These guidelines have been replaced by British Guideline on the Management of Asthma. A national clinical guideline. Superseded By 2012 Revision Of 2008 Guideline: British Guideline on the Management of Asthma. Thorax 2008 May; 63(Suppl 4): 1–121.

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British guideline on the management of asthma: A national clinical guideline

Diabetes self-management education (DSME) is a critical element of care for all people with diabetes and is necessary in order to improve patient outcomes. The National Standards for DSME are designed to define quality diabetes self-management education and to assist diabetes educators in a variety of settings to provide evidence-based education. Because of the dynamic nature of health care and diabetes-related research, these Standards are reviewed and revised approximately every 5 years by key organizations and federal agencies within the diabetes education community.

A Task Force was jointly convened by the American Association of Diabetes Educators and the American Diabetes Association in the summer of 2006. Additional organizations that were represented included the American Dietetic Association, the Veteran's Health Administration, the Centers for Disease Control and Prevention, the Indian Health Service, and the American Pharmaceutical Association. Members of the Task Force included a person with diabetes; several health services researchers/behaviorists, registered nurses, and registered dietitians; and a pharmacist.

The Task Force was charged with reviewing the current DSME standards for their appropriateness, relevance, and scientific basis. The Standards were then reviewed and revised based on the available evidence and expert consensus. The committee convened on 31 March 2006 and 9 September 2006, and the Standards were approved 25 March 2007.

Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.

Before the review of the individual Standards, the Task Force identified overriding principles based on existing evidence that would …

/pdf/national-standards-for-diabetes-self-management-education-2tec6l36is.pdf

National Standards for Diabetes Self-Management Education

CAROLÉ MENSING, RN, MA, CDE (TASK FORCE CHAIR) JACKIE BOUCHER, MS, RD, LD, CDE MARJORIE CYPRESS, MS, C-ANP, CDE KATIE WEINGER, EDD, RN KATHRYN MULCAHY, MSN, RN, CDE PATRICIA BARTA, RN, MPH, CDE GWEN HOSEY, MS, ARNP, CDE WENDY KOPHER, RN, C, CDE, HTP ANDREA LASICHAK, MS, RD, CDE BETTY LAMB, RN, MSN MAVOURNEEN MANGAN, RN, MS, ANP, C, CDE JAN NORMAN, RD, CDE JON TANJA, BS, MS, RPH LINDA YAUK, MS, RD, LD, CDE KIMBERLYDAWN WISDOM, MD, MS CYNTHIA ADAMS, PHD

By the most recent estimates, 18.8 million people in the U.S. have been diagnosed with diabetes and an additional 7 million are believed to be living with undiagnosed diabetes. At the same time, 79 million people are estimated to have blood glucose levels in the range of prediabetes or categories of increased risk for diabetes. Thus, more than 100 million Americans are at risk for developing the devastating complications of diabetes (1).

Diabetes self-management education (DSME) is a critical element of care for all people with diabetes and those at risk for developing the disease. It is necessary in order to prevent or delay the complications of diabetes (2–6) and has elements related to lifestyle changes that are also essential for individuals with prediabetes as part of efforts to prevent the disease (7,8). The National Standards for Diabetes Self-Management Education are designed to define quality DSME and support and to assist diabetes educators in providing evidence-based education and self-management support. The Standards are applicable to educators in solo practice as well as those in large multicenter programs—and everyone in between. There are many good models for the provision of diabetes education and support. The Standards do not endorse any one approach, but rather seek to delineate the commonalities among effective and excellent self-management education strategies. These are the standards used in the field for recognition and accreditation. They also serve as a guide for nonaccredited and nonrecognized providers and programs.

Because of the dynamic nature of health care and diabetes-related research, the Standards are reviewed and revised approximately every 5 years by key stakeholders and experts within the diabetes education community. In the fall of 2011, a Task Force was jointly convened by the American Association of Diabetes Educators (AADE) and the American Diabetes Association …

/pdf/national-standards-for-diabetes-self-management-education-45ru8y7m5n.pdf

National Standards for Diabetes Self-Management Education and Support

Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements—engaged leadership, data-driven improvement, empanelment, and team-based care—that assist the implementation of the other 6 building blocks—patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.

https://www.annfammed.org/content/annalsfm/12/2/166.full.pdf

The 10 Building Blocks of High-Performing Primary Care

Objective: To assess the persistence of outcomes for up to 5 years following the initiation of community-based pharmaceutical care services (PCS) for patients with diabetes. Design: Quasi-experimental, longitudinal pre−post cohort study. Setting: Twelve community pharmacies in Asheville, N.C. Patients and Other Participants: Patients with diabetes covered by self-insured employers’ health plans. Community pharmacists trained in a diabetes certificate program and reimbursed for PCS. Interventions: Education by certified diabetes educators, long-term community pharmacist follow-up using scheduled consultations, clinical assessment, goal setting, monitoring, and collaborative drug therapy management with physicians. Main Outcome Measures: Changes in glycosylated hemoglobin (A1c) and serum lipid concentrations and changes in diabetes-related and total medical utilization and costs over time. Results: Mean A1c decreased at all follow-ups, with more than 50% of patients demonstrating improvements at each time. The number of patients with optimal A1c values (< 7 %) also increased at each follow-up. More than 50% showed improvements in lipid levels at every measurement. Multivariate logistic regressions suggested that patients with higher baseline A1c values or higher baseline costs were most likely to improve or have lower costs, respectively. Costs shifted from inpatient and outpatient physician services to prescriptions, which increased significantly at every follow-up. Total mean direct medical costs decreased by $1,200 to $1,872 per patient per year compared with baseline. Days of sick time decreased every year (1997‐2001) for one employer group, with estimated increases in productivity estimated at $18,000 annually. Conclusion: Patients with diabetes who received ongoing PCS maintained improvement in A1c over time, and employers experienced a decline in mean total direct medical costs.

The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program.

RESEARCH Objective: Assess clinical and economic outcomes of a community-based, long- term medication therapy management (MTM) program for hypertension (HTN)/dys- lipidemia. Design: Quasi-experimental, longitudinal, pre-post study. Setting: 12 community and hospital pharmacy clinics in Asheville, N.C., over a 6-year period from 2000 through 2005. Participants: Patients covered by two self-insured health plans; educators at Mis- sion Hospitals; 18 certificate-trained pharmacists. Interventions: Cardiovascular or cerebrovascular (collectively abbreviated as CV) risk reduction education; regular, long-term follow-up by pharmacists (reimbursed by health plans) using scheduled consultations, monitoring, and recommendations to physicians. Main outcome measures: Clinical and economic parameters. Results: Sufficient data were available for 620 patients in the financial cohort and 565 patients in clinical cohort. Several indicators of cardiovascular health improved over the course of the study: mean systolic blood pressure, from 137.3 to 126.3 mm Hg; mean diastolic blood pressure, from 82.6 to 77.8 mm Hg; percentage of patients at blood pressure goal, from 40.2% to 67.4%; mean low-density lipoprotein (LDL) cholesterol, from 127.2 to 108.3 mg/dL; percentage of patients at LDL cholesterol goal, from 49.9% to 74.6%; mean total cholesterol, from 211.4 to 184.3 mg/dL; and mean serum triglycerides, from 192.8 to 154.4 mg/dL. Mean high-density lipoprotein (HDL) cholesterol decreased from 48 to 46.6 mg/dL. The CV event rate during the his- torical period, 77 per 1,000 person-years, declined by almost one-half (38 per 1,000 person-years) during the study period. Mean cost per CV event in the study period was $9,931, compared with $14,343 during the historical period. During the study period, CV medication use increased nearly threefold, but CV-related medical costs decreased by 46.5%. CV-related medical costs decreased from 30.6% of total health care costs to 19%. A 53% decrease in risk of a CV event and greater than 50% decrease in risk of a CV-related emergency department (ED)/hospital visit were also observed. Conclusion: Patients with HTN and/or dyslipidemia receiving education and long- term MTM services achieved significant clinical improvements that were sustained for as long as 6 years, a significant increase in the use of CV medications, and a decrease in CV events and related medical costs.

http://c.ymcdn.com/sites/www.chronicdisease.org/resource/resmgr/cvh/asheville_project_2008.pdf

The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia.

Objective: To assess clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program for 207 adult patients with asthma over 5 years. Design: Quasi-experimental, longitudinal pre‐post study. Setting: 12 pharmacy locations in Asheville, N.C. Patients/Other Participants: Patients with asthma covered by two selfinsured health plans; professional educator at Mission Hospitals; 18 certificatetrained community and hospital pharmacists. Interventions: Education by a certified asthma educator; regular long-term follow-up by pharmacists (reimbursed for MTM by health plans) using scheduled consultations, monitoring, and recommendations to physicians. Main Outcome Measures: Changes in forced expiratory volume in 1 second (FEV 1 ), asthma severity, symptom frequency, the degree to which asthma affected people’s lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time. Results: All objective and subjective measures of asthma control improved and were sustained for as long as 5 years. FEV 1 and severity classification improved significantly. The proportion of patients with asthma action plans increased from 63% to 99%. Patients with emergency department visits decreased from 9.9% to 1.3%, and hospitalizations from 4.0% to 1.9%. Spending on asthma medications increased; however, asthma-related medical claims decreased and total asthma-related costs were significantly lower than the projections based on the study population’s historical trends. Direct cost savings averaged $725/patient/year, and indirect cost savings were estimated to be $1,230/patient/year. Indirect costs due to missed/nonproductive workdays decreased from 10.8 days/year to 2.6 days/year. Patients were six times less likely to have an emergency department/hospitalization event after program interventions. Conclusion: Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.

http://drtedwilliams.net/cop/721/AshvilleAsthma.pdf

The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma.

Objective To assess the clinical and economic impact of a pharmacist-focused health management program for patients with depression. Design Prospective, nonrandomized, proof-of-concept investigation. Setting Asheville, NC, from July 2006 through December 2007. Participants Employees or adult dependents with depressive symptoms who agreed to enroll in an employer-sponsored treatment program conducted at two ambulatory clinics where consultative services were provided. Participants were included in the analysis if they participated in the program for at least 1 year and had two or more documented visits with a pharmacist. Intervention Outpatient-based pharmacists provided assessment, self-management services follow-up, and treatment recommendations to primary care providers within a collaborative care management model. Main outcome measures Changes in severity of depressive symptoms and impact on overall health care costs for employers and beneficiaries. Results Of the 151 beneficiaries referred to the program, 130 (82%) remained under pharmacist care for a minimum of 1 year and were included in the aggregate analysis. Statistically significant improvements were observed for Patient Health Questionnaire (PHQ)-9 scores from baseline to endpoint (11.5 ±  to 5.3 ±  [mean ± SD], P Conclusion Patients in the first year of the program had significant improvement in the PHQ-9 clinical indicator of depression severity. Total health care costs per patient per year were reduced compared with projected costs without the program. Employers expressed their appreciation for this collaborative care program and continued to offer this voluntary health benefit after the study's conclusion.

Clinical and economic outcomes of a pilot project examining pharmacist-focused collaborative care treatment for depression

Research into the impact of pharmaceutical care need not be complex, but it is difficult in real-world settings. Pharmaceutical care projects need a committed project manager, dedicated pharmacists, an involved payer, and patients who believe they have a problem that needs to be addressed. Significant differences in outcomes are more likely with some chronic diseases than with others. Adequate funding of pharmaceutical care studies is needed to support identification of drug-related problems and outcomes in larger numbers of patients and over longer time periods. Demonstrating changes in patient satisfaction with providers and in health-related quality of life is difficult.

https://www.japha.org/article/S1544-3191(15)31900-2/pdf

Barry A. Bunting

Papers

The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program.

The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia.

The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma.

Clinical and economic outcomes of a pilot project examining pharmacist-focused collaborative care treatment for depression

Studying pharmaceutical care: difficult but necessary.