Diabetes: Pharmacy Strategies and Behavior Change

JANUARY 26, 2018


Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; and Dhiren Patel, PharmD, discuss opportunities to influence behavior change among patients with type 2 diabetes mellitus at the pharmacy level.

Troy Trygstad, PharmD, MBA, PhD: Tripp, 80 patients walk into your pharmacy in a typical day. What percentage of those patients require a little bit of extra due care and attention because of metabolic syndrome, generally, or specifically because of their issues related to their diabetes?

Tripp Logan, PharmD: What I’m hearing is exactly what we’re seeing in practice. The solution here, to this mega problem, is not always clinical. We’ve got that part figured out. We’ve got guidelines. We’ve got all of these things that can help to solve this problem. But the major barriers that we see are nonclinical issues. They are, “How expensive is this food?” And so, that’s where, in the community pharmacy space, we’re spending a lot of our time. We are not only reinforcing guidelines, looking at metabolic syndrome as a whole, and making sure the blood pressure is at goal, the A1C is at goal, and that the lipids are at goal. But in order to get there, you’re not going to get there with just medicine. You’re not going to get there. And when you get there, you don’t get there because then there’s always tomorrow. You’re never adherent. You never say, “Oh, my patients are at goal.” Really, they’re not. They’re at goal today, but they’re not at goal 2 weeks from now. So, it’s constant reinforcement. It includes bringing the family in, offering support group atmospheres, and taking short baby steps toward goals.

We had a patient walk in not too long ago who had been diagnosed with diabetes. Their A1C was through the roof. Their lipids were through the roof. We found out that they were consuming over a case of soda soft drink a day. And so, what they heard was, “You’ve got to stop this. Stop all white food. Stop all.” You know, “Stop, stop, stop, stop, stop.” So, they walked out not only with diabetes, but with depression as well. They didn’t know what to do. So, our perspective is, let’s slow down. Let’s reduce this soda intake by 10% a week. Let’s work our way into a short-term goal process instead of just stopping. We think that’s more sustainable. So, it’s not always clinical.

Troy Trygstad, PharmD, MBA, PhD: What I hear you describing, then, is not only that the patient walks in with diagnosed diabetes, and that it’s not just about that patient who you’re trying to influence, but it’s also about the environment, the patient’s caregivers, and their family.

Tripp Logan, PharmD: We invite family to support the patient. We have diabetes support groups once a month in our pharmacy for this very reason. We invite family, specifically.

Troy Trygstad, PharmD, MBA, PhD: This sounds a little like smoking cessation, right?

Tripp Logan, PharmD: It’s the same thing.

Troy Trygstad, PharmD, MBA, PhD: Which is behavior change.

Tripp Logan, PharmD: Right.

Troy Trygstad, PharmD, MBA, PhD: So, all of this is wrapped in. But what I’m also hearing you say is, there’s such a long-time horizon to this, too? If a 35-year-old walks into your clinic, the scenario is, “Hey, you’re a newly diagnosed type 2 diabetes patient.” You’re going to have a conversation with them not about, “Here’s what we’re going to do next week. Then your problems will go away.” Right? You’re having a conversation like, “This is going to be a multi-year, multi-decade, perhaps, experience.” We’re asking these patients to change their way of life.

Dhiren Patel, PharmD: I think what you mentioned, to that point, is very important. It’s the frequency of touch points. That behavior change has to be really, really small. If you think about the time that they get in clinic, it’s about 67 minutes. That is what the United States average is. And so, over the course of a year, you multiply that. If they have 3 to 4 visits, it’s a couple of hours. You’re awake for about 6000 hours. There’s about 5998 hours in which they’re at home. When you look at the extension for which they spend the majority of their time, no one’s engaging these patients. We’re spending a lot of time and resources in the 2 to 3 hours when they’re in the health system, or at the hospital, or at the visit. But if we could spend more of our time engaging outside, I think that’s where we’re going to make a huge impact in chronic conditions. Specifically, something like diabetes.
 


Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; and Dhiren Patel, PharmD, discuss opportunities to influence behavior change among patients with type 2 diabetes mellitus at the pharmacy level.

Troy Trygstad, PharmD, MBA, PhD: Tripp, 80 patients walk into your pharmacy in a typical day. What percentage of those patients require a little bit of extra due care and attention because of metabolic syndrome, generally, or specifically because of their issues related to their diabetes?

Tripp Logan, PharmD: What I’m hearing is exactly what we’re seeing in practice. The solution here, to this mega problem, is not always clinical. We’ve got that part figured out. We’ve got guidelines. We’ve got all of these things that can help to solve this problem. But the major barriers that we see are nonclinical issues. They are, “How expensive is this food?” And so, that’s where, in the community pharmacy space, we’re spending a lot of our time. We are not only reinforcing guidelines, looking at metabolic syndrome as a whole, and making sure the blood pressure is at goal, the A1C is at goal, and that the lipids are at goal. But in order to get there, you’re not going to get there with just medicine. You’re not going to get there. And when you get there, you don’t get there because then there’s always tomorrow. You’re never adherent. You never say, “Oh, my patients are at goal.” Really, they’re not. They’re at goal today, but they’re not at goal 2 weeks from now. So, it’s constant reinforcement. It includes bringing the family in, offering support group atmospheres, and taking short baby steps toward goals.

We had a patient walk in not too long ago who had been diagnosed with diabetes. Their A1C was through the roof. Their lipids were through the roof. We found out that they were consuming over a case of soda soft drink a day. And so, what they heard was, “You’ve got to stop this. Stop all white food. Stop all.” You know, “Stop, stop, stop, stop, stop.” So, they walked out not only with diabetes, but with depression as well. They didn’t know what to do. So, our perspective is, let’s slow down. Let’s reduce this soda intake by 10% a week. Let’s work our way into a short-term goal process instead of just stopping. We think that’s more sustainable. So, it’s not always clinical.

Troy Trygstad, PharmD, MBA, PhD: What I hear you describing, then, is not only that the patient walks in with diagnosed diabetes, and that it’s not just about that patient who you’re trying to influence, but it’s also about the environment, the patient’s caregivers, and their family.

Tripp Logan, PharmD: We invite family to support the patient. We have diabetes support groups once a month in our pharmacy for this very reason. We invite family, specifically.

Troy Trygstad, PharmD, MBA, PhD: This sounds a little like smoking cessation, right?

Tripp Logan, PharmD: It’s the same thing.

Troy Trygstad, PharmD, MBA, PhD: Which is behavior change.

Tripp Logan, PharmD: Right.

Troy Trygstad, PharmD, MBA, PhD: So, all of this is wrapped in. But what I’m also hearing you say is, there’s such a long-time horizon to this, too? If a 35-year-old walks into your clinic, the scenario is, “Hey, you’re a newly diagnosed type 2 diabetes patient.” You’re going to have a conversation with them not about, “Here’s what we’re going to do next week. Then your problems will go away.” Right? You’re having a conversation like, “This is going to be a multi-year, multi-decade, perhaps, experience.” We’re asking these patients to change their way of life.

Dhiren Patel, PharmD: I think what you mentioned, to that point, is very important. It’s the frequency of touch points. That behavior change has to be really, really small. If you think about the time that they get in clinic, it’s about 67 minutes. That is what the United States average is. And so, over the course of a year, you multiply that. If they have 3 to 4 visits, it’s a couple of hours. You’re awake for about 6000 hours. There’s about 5998 hours in which they’re at home. When you look at the extension for which they spend the majority of their time, no one’s engaging these patients. We’re spending a lot of time and resources in the 2 to 3 hours when they’re in the health system, or at the hospital, or at the visit. But if we could spend more of our time engaging outside, I think that’s where we’re going to make a huge impact in chronic conditions. Specifically, something like diabetes.
 
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