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Pharmacists: The Missing Link In Diabetes Management?

Posted: Friday, February 13, 2004

Pharmacist Sandra Leal, working under a recently awarded state certification and an agreed-upon protocol, can independently order drugs, dosage adjustments and lab tests for patients referred to her by El Rio doctors.

She is the first pharmacist in the state certified by the Arizona Board of Pharmacy to have collaborative prescribing authority. What it means is that doctors who agree to an overall treatment plan for a diabetic patient can delegate prescribing authority to Leal.

As of June, 43 states grant pharmacists some degree of prescribing authority in programs that focus on managing chronic disease such as diabetes, asthma, arthritis, hypertension and coronary heart disease. Each state is different, but laws generally limit the authority to specific drugs or to drugs for the specific condition in which the pharmacist has specialized knowledge.

The Arizona Legislature in a bill passed in 2000 allowed for such an increased role for pharmacists in institutional settings who go through a certification process.

Hal Wand, executive director of the state pharmacy board, said there have been three applicants for certification, including Leal. He said the requirements are rigorous.

"She's the only one that has survived the process. The other people are close. ... For her to be the first one in the state is quite a compliment," Wand said.

In addition to having a doctorate in pharmacy, Leal is certified by the National Certification Board of Diabetes Educators as a diabetes educator. She also had to submit to the board a protocol specific to the El Rio program.

In many of the first 452 patients referred to Leal, glucose levels, cholesterol counts and blood pressure readings that started at four to five times normal have been reduced to normal or near-normal levels. For one key reading, an A1C test that measures a patient's average blood sugar level for a two- to three-month period, the mean reading for patients in the clinic has dropped from a poor 9.6 percent when they started to a slightly above normal 7.4 percent after entering the program.

The numbers are remarkable, considering that Leal's patients had not previously been able to control their disease.

"I've seen excellent improvements," said Dr. Linda Williams, an El Rio primary care doctor.

Leal has run the center's pharmacy-based diabetes-management program since August 2001. Before her special certification, Leal could order the drugs she felt necessary but had to get a doctor's co-signature on every prescription. Her prescriptions are still written under a physician's authority, but the doctor doesn't need to review or sign the prescriptions.

Leal said pharmacy-based disease-management programs are a growing trend around the country. The El Rio program started under a federal grant to prove the value of such programs for various diseases. El Rio has submitted the results to a major medical journal, and the federal government recently extended the grant for 2004.

Leal said the hope is that Medicare will start paying for the additional services of clinical pharmacists and the program will pay for itself.

She said El Rio chose to specialize in diabetes because 76 percent of its patients are Hispanic, and 13 percent are Native American. Both are groups in which diabetes runs rampant. El Rio has 4,000 diabetes patients.

Mortality data show American Indians have the highest death rate due to diabetes in the state - 75 deaths per 100,000 people - and Hispanics have a rate of 41 deaths per 100,000 people. In comparison, the rate for all Arizonans is 19 per 100,000.

Leal said patients benefit not only from her specialized knowledge but from the intensive care she can give them.

Source: Diabetes In Control.com.