Valentina B Petkova
Guenka I Petrova
Department of Social Pharmacy
Faculty of Pharmacy
Medical University of Sofia
Diabetes is a rapidly growing disease with obvious clinical, social and economic impact.(1,2) Incidence of both type 1 and type 2 diabetes has been rising around the world, but type 2 diabetes is considered the more common form. It is estimated that during the period 2000-2030, the number of people with diabetes in the former socialist economies – including Bulgaria – will rise by some 20%.(3) The most significant global challenges regarding type 2 diabetes mellitus management are: underdiagnosis; the need for regular follow-up care; and support for appropriate patient self-management. Statistics indicate that the prevalence of preventive-care practices is suboptimal, and compliance with national health recommendations is poor. In some countries – Bulgaria included- only a minority of diabetic patients receive proper treatment and education on self-monitoring.(4,5) This is because the input into educational programmes that is required from healthcare providers – in terms of considerable amounts of time, specific training, financial support and communication skills – is frequently insufficient. The lack of educational resources for diabetes patients is critical in Bulgaria, where the costs of diabetes treatment arise mainly from complications of the disease.(6,7)
The role of pharmacists in patient education
Pharmacists would seem to be the healthcare professionals best placed to improve the self-care management of people with diabetes – via a range of activities, including collecting patient information, conducting drug regimen reviews, counselling patients, providing consultations with doctors regarding prescribed drug therapy and monitoring patients’ treatment process.(8-10) Pharmacists are often the first point of contact for people with the disease, and this can lead to provision of advice on self-treatment and best use of prescribed medicines.(11) Studies have shown that community pharmacies can provide patients with easy access to pharmacists, with consultations being free of charge.(10,12)
Given these facts, we set out to find an educational programme suitable for implementation (with adaptation) in community pharmacies in Bulgaria, which could easily be applied by pharmacists after a short training period, and then used to evaluate this programme’s effect on clinical, therapeutic and economic outcomes. After investigating several diabetes patient education programmes offered by various medical care providers, we chose one promoted by Novo Nordisk for physicians and nurses that had been successfully implemented in several central and eastern European countries, including Poland, the Czech Republic, Russia, Hungary, Slovakia and Slovenia.
As stated, we aimed to adapt the programme and test its applicability in the community pharmacy context. Finding enough volunteers to participate presented some problems, because not all patients satisfied the criteria for inclusion:
- Having type 2 diabetes, but without severe complications such as retinopathy or nephropathy.
- Being prepared to invest time in receiving additional information about their disease.
In the end the course was presented to 24 ambulatory patients, as a pilot stage. Optimum conditions for allowing good interaction between patients and pharmacists were specified. Personal data for each patient covered duration of the disease, prescribed drug treatment and frequency of hypoglycaemic and hyperglycaemic incidents. At the beginning and end of the project a WHO patient satisfaction questionnaire was utilised to assess changes in patients’ quality of life before and after application of the programme. The optimal duration of an individual project was six months, with each project including five-month teaching units providing general coverage of: type 2 diabetes and the need for self-monitoring; the effect on insulin sensitivity of obesity and the advantages of weight reduction; foot care; diabetic eye diseases (including diabetic retinopathy, cataract and glaucoma); and possible adverse drug reactions during treatment. Each patient received instruction on these diabetic complications, and a practicum was performed where necessary so as to allow maximum application of the newly acquired knowledge. At the end of each session patients received written materials on the subjects discussed. Pharmacy students at the end of the initial stage of training were used as educators. During the lifetime of the project significant metabolic and behavioural changes were observed: blood glucose levels reported for all patients decreased from 8.0â€‰-â€‰1.95â€‰â€‰mmol/l to 7.2â€‰-â€‰0.99â€‰mmol/l (pâ€‰<â€‰0.05), while patient records indicated that the number of hypoglycaemic and/or hyperglycaemic incidents requiring check-up fell to 0%. Quality of life assessment indicated an average of 5% improvement on the five main indices.
The cost of six months’ education was about e6 per patient – the minimal possible cost of such a programme. The cost-effectiveness ratio, calculated on the basis of per-patient decrease in blood glucose level, was e7.50 per intermediate clinical outcome (e6 per 0.8â€‰mmol/l). Given that the project’s duration was only six months, long-term clinical outcomes could not be observed. However, the achievement of steady decreases in blood glucose levels and hypoglycaemic incidents, as well as increases in overall quality of life, suggested that programmes such as these would indeed be worthwhile.(13)
The results of this study support evidence elsewhere in the literature to the effect that education of patients with type 2 diabetes can be cost-effective and cost-beneficial, and that such education can be performed by pharmacists.(8,10,14) Frequent contact with patients provides pharmacists with opportunities to increase patients’ knowledge and understanding about their diabetes, reduce complications related to adverse drug reactions, and achieve desired therapeutic outcomes. This will also boost pharmacists’ recognition as qualified healthcare providers.(15)
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- Wild S, Roglic G, Green A., et al. Global prevalence of diabetes estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27;5:1047-53.
- Gagliardino JJ, Etchegoyen G. A model educational program for people with type 2 diabetes. Diabetes Care 2001;24:1001-7.
- Miller CK, Edwards L, Kissling G, Sanville L. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: results from a randomized controlled trial. Prev Med 2002;34:252-9.
- NHIF. Country strategy for diabetes treatment and prevention, Ministry of Health/National Health Insurance Fund, Sofia, Bulgaria. January 2003. Available from: http://www.nhif.bg
- International Diabetes Federation. Regional overview of care, education and program for action. Brussels: IDF; 2005. Available from: http://www.idf.org/e-atlas/home/index.cfm?node84
- Farris KB, Kirking DM. Assessing the quality of pharmaceutical care, II: application of concepts of quality assessment from medical care. Ann Pharmacother 1993;27:215-22.
- Truter DI. An investigation into antidiabetic medication prescribing in South Africa. J Clin Pharm Ther 1998;23:417-22.
- Abduelkarem AR, Sackville MA, Morgan RM, Hildreth AJ. An assessment of the level of type 2 diabetes patients’ satisfaction with community pharmacists’ services. Pharm J 2003;270:446-9.
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- Jaber LA, Halapy H, Fernet M, et al. Evaluation of a pharmaceutical care model on diabetes management. Ann Pharmacother 1996;30:238-43.
- Petkova VB, Petrova GI. Pilot project for education of patients with type 2 diabetes by pharmacists. Acta Diabetol 2006;43(2):37-42.
- Loveman E, Cave C, Green C, et al. The clinical and cost-effectiveness of patient education models for diabetes: a systematic review and economic evaluation. Health Technology Assessment 2003;22:201. Available from: http://www.ncchta.org
- Hawkins D, Bradberry Ch, Cziraky M, et al. National Pharmacy Cardiovascular Council treatment guidelines for the management of type 2 diabetes mellitus: toward better patient outcomes and new roles for pharmacists. Pharmacotherapy 2002;22(4):436-44.