Role of Medication Adherence in Diabetes Treatment by Mid-Level Clinicians - Abstract
Purpose: To determine whether and how diabetes-trained mid-level clinicians (2 nurse practitioners and a physician assistant) could effectively improve HbA1c levels in poorly controlled, minority patients. Patients and Methods: In a retrospective, observational study using de-identified data (therefore not requiring IRB approval), 96 patients fulfilled the inclusion criteria of initial Hb A1c levels ?64 mmol/mol (8.0%), at least 2 visits and 2 HbA1c tests and not documented as non-adherent when treated. The primary outcome was the change in HbA1c levels from baseline. The secondary outcome was the proportion of patients in 1% HbA1c ranges from <53 mmol/mol (7.0%) to >97 mmol/mol (11.0%), both outcomes compared between initial and final visits. Results: Patients were treated for a mean of 7 months before the Covid-19 pandemic stopped in-person visits. Baseline HbA1c levels (mmol/mol) measured at referral fell from 97 mmol/mol (11.0% ± 1.8 [SD]) to 68 mmol/mol (8.4% ± 1.8 [P <10-21]). Treatment intensification did not occur, strongly suggesting that increased medication adherence was mainly responsible. At the last visit, 96% of patients met the American Diabetes Association’s blood pressure target of <140/90 mm Hg and 57% the LDL cholesterol target of <2.6 mmol/L (100 mg/dl). Conclusion: These culturally competent mid-level clinicians (2 African-Americans and one Latino), were better able to engage patients which greatly improved their medication adherence. Busy primary care practices should consider supporting diabetes-trained mid-level clinicians to interact with all patients with diabetes at important treatment junctures (not just the limited number assigned to them for total care). An added benefit for practices serving a minority, population would be culturally competent mid-level clinicians.