Effects of a Community Pharmacist-Based Diabetes Patient-Management Program on Intermediate Clinical Outcome Measures

Transcription

1 RESEARCH Effects of a Community Pharmacist-Based Diabetes Patient-Management Program on Intermediate Clinical Outcome Measures OBJECTIVES: Evaluate a community pharmacist-based diabetes patient-management program by examining the pharmacists impact on five intermediate outcomes: glycosolated hemoglobin (HbA1c), blood pressure, body mass index, lipid levels, and medication use in patients with diabetes. SETTING: A network of community pharmacies in West Virginia and southeastern Ohio. PATIENTS: The program was available to all patients with diabetes who attended the network pharmacies regardless of baseline glycemic control. Of the 47 patients initially enrolled, 32 stayed in the program for at least 6 months during the year-long study (median time in program was 9 months). INTERVENTION: Pharmacists provided a basic, standardized diabetes education program during three 1-hour sessions. This was accompanied by a clinical assessment and a report to the patient s primary care physician. The patients met with the pharmacist every 3 months for continued monitoring. After each visit, the patient s primary care physician was sent a report along with recommendations for drug therapy modification when appropriate. MAIN OUTCOME MEASURES: HbA1c, blood pressure, total cholesterol, lowdensity lipoproteins (LDL), high-density lipoproteins (HDL), triglycerides, body mass index, and the number of drug therapy modifications. RESULTS: There was significant improvement in total cholesterol (t= 2.58, p=0.015) and LDL (t= 2.56, p=0.017) for the 32 participating patients. HbA1c, BMI, blood pressure, HDL and triglycerides did not change significantly across all patients. For a subgroup of 10 patients with baseline HbA1c>8%, average HbA1c declined significantly from 9.8% to 8.6% (t= 3.00, p=0.015). During the study, the 32 patients had a total of 53 modifications to their medication regimens. The most common was a change in dose of oral diabetes medications. CONCLUSIONS: The pharmacist-based diabetes patient-management program was associated with improvements in total cholesterol and LDL across all patients who maintained enrollment in the program for at least 6 months. Improvements in HbA1c were also demonstrated for a subgroup of patients who had poor glycemic control at baseline. KEYWORDS: Diabetes, Disease Management, Pharmaceutical Care J Managed Care Pharm 2001: DAVID P. NAU, R.PH., PH.D.,* is Assistant Professor, College of Pharmacy, University of Michigan, Ann Arbor, Michigan; CHARLES D. PONTE, PHARM.D., CDE, BCPS, FASHP, FCCP, FAPHA, is Professor, Departments of Clinical Pharmacy and Family Medicine, West Virginia University, Morgantown, West Virginia ADDRESS CORRESPONDENCE: David Nau, College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI, ; Tel: (734) ; Fax: (734) ; dnau@umich.edu * At the time of this study, Dr. Nau was an Assistant Professor, West Virginia University School of Pharmacy. This study was funded in part by The Health Plan of the Upper Ohio Valley, The National Community Pharmacists Association Foundation, Hoerchst-Marion Roussel (now Aventis), and Bristol-Myers Squibb. The authors thank Joshua Blevins for assistance with data collection and the pharmacists of OVPCN who participated in this project (John Bernabei, Roger Cole, Aldo Cristante, Bob Gelner, Mike Kacsmar, Joe Jefferies, and Adele Storm). Copyright 2002 Academy of Managed Care Pharmacy, Inc. All rights reserved. by David P. Nau and Charles D. Ponte Disease management programs for diabetes have become increasingly common. This is likely due to the high costs of diabetes complications, which lead to health plans spending up to four times as much on the care of persons with diabetes compared to the general population. 1 Many of these higher costs are associated with the management of the complications of diabetes, such as myocardial infarction (MI) which is estimated to cost $27,630 per event or end-stage renal disease (ESRD) which is estimated to cost $53,659 per year. 2,3 However, the American Diabetes Association (ADA) estimates that the complications of diabetes could be reduced dramatically if patients maintained adequate control of their diabetes. Results from the Diabetes Control and Complications Trial (DCCT) suggest that intensive treatment and monitoring for persons with Type 1 diabetes could lead to substantial reductions in the risk of retinopathy, nephropathy, neuropathy, dyslipidemia, and cardiovascular disease. 4 Likewise, the United Kingdom Prospective Diabetes Study (UKPDS) found that intensive glycemic control of persons with Type 2 diabetes can reduce the overall rate of microvascular complications by approximately 25%. However, the rate of macrovascular complications (e.g., fatal and nonfatal myocardial infarction and sudden death) was not significantly affected by tight glycemic control. 5 Unfortunately, many persons with diabetes fail to receive education about diabetes and many do not receive or selfadminister the recommended frequency of tests to monitor their disease. 6,7,8 The National Committee for Quality Assurance (NCQA) HEDIS (Healthcare Employer Data and Information Set) indicators for diabetes were expanded in The new Comprehensive Diabetes Care indicator set estimates the percentage of health plan members, 18 to 75 years old, with Type 1 and Type 2 diabetes who during the measurement year: (1) received a glycosylated hemoglobin (HbA1c) test; (2) had poorly controlled HbA1c (HbA1c >9.5%); (3) received a cholesterol (LDL-c) test; (4) had an LDL-c level less than 130mg/dl; (5) received a microalbumin test; or (6) received a dilated eye exam. 9 As a result, many managed care organizations have increased their focus on the quality of care for members with diabetes and have 48 Journal of Managed Care Pharmacy JMCP January/February 2002 Vol. 8, No. 1

2 developed disease management programs that rely heavily on non-physician providers of care. Several studies have shown that disease management services are effective in improving the quality of care for persons with diabetes. 10,11,12 An increasing number of disease management programs utilize pharmacists to assist in the monitoring and management of patients with diabetes. The VA Medical Center in Pittsburgh found that persons with Type 2 diabetes who were enrolled in its pharmacist-based program experienced significant improvements in glycemic control within 6 months. 13 After adjusting for the costs of the program, it was estimated that the net savings to the VA Medical Center for 15 of the most severely ill patients was more than $103,000 per year. In 1997, Fincham and Lofholm evaluated community pharmacists diabetes-related interventions and estimated the one-time cost-savings from the prevention of hospitalizations or unnecessary office visits were $4,295 per patient. 14 A network of community pharmacists saved the city of Asheville, North Carolina, more than $900 per patient per year on diabetes care, while several other authors have reported the positive impact of pharmacist-based services on glycemic control Nonetheless, managed care organizations have not yet fully utilized community pharmacists to improve the quality of diabetes care. Diabetes Care Network FIGURE 1 The Ohio Valley Pharmacist Care Network (OVPCN) is a group of independent community pharmacists located in the northern panhandle of West Virginia and southeastern Ohio. This network was formed in 1998 with the goal of establishing common pharmaceutical care programs that would meet the needs of patients, physicians, and payers in the region. At the time of this publication, the membership of OVPCN consisted of 13 pharmacists at seven pharmacies. Additional details on the network are available in the July/August 2001 issue of JMCP. 19 A consultant from the West Virginia University School of Pharmacy assisted the pharmacists in developing standardized diabetes care services at the network pharmacies. The goals of the program are based on the American Diabetes Association Standards of Medical Care for Patients with Diabetes Mellitus. 20 All network pharmacists completed a series of training programs in diabetes care prior to program implementation. The training included certificate programs in diabetes care (either the program offered jointly by the American Pharmaceutical Association and American Association of Diabetes Educators or the home-study program offered by the National Institute for Pharmaceutical Care Outcomes) and a two-day training program offered by West Virginia University. Additionally, the pharmacists received training in the operation of equipment and devices to be used in the diabetes care program. OVPCN established a tentative agreement with a local managed care organization (MCO) to assess and improve the quality of diabetes care for the MCO s enrollees. The agreement specified the conduct of a pilot study prior to consideration of expansion of the clinical intervention program to all diabetic patients. The MCO is an IPA-HMO with just over 100,000 covered lives in southeastern Ohio and northern West Virginia. Objective The objective of this pilot study was to determine whether the diabetes patient-management program provided through the OVPCN was an effective means of improving clinical outcomes in persons with Type 2 diabetes. Methods Components of Education Program for Patients Session 1 Overview: The pharmacist gave a basic overview of the causes and complications of diabetes, goals of diabetes control, measuring outcomes of diabetes management, and symptoms and treatment of hypoglycemia. Blood Glucose Monitoring: This section reviewed the importance of blood glucose monitoring, how to use a blood glucose meter, when to check blood glucose, and target levels. Session 2 Insulin: The pharmacist reviewed how insulin works in the body; for patients using insulin, the pharmacist explained how to use, store, mix, and inject insulin, and discussed dosing schedules and adjustments. Oral Medications for Diabetes: This session covered the different options to treat diabetes with oral medication. The pharmacist reviewed how they work, their potential side effects and drug interactions, and how to take them correctly. Session 3 Ongoing Monitoring of Diabetes: The pharmacist discussed monitoring of blood glucose, blood pressure, and hemoglobin A1c, urine testing, and lipids. Avoiding Long-Term Complications: This section describe lifestyle modifications and reviewed the body systems that can be damaged by diabetes. Design This pilot study used a single-group, retrospective, non-experimental, pre/post design to assess change in selected clinical measures in a small group of Type 2 diabetic patients. Since the service was only available to patients at a limited number of pharmacies, only a small proportion of the total persons with diabetes in the HMO were able to use the service. Data were collected as part of the ongoing diabetes care program. Thus, data included in this study came from the baseline assessment and from follow-up visits that occurred every 3 months. Subjects data were not included in the final analyses if Vol. 8, No. 1 January/February 2002 JMCP Journal of Managed Care Pharmacy 49

3 they did not return for follow-up visits at least once in the 6 months after enrollment. Additional details on the baseline data from this project are published in the July/August 2001 JMCP. 19 Subjects At the request of the HMO, all patients diagnosed with Type 2 diabetes were eligible to receive the pharmacists services. Each of the network pharmacists solicited the involvement of current patients and also accepted referrals from physicians (although physician referral was not required in order for the pharmacists to obtain compensation). None of the patients were newly diagnosed at the time of enrollment. No payment was required of patients who participated in this program. Patient-Management Services Standardized diabetes patient-management services were established at the network pharmacies to ensure consistency of care. The services were provided through scheduled appointments in the pharmacy and consisted of a baseline assessment and education program, as well as follow-up visits with patients to evaluate their progress toward the clinical goals. The goals of the program were based on the ADA Standards for Medical Care for persons with diabetes and are summarized in a prior description of the OVPCN services. 20 The educational program was conducted through three individual face-to-face discussions between pharmacist and patient in the pharmacist s office. Each educational session lasted approximately 60 minutes. The basic components of the educational program were standardized, although the pharmacist tailored the material to the patient s drug therapy and existing knowledge of diabetes. A desktop flip-chart with color graphics was used to guide the patient through the basics of diabetes management and also enhanced consistency between the participating pharmacists. The key components of the diabetes education program are presented in Figure 1 (page 49). The pharmacists also collected data that helped to identify drug-related problems and the need for therapy modification. These data included HbA1c, blood pressure, lipid profile, and BMI (estimated from weight and height). The pharmacists also determined whether the patient s care conformed to the HMO s therapeutic guidelines for primary care physician visits, eye/foot exams, immunizations, and smoking cessation or dietician referrals. All data were provided to the patient s primary care physician. The primary care physician was also contacted to discuss the patient s need for therapy modification or referrals. The patient s progress towards the ADA-recommended therapeutic goals was tracked by the pharmacist via follow-up appointments scheduled approximately 3 months apart. These data were also provided to the patients and their physicians. Thus there were three components to the diabetes patient-management services: (1) patient education, (2) patient monitoring, and (3) physician-pharmacist collaboration. Clinical data collection The clinical data were collected and recorded by the pharmacists as part of the standard care program. Additional detail on the data collection methods can be found in the July/August 2001 issue of JMCP. 19 The HbA1c levels were determined by analyzing blood samples in the Bayer DCA2000+ machine. The HbA1c reagent cartridge requires only 1 microliter of blood from a fingerstick and results are reported within 5 minutes. The lipid profile was conducted through the use of the Cholestech LDX analyzer using a fingerstick sample of blood. This test provides estimates of the total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglyceride and glucose levels. All samples were drawn from patients in a fasting state. The analyses conducted with the Cholestech LDX and DCA2000+ are waived tests under the Clinical Laboratory Improvement Amendment (CLIA) and can be performed in the pharmacy by trained personnel. 21 The pharmacists also monitored the patient s blood pressure at each visit using a manual sphygmomanometer. Two blood pressure readings were taken with the patient in the sitting position. The mean of the two blood pressures was used for analyses. Medication changes The changes in each patient s drug therapy were determined by review of the patient s chart in the pharmacy as well as the electronic dispensing record. In many instances, the specific change arose from a conversation between the pharmacist and physician in which numerous options were discussed. Thus, there were not always explicit recommendations from the pharmacists that could be accepted or rejected by the physician. However, since all of the changes occurred subsequent to a verbal or written interaction between the pharmacist and physician, it was assumed that all changes were influenced by the pharmacist-physician interaction. Statistical analyses All data were analyzed using SPSS-PC version 7.5. To evaluate the change in clinical endpoints, a paired t-test was conducted on each variable using a significance level of p<0.05. The patients had differing lengths of time between the baseline and follow-up assessments, and some patients had multiple followup assessments. To simplify the analyses, data from the last follow-up visit during the year-long study were used for comparisons with baseline. Results Subjects Although 47 patients were initially enrolled in the study, only 32 maintained participation in the program for at least 6 months. There were no significant differences in baseline characteristics 50 Journal of Managed Care Pharmacy JMCP January/February 2002 Vol. 8, No. 1

4 between the patients who continued and those who did not. All subsequent analyses are based on the 32 participants who maintained enrollment for at least 6 months (Table 1, this page). Clinical Measures A summary of the clinical measures is presented in Table 2 (this page). The mean baseline HbA1c for the 32 participants was 7.4%, which is indicative of relatively good control. However, 10 of the 32 participants had an HbA1c over 8% at baseline, while 23 had an LDL greater than 100mg/dl and 22 had a BMI greater than 30kg/m 2. The mean scores on all measures moved in the desired direction with statistically significant improvements found in total cholesterol (t= 2.58, p=0.015) and LDL (t= 2.56, p=0.017). Blood pressure, HDL, triglycerides, BMI, and HbA1c did not change significantly across all 32 patients. For the 10 patients with baseline HbA1c >8%, the average HbA1c declined significantly, from 9.8% to 8.6% (t= 3.00, p=0.015). Medication Use The 32 participants experienced 53 medication changes during the study period (Table 3, this page). Twenty-seven (51%) of the changes involved a modification of oral diabetes medications. One patient was started on insulin while one patient had an adjustment in insulin dose. Drug therapy for dyslipidemia was initiated in five patients and was modified in seven patients. Antihypertensive medications were started in two patients and adjusted in 10 patients. Discussion This report provides some support for a positive impact of specially-trained community pharmacists in the care of persons with diabetes. However, the study also highlights the difficulties of conducting a program evaluation in real-world settings. The OVPCN services were created to provide additional education and monitoring for persons with diabetes in collaboration with physicians. The collaborating HMO supported the idea of opening the services to any of its members with Type 2 diabetes without the need for a physician referral. This led to enrollment in the services by patients with quite disparate levels of glycemic control. The HMO sought to determine whether patients with diabetes could benefit from the services even if their baseline glycemic control was within an acceptable range (i.e., HbA1c <8%). It appears that the OVPCN services were beneficial to the population of patients who enrolled. Although the mean HbA1c across all 32 participants did not improve significantly, the subset of patients with an HbA1c above 8% at baseline did achieve significant improvement in glycemic control. The average reduction in HbA1c by 1.2% should lead to significant reduction in the risk of diabetes complications for these patients. 4, 5 The most common drug-therapy changes during the study were TABLE 1 Age (mean ± sd.) Demographics (n=32) 58.7 ± 11.5 years Gender Female 17 (53.1%) Male 15 (46.9%) HbA1c (baseline) Level Patients 6% % % 11 > 8% 10 TABLE 2 Baseline Follow-up Mean SD Mean SD HbA1c (%) Systolic BP (mmhg) Diastolic BP (mmhg) Cholesterol (mg/dl) a LDL (mg/dl) b HDL (mg/dl) Triglycerides (mg/dl) BMI (kg/m 2 ) SD = standard deviation, BP = blood pressure, LDL = low-density lipoproteins, HDL = high-density lipoproteins a. Significant improvement (t= 2.58, p=0.015) b. Significant improvement (t= 2.56, p=0.017) TABLE 3 Clinical Measures: Mean Scores and Standard Deviation (n=32) Medication Changes Oral Antidiabetic Change drug Change dose Add second drug Insulin Change dose Initiate insulin Antilipidemic Change drug Change dose Initiate drug Antihypertensive Change drug Change dose Initiate drug Total Vol. 8, No. 1 January/February 2002 JMCP Journal of Managed Care Pharmacy 51

5 an increase in dose of an existing antidiabetic agent or the addition of a second antidiabetic drug. Most of these changes occurred in the patients who had the worst glycemic control at baseline. Another important finding was that many patients had uncontrolled dyslipidemia. In our previous report on the OVPCN program, we identified that elevated LDL was a more common problem than poor glycemic control in the patients who participated in a baseline assessment. 19 Subsequent to the pharmacist-conducted lipid profile and the pharmacists dialogue with the patients physicians, five patients were initiated on therapy for dyslipidemia and seven other patients received dosage increases. The longitudinal data presented in this report show that both total cholesterol and LDL improved significantly across all patients in the program. This should lead to a significant reduction in the risk of cardiovascular events, which are a major cause of death among people with Type 2 diabetes. 22 Consequently, it appears that many patients with diabetes may still benefit from pharmacist-based diabetes management programs even if they have acceptable glycemic control prior to enrollment. An additional concern in adults with diabetes is blood pressure control. The mean blood pressure of patients enrolled in the patient-management program was fairly good at baseline (systolic=136.4mmhg; diastolic=82.2mmhg) and did not change significantly across all 32 patients. Nonetheless, the pharmacists worked with the patients physicians to initiate antihypertensive therapy in two patients and change therapy in 10 patients. Five of the changes in antihypertensive therapy involved the switch from a diuretic to an angiotensinogen-converting enzyme (ACE) inhibitor (or ACE/diuretic combination product) in patients whose hypertension was relatively well controlled. Although the patients who had this therapy change did not experience substantial changes in blood pressure control, they received greater renal protection through the use of the ACE inhibitor. Many drug therapy changes were made for the patients enrolled in the diabetes care program. Although most of the therapy modifications occurred after the physician and pharmacist communicated about the patient s progress, it is difficult to assess how many of the changes in drug therapy may have occurred without the pharmacist s monitoring. In some situations, the pharmacist made explicit recommendations for change. Other times, the pharmacist notified the physician that the patient was not reaching goal and the physician independently selected a course of action. Regardless of whether or not the pharmacist made explicit recommendations for drug therapy modification, we believe the monitoring report from the pharmacist and the subsequent pharmacist-physician dialogue increased the likelihood of action by the physician. The loss of patients at follow-up also points out the difficulties encountered by all practitioners who strive to provide ongoing care to patients with chronic diseases. Telephone calls to the patients who dropped out prior to their 6-month follow-up revealed a myriad of reasons for not returning. The most common reasons cited by patients for not keeping appointments were impairments to their mobility and a lack of perceived need for continued monitoring. Several more patients expressed interest in maintaining participation in the program but continually failed to keep appointments. The ideal design to evaluate the impact of pharmaceutical care for diabetes would be a prospective, randomized, controlled trial in a large number of pharmacies. Without a control group, it is difficult to assess whether the pharmacists services were truly the cause of clinical improvement. Retrospective selection of a truly comparable control group is challenging in practice-based research. A review of claims data for this HMO revealed that fewer than 10% of patients with diabetes had claims for both HbA1c and lipid profiles spaced approximately one year apart during the study period. Thus, it is unclear whether control group patients selected from this very small subset would be truly representative of the HMO s diabetic population. Additionally, clinical data (e.g., HbA1c, LDL, BP) for potential control group patients in this IPA-model HMO are only available through the patients charts kept in the physicians offices. Therefore, data collection for the formation of a control group is also challenging. It is also difficult for a community pharmacy to enroll large numbers of patients with a single disease and to maintain all of those patients in the service for an extended period of time. Many of the best-known pharmaceutical care projects for diabetes (e.g., projects in North Carolina, New Jersey, and Iowa) have maintained enrollment of fewer than 50 patients during the initial study period. It is also difficult to involve large numbers of pharmacies in such studies due to the high degree of additional training and support required by the pharmacies. Although several small studies have documented the positive impact of pharmaceutical care on diabetes patient outcomes, there is a need for larger, longer, more controlled studies of pharmaceutical care for patients with diabetes Conclusion Community pharmacists who have completed additional training in diabetes care can have a beneficial impact on the care of patients with Type 2 diabetes. Pharmacist-based patient-management services not only help to improve glycemic control in adults with HbA1c >8% but can also identify patients with uncontrolled hypertension and dyslipidemia and produce reductions in total cholesterol and LDL. Therefore, pharmaceutical care may be beneficial for all patients with diabetes regardless of baseline glycemic control. Disclosures David Nau is the principal author of this paper. Study concept and design, 52 Journal of Managed Care Pharmacy JMCP January/February 2002 Vol. 8, No. 1

6 drafting of the manuscript and statistical expertise was provided by Nau. Nau and Ponte collaborated on analysis and interpretation of data and critical revision of the manuscript. Joshua Blevins, while employed by West Virginia University, assisted with data collection. The following pharmacists of OVPCN participated in this project: John Bernabei, Roger Cole, Aldo Cristante, Bob Gelner, Mike Kacsmar, Joe Jefferies, and Adele Storm. Funding was obtained by Nau. Funding and support for this study was contributed by The HealthPlan of the Upper Ohio Valley, Aventis, Bristol- Myers Squibb, and the National Community Pharmacists Association Foundation. Administrative and technical support was provided by Steve Neal, Shelly Rouse and Kathy Parsons, all employees of The HealthPlan. References 1. American Diabetes Association. Economic consequences of diabetes mellitus in the U.S. in Diabetes Care 1998; 21: American Diabetes Association. Position statement: Diabetic nephropathy. Diabetes Care 1997; 20: S24-S O Brien JA, et al. Direct medical costs of complications resulting from Type 2 diabetes in the U.S. Diabetes Care 1998; 21: The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33). Lancet 1998; 352: Coonrod BA, Harris MI, Betschart J. Frequency and determinants of diabetes patient education among adults in the U.S. Population. Diabetes Care 1994; 17: Peters AL, Ossorio RC, Legorreta AP, Davidson MB. Quality of outpatient care provided to diabetic patients. Diabetes Care 1996; 19: Asch SM, et al. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA 2000; 284; National Committee for Quality Assurance. The State of Managed Care Quality, Rubin RJ, Dietrich KA, Hawk AD. Clinical and economic impact of implementing a comprehensive diabetes management program in managed care. J Clin Endocrinol Metab 1998; 83: Sikka R, et al. Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes. Diabetes Care 1999; 22: Piette JD, et al. Use of automated telephone disease management calls in an ethnically diverse sample of low-income patients with diabetes. Diabetes Care 1999; 22: Coast-Senior EA, Kroner BA, Kelley CL, Trilli LE. Management of patients with Type 2 diabetes by pharmacists in primary care clinics. Annals Pharmacother 1998; 32: Fincham JE, Lofholm PW. Saving money and lives pharmacist care for diabetes patients. America s Pharmacist 1998; (March): The Asheville project. Pharmacy Times 1998 (October supplement). 16. Berringer R, et al. Outcomes of a community pharmacy-based diabetes monitoring program. J Am Pharm Assoc 1999; 39: Baran RW, et al. Improving outcomes of community-dwelling older patients with diabetes through pharmacist counseling. Am J Health-Syst Pharm 1999; 56: Kelly C, Rodgers PT. Implementation and evaluation of a pharmacist-managed diabetes service. J Managed Care Pharm 2000; 6: Nau DP, Blevins JD, Neal SE. Collaborating with community pharmacists to improve the quality of diabetes care in an IPA-model HMO. J Managed Care Pharm 2001; 7: American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2000; 23: S32-S Rosenthal WM. Establishing a pharmacy-based laboratory service. J Am Pharm Assoc. 2000; 40: American Diabetes Association. Management of dyslipidemia in adults with diabetes. Diabetes Care 2000; S57-S60. Vol. 8, No. 1 January/February 2002 JMCP Journal of Managed Care Pharmacy 53