Implementation of a pharmacistrun telephonic insulin titration service
ABSTRACT OBJECTIVES To describe an insulin titration-by-phone service conducted by pharmacists and to discuss the effects of this service on patient care and outcomes in the first year of its existence. SETTING An academic family medicine department in which pharmacists practice in nondistributory roles, from March 2009 through March 2010. PRACTICE DESCRIPTION Pharmacy services within the department include a chronic disease medication therapy management clinic as well as consultation in various other primary care and specialty clinics. Fourth-year student pharmacists complete advanced pharmacy practice experiences at this site as well. PRACTICE INNOVATION Based upon a need identified by department providers (physicians and physician assistants), an insulin titration-by-phone service was implemented by two faculty pharmacists. Patients were referred into this service by their primary care provider (PCP) and were called by one of the pharmacists on a regular basis. Pharmacist recommendations for insulin dose adjustments were made based on patient reported self-monitored glucose values. PCP approved recommendations and the patient was notified of changes. MAIN OUTCOME MEASURE Decrease in glycosylated hemoglobin (A1C ) within 9 months of referral to the service when compared with baseline. RESULTS Analysis included 76 patients. The mean decrease in A1C was 1.55% (SD 2.31; P <0.001). The largest decrease in A1C (1.4%) was seen in the first 3 months after referral. Seven patients achieved an A1C ≤7% ( P = 0.007). Forty-one patients had a decrease in A1C of at least 1% during the first 9 months after their referral ( P <0.001). CONCLUSION The implementation of a pharmacist-run insulin titration-by-phone service resulted in improvements in A1C that were most pronounced in the first 3 months after referral.
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ABSTRACT: Patients on insulin glargine typically visit a clinician to obtain advice on how to adjust their insulin dose. These multiple clinic visits can be costly and time-consuming, particularly for low-income patients. It may be feasible to achieve insulin titration through text messages and phone calls with patients instead of face-to-face clinic visits. The objectives of this study are to (1) evaluate if the Mobile Insulin Titration Intervention (MITI) is clinically effective by helping patients reach their optimal dose of insulin glargine, (2) determine if the intervention is feasible within the setting and population, (3) assess patient satisfaction with the intervention, and (4) measure the costs associated with this intervention. This is a pilot study evaluating an approach to insulin titration using text messages and phone calls among patients with insulin-dependent type 2 diabetes in the outpatient medical clinic of Bellevue Hospital Center, a safety-net hospital in New York City. Patients will be randomized in a 1:1 ratio to either the MITI arm (texting/phone call intervention) or the usual-care arm (in-person clinic visits). Using a Web-based platform, weekday text messages will be sent to patients in the MITI arm, asking them to text back their fasting blood glucose values. In addition to daily reviews for alarm values, a clinician will rereview the texted values weekly, consult our physician-approved titration algorithm, and call the patients with advice on how to adjust their insulin dose. The primary outcome will be whether or not a patient reaches his/her optimal dose of insulin glargine within 12 weeks. Recruitment for this study occurred between June 2013 and December 2014. We are continuing to collect intervention and follow-up data from our patients who are currently enrolled. The results of our data analysis are expected to be available in 2015. This study explores the use of widely-available text messaging and voice technologies for insulin titration. We aim to show that remote insulin titration is clinically effective, feasible, satisfactory, and cost saving for low-income patients in a busy, urban clinic. Clinicaltrials.gov NCT01879579; http://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6WUEgjZUO).01/2015; 4(1):e31. DOI:10.2196/resprot.4206
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ABSTRACT: The telehealth insulin program (TIP) is an evidence-based approach to initiate and titrate insulin in a primary care practice. Outcomes show that TIP is effective and safe. This article describes how to initiate and titrate insulin using telehealth. Guidelines and protocols for primary care clinicians to start a telehealth program are included. With the rise in diabetes and expected increase in number of insured patients seeking primary care through the Affordable Care Act, nurse practitioners have the opportunity to support the nation’s challenge in diabetic care and be experts in insulin treatment.The Journal for Nurse Practitioners 09/2014; 10(8):567–574. DOI:10.1016/j.nurpra.2014.07.027