Clinical Pharmacist Manages Diabetes for Limb-Salvage Team

A clinical pharmacist in Chicago is providing diabetes management in an unusual setting — an interprofessional limb-salvage clinic for patients with diabetic foot infections.

The half-day, once-weekly clinic was established by infectious disease (ID) and podiatry specialists affiliated with the John H. Stroger, Jr. Hospital of Cook County, Illinois, said Molly Rockstad, who has been the clinic’s pharmacist since July 2017.

Rockstad described the clinic as a transitional care setting.

“We see them for the acute phase of their infection ... immediately after their hospital discharge. And then we’ll keep them until they’re no longer having any acute issues on any of the fronts that we tend to,” she said. Once the acute issues are resolved, she said, there’s a “warm handoff” to the patient’s primary care provider.

She estimated that the clinic cares for about four new patients each week, plus 4–6 who come for follow-up visits.

Rockstad’s role on the interprofessional team is to help patients control their diabetes and decrease the risk of amputation.

She said the clinic’s ID and podiatry specialists originally focused on wound care and treating the infection that led to the hospitalization.

“Typically, the patients would have their wound debrided and then also discuss ... how their antibiotics were going,” she said.

But she said the team eventually decided that they needed include diabetes management in the patients’ care plans.

“A lot of these patients were coming back [to the clinic] with horribly controlled diabetes. And it just wasn’t getting addressed,” Rockstad said.

According to the Centers for Disease Control and Prevention, 60–70 percent of people with diabetes have diabetic neuropathy, commonly affecting the feet. Patients with neuropathy whose diabetes is poorly controlled are at increased risk for infection and resultant limb loss.

Rockstad said the clinic’s lead ID physician first inquired about bringing one of the hospital’s medical residents onsite to handle diabetes management. But the hospital’s family medicine chief recommended Rockstad for the clinic.

“He’s my biggest physician champion,” she explained. “It was really his idea to look at pharmacy services instead of medicine services” for diabetes management.

Rockstad said she was initially asked to perform diabetes education at the clinic. But her role soon expanded to include comprehensive diabetes management.

She said a typical visit for clinic patients usually includes a session with the ID staff and the podiatry specialists.

“Then they’ll sit down with me,” she said.

During that portion of the visit, she reviews the patient’s medication regimen, optimizes medications and dosages, counsels the patient, and answers questions. A pharmacy resident also participates in visits while on rotation at the clinic, Rockstad said.

Rockstad and colleagues presented initial data on the pharmacists’ services at the Infectious Diseases Society of America’s 2018 IDWeek forum, held last October in San Francisco.

From October 2017 through August 2018, the pharmacists recorded a total of 107 interventions in 60 patients, each of whom required at least 1 intervention to improve their diabetes control. Thirty-one of the interventions were medication dosage increases, 25 consisted of adherence education, and 19 involved the initiation of new therapy.

The baseline glycosylated hemoglobin (HbA_1c) level averaged 10 percent among the study population. That value dropped by two percentage points, on average, for the 31 patients who returned for their six-month follow-up visit.

“We are definitely seeing an improvement in their diabetes control,” Rockstad confirmed in January.

She said most of the patients, when they first come to the clinic after an inpatient stay, have additions or changes to their previous diabetes medication regimen. The clinic’s pharmacists focus on optimizing the those regimens.

“We can really attack any efficacy and safety issues right away,” she said.

Some clinic patients have never had regular care for their diabetes.

“A lot of these people, before they came to the hospital with this foot infection, hadn’t been seen by anybody in years. They weren’t on medications at all,” Rockstad said. “They ... were lost to follow-up for insurance issues or homelessness or things like that.”

According to 2016 data from the Illinois Department of Public Health, about 47 percent of inpatients at the John H. Stroger, Jr. Hospital were covered by Medicaid, 15 percent by Medicare, 19 percent received charity care, 14 percent were private pay, and 5 percent had private insurance.

But Rockstad said patients have shown that they can get healthier despite their socioeconomic challenges.

She said one of the clinic’s “poster patients” for success is a man with a long history of uncontrolled diabetes who refused to follow his care plan despite having an HbA_1c level as high as 14 percent.

“When we sat down with him, ... we were able to figure out what motivated him. Really, all he wanted was to switch to an insulin pen. And as soon as we did that, it made a huge difference,” Rockstad said. Now, she said, the patient is engaged in his care and has reached and maintained his blood glucose target goal.

Rockstad said she hopes data from the limb-salvage clinic will ultimately demonstrate improvements in patient outcomes, cost of care, and 30-day readmission rates for vulnerable patients.

[This news story appears in the April 1, 2019, issue of AJHP.]