for behavior change [16]. It is based on exploring patient beliefs about perceived difficulties in changing their behavior. The collaborative goal setting technique involves the negotiation and setting of small, achievable and specific goals by patients with the assistance of their HCP to address their most pressing problems. Each goal is supported by a strategy designed to help the patient achieve those goals. The attainment of behavior change is optimized through the patient's personal investment in this process.

The positive effects of goal setting in changing behavior may be explained by the self-efficacy theory [17] which suggests that successful goal attainment enhances self-efficacy by motivating the patient to set and pursue future goals [18] and increases resilience when faced with barriers in goal pursuit [19]. The goal setting technique has been recognised by the American Diabetes Association to be a key component of diabetes self-management education programs [20].

Community pharmacies provide easily accessible HCPs for ongoing self-management support of chronic conditions such as asthma [21] and T2DM [22]. However, the training of pharmacists in behavior change strategies and evaluation of their application in patients with T2DM has not been previously reported. A recent trial, the Diabetes Pilot Program, funded by the Australian Government Department of Health and Ageing as part of the Fourth Community Pharmacy Agreement, involved the development of a training program to prepare pharmacists to deliver the Diabetes Medication Assistance Service (DMAS), a care cycle of assessment, counseling, education and review for people with T2DM, provided at regular intervals at the pharmacy over a 6 month period.

The aim of this study was to evaluate (1) the impact of pharmacist training on the process of service delivery via the number and types of self-management support interventions (SMSIs) delivered by the DMAS pharmacists; (2) the impact of DMAS on patient self-management behaviours via the number and types of goals set and subsequently attained by patients; and (3) the impact of the DMAS on patients’ outcomes including mean blood glucose levels, medication adherence and patient satisfaction with the service.