Innovative Diabetes Professional Care Services and Management – Chemistworks Wetherill Park
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder categorised by the progressive failure of insulin secretion and increasing resistance of body tissues to insulin, resulting in high blood glucose levels (hyperglycaemia).1
The estimated prevalence of diagnosed T2DM increased from 1.5% in 1989/1990 to 4.4% in 2014/2015.2,3 There are approximately 1.2 million Australians with diagnosed T2DM with an estimated further 500,000 with undiagnosed T2DM.4,5
Almost one in six Australian adults over the age of 25 years are affected by pre-diabetes.6 Community pharmacy provides an ideal setting and support mechanism for T2DM screening. This includes care and management in testing while maintaining capillary blood glucose and glycosylated haemoglobin (HbA1c) levels. Point of Care testing (POCT) and analysis outside a laboratory is becoming more common in pharmacy. The advantages of POCT extend to the accessibility, convenience, cost effectiveness, validity and accuracy of the respective analysis tool/s employed.
Tony Golshani is the Pharmacy Manager at Chemistworks Wetherill Park, Sydney. Mr Golshani is a primary care credentialed diabetes educator (CDE), managing a diabetes clinic within a busy community pharmacy setting. He reports improved patient health outcomes, adherence, self-management and confidence through patient participation in the clinic’s comprehensive program.
Further, he outlines the role of the clinic and patient engagement, including point-of-care testing.
‘Diabetes is a major health concern in the local area. Wetherill Park rates in the Top 10 in NSW for individuals who have T2DM. We decided to establish a clinic and assemble a multidisciplinary team. We have access to a dietitian, exercise physiologist and a diabetes educator. This extends to the use of a patient’s healthcare plan available through their doctor,’ Mr Golshani outlined.
‘One-on-one individual consults and group education sessions provide a valuable platform to educate patients. We are strong advocates in providing patients with information and enabling them to make more informed decisions regarding their health,’ he continued.
The clinic has developed a multidisciplinary approach and cooperation between the patient’s doctor and allied health service providers, strengthening as it has developed.
‘A patient generally presents at the dispensary counter. We have a dispensing process, including a questionnaire — similar to The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK).
‘The clinic maintains ongoing follow-up, facilitating a structured referral process as required. This has been effective: telephoning the patient, introducing the clinician/s, outlining the services, all the while liaising with the doctor to ensure communication between clinic, patient and doctor is maintained.
‘The value of POCT testing is important for the clinic and patient alike. We continually monitor HbA1c levels. With the multidisciplinary approach of our program, we are confident in seeing improvements in these levels,’ Mr Golshani said.
On average, the clinic reports a 1% reduction in HbA1c levels by patients. Encouragingly, some patients have reduced levels by over 3% across a 3-month period. The point-of-care testing, in combination with the strategies of patient adoption, including weight reduction, is showing measurable results. For patients who return to their doctor and are asked to re-run the HbA1c test in a pathology laboratory, the accuracy of results is reported as almost identical to those provided in the Chemistworks clinic.
The consideration of an appropriate analyser is important within the clinic environment, as there has previously been a restriction to testing in a pathology laboratory only.
‘The analyser we use, Afinion, is laboratory standard — it’s of a clinical quality in point-of-care testing, while being offered conveniently in a clinic setting,’ Mr Golshani stated.
The success of the program is evident with over 250 patients participating in the program to date. The program’s duration is 3 months with multiple touch points throughout.
‘We invite patients to the clinic, as CDE and ancillary practitioners are accessible within one location. At their first consultation, the patient is provided with a schedule of each of their appointments for the duration of the program. Everything is automated and the patient receives a text the day before their appointment,’ he said.
‘The program has multiple touch points. For eight weeks, we see them on a weekly basis as the group sessions are conducted. Further, there are one-on-one reviews with a dietician, exercise physiologist and the CDE,’ Mr Golshani added.
After eight weeks, the clinic allocates a further month to self-management. The information and results are uploaded, and the results are measured against the strategies as they are implemented.
‘At the end of the month they return and see me and I offer to run the bloods again to demonstrate the improvement. I take the waist circumference, the hip circumference and the body weight,’ Mr Golshani outlined.
For patients enrolling in the program, who have T2DM, there is no out-of-pocket expense.
‘As a disclaimer, if they require their HbA1c level test pre- and post-program, there’s a cost associated with that and the total visits. But we reinforce that’s up to the patient. With regards to the one-on-one appointments with practitioners and the group education sessions, they’re covered for patients with type 2 diabetes,’ he advised.
In real case study terms, the results and success of the program are conclusive, and the future of the clinic is bright.
‘With regard to outcomes, on average, patients register 7.5 centimetres off their waistline after three months. As a result, their HbA1c levels drop on average over 1%,’ he said.
Tony added that for some patients, there has been a reduction of over 3%. Some patients have lost over 20 centimetres off their waist circumference.
‘One such example stands out amongst many. I had a patient with chronic pain and as she started the program, her HbA1c test levels were 9.6% and triglycerides were recorded at 2.74 mmol. This is one of the key measurements we look at. As she began the program, her waist circumference was 123 centimetres, and total body weight was 111.1 kilograms.
‘When I reassessed three months later, her waist circumference had dropped to 118 centimetres, total body weight was 107.4 kilograms and the HbA1c had reduced to 5.9%. This meant she had completely reversed her T2DM, as Type 2 Diabetes indicates a HbA1c of 6.5% or greater and 5.7% to 6.4% in pre-diabetes,’ Mr Golshani outlined.
So, how can community pharmacy increase the focus on diabetes care as part of an innovative professional services program?
‘Well, I think there’s a big opportunity for community pharmacy. We see patients in our pharmacy, on average, 12 to 14 times. Conversely, a doctor sees a patient, on average, one or two times a year. So, there’s multiple and regular touch points that you can have with the patient to discuss their diabetes management plan.
‘Community pharmacy is non-confrontational, accessible and we are always available for a chat. So, it provides an opportunity to engage a multidisciplinary team, in a non-invasive and non-threatening setting. Ease of parking is also a consideration — it’s a lot easier for patients to visit one location and receive our help,’ Mr Golshani concluded.
- Kahn SE, Cooper ME, Del Prato S. Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future. Lancet2014; 383:1068–83. 10.1016/S0140-6736(13)62154-6
- Australian Institute of Health and Welfare. Cardiovascular disease, diabetes and chronic kidney disease: Australian facts: prevalence and incidence. In Cardiovascular, diabetes and chronic kidney disease. Series no 2. Canberra, Australia: Australian Institute of Health and Welfare, 2014
- Australian Bureau of Statistics. National Health Survey Australia 2014–2015. Canberra, Australia: Australian Bureau of Statistics
- Diabetes Australia. Diabetes in Australia. 2017. https://www.diabetesaustralia.com.au/diabetes-in-australia
- International Diabetes Federation. The IDF Diabetes Atlas. 7th Edition, 2015.http://www.diabetesatlas.org/resources/2015-atlas.html
- Baker IDI Heart and Diabetes Institute. Diabetes: the silent pandemic and its impact on Australia. Melbourne, Australia: Baker IDI in partnership with Diabetes Australia and Juvenile Diabetes Research Foundation, 2012.