INTRODUCTION

Diabetes mellitus is a chronic devastating disease that, despite recent advances in medical care and management, still precipitates substantial morbidity and long-term complications.¹ It is a growing chronic disease with a global prevalence of 415 million, and this figure is expected to be more than 642 million by the year 2040.² In Ethiopia, the number of patients living with diabetes is increasing in alarming rate with a national prevalence close to 6.5%.³ The high prevalence and the chronic nature of the disease necessitate the need for diabetes disease state management. Many approaches are known to improve diabetes disease control including effective screening, management, regular monitoring and consistent follow up.⁴ Medication adherence, lifestyle modifications and regular monitoring of blood glucose are some of the factors which contribute to better health outcomes and can be significantly affected by health education and counseling.⁵,⁶

It has been known, in the past decades, that medication therapy management is associated with reduced mortality, morbidity and increased health related quality of life.⁷ Yet, there has been an increase in irrational use of medicines with more than half of medicines prescribed and/or dispensed inappropriately. In addition, more than half of patients fail to adhere to their prescribed medicines.⁸ Consequently, the healthcare system suffers from a number of health and economic losses.⁹ In recognition to this problem, there has been a rising interest in interdisciplinary healthcare approach involving all specialties of healthcare providers as an effective way of improving medication adherence and overall health outcomes.¹⁰ The role of pharmacists is expanding globally from merely dispensing medications to involvement in different patient care services and disease state management.¹¹,¹²,¹³,¹⁴ Medication therapy management (MTM), one of the well-established roles of pharmacists, could be used as one of the effective approaches to improve adherence to anti-diabeic medications and health outcomes.⁷,¹⁵ Furthermore, clinical pharmacists, with their pharmacotherapeutic knowledge and patient centered training, are uniquely positioned to educate, elaborate, implement and monitor patients on medication therapies, which ultimately results in better health outcomes.⁷,¹⁶,¹⁷,¹⁸

Cognizant of the global paradigm shift in pharmaceutical education and practice, Public universities in Ethiopian revised their undergraduate pharmacy curriculum in 2008 to be more patient focused and a limited number of pharmacy schools also started a postgraduate course in clinical pharmacy. Even though there has been an increase in pharmacists’ involvement in patient care in Ethiopia, their full potential and role in clinical practice is yet to be explored.¹⁹,²⁰ The present study has been conducted with the objective of evaluating the effectiveness of pharmacists-led MTM service on adherence and hospital admission among patients with type 2 diabetes mellitus who visited the diabetes illness follow-up care clinic of University of Gondar Referral and Teaching Hospital (UoGRTH), Ethiopia.

METHODS

RESULTS

Out of 172 eligible patients recruited, 127 of them agreed to participate and 45 excluded (29 declined to participate after a detailed description of the study protocol, 9 patients excluded due to uncontrolled psychiatric disease that hindered them from fully participating in the study and the rest 7 had not been contacted). The detailed flow of patients through the study period is presented in Figure 1.

Figure 1 Flow of participants through the study 

A total of 127 eligible participants were randomly assigned into one of the two groups, with 62 patients allocated to the pharmacist-led MTM group and 65 to the non-MTM (control) group. Majority of patients in our study used metformin with glibenclamide (glyburide) (49.5%) followed by metformin only (40.2%). There were no statistically significant differences between the two groups in demographic and clinical parameters including mean age, gender, and other functional variables (Table 1).

A marked and statistically significant increase in medication adherence from baseline to 3 and 6 months were noted in the MTM group (increased from 9.2% at baseline to 61% at 6 month) than the control or non-MTM group (increased from 13.2% at baseline (to 30.2% at 6 month; p<0.01) (Table 2). A significant difference in Morisky score were also noted between different time points (p<0.001).

At the 6-month follow-up, only 23 patients in MTM group with poorly controlled blood sugar levels resulted in hospital admissions compared to 48 patients in non-MTM group, resulting in a 52.1% fewer hospital admissions (p<0.001). A higher rate of hospitalization (at least one hospitalization during the study period) was reported in control group (48 out of 53 patients) than intervention group (23 out of 54 patients) (Figure 2).

Figure 2 Number of hospital admissions for patients 

DISCUSSION

The involvement of pharmacists, as part of the interdisciplinary healthcare team, in every step of the medication use process has been shown to improve disease state management and pharmacotherapy, patient adherence and overall health-related quality of life.²⁵ To the best of our knowledge, this is the first study to evaluate the impact of pharmacist-led MTM service on medication compliance and hospital admission in patients with type 2 diabetes in Ethiopia.

In our study, patients in both the intervention and control groups demonstrated poor adherence to anti-diabetic medications and high hospital admission rates at baseline. This could be explained by the relatively low socioeconomic and educational status of patients in our study. A study conducted in Northwest Ethiopia by Abebe et al. identified low educational status and dissatisfaction with the service received at the diabetic clinic as the main predictors of poor adherence to anti-diabetic medications.²⁶ Patients with low socioeconomic and educational status are less likely to access education, and health care services including medication refills on time, which may increase patients’ difficulty in adhering to their treatment regimens.²⁷ Furthermore, it has been shown that non-adherent patients had a higher hospitalization and mortality rate compared to adherent diabetic patients.²⁸

The findings of the present study revealed a marked increase in medication adherence and reduction in hospital admission from baseline to 3 and 6 months in the intervention group than the control group. Our findings are similar to previous studies demonstrating the effect of pharmacist interventions to improve medication adherence.²⁹,³⁰,³¹ A systematic review of randomized clinical studies conducted by Cutrona et al. to improve medication adherence reported that 5 out of 6 studies that measured a customized pharmacist interventions significantly improved medication adherence by 7% to 27%.³² Another study conducted by Adepu et al. revealed that continuous monthly education for 3 months tended to improve adherence compared to a single educational session.³³

Compared to the usual care, patients in the intervention group showed greater reduction in hospital admission. This may be due to the fact that the pharmacist adopted and utilized a pharmaceutical care plan, which involved preventing and resolving a number of medication therapy problems which leads to acute complications and subsequent hospital admissions such as hypoglycemia. A number of similar studies also reported that number of hospital admission and diabetic complication is minimized by pharmacist-led patient counseling and self-care practice training.³⁴,³⁵ Worldwide health care expenditures associated with diabetes including the cost of hospitalizations due to microvascular and macrovascular complications in patients with diabetes mellitus were more than 450 billion USD in 2011, accounting for about 10% of the total healthcare expenditure for adults. Even though there is a difference in the cost of treatment of diabetes and diabetes-related complications in different countries³⁶,³⁷, costs associated with the medications for diabetes disease state management, outpatient medications for diabetes related complications and the hospitalizations remains the main cost drivers in countries like Ethiopia. This is particularly important for developing countries like Ethiopia, where the governments’ annual per capita health care expenditure is less than USD 20 and patients generally can’t afford to pay for the additional costs associated with diabetes related hospitalizations. Such costs could be minimized by reducing the number of hospitalization through extensive pharmaceutical care service, as evidenced by the findings of our study.

CONCLUSIONS

The findings of the present study implied that a pharmacist-led MTM might improve medication adherence and reduce number of hospitalizations in patients with type 2 diabetes mellitus. Our study adds to the existing literature by demonstrating the positive impact of pharmacist-led MTM on medication adherence. Hence, policies and guidelines should be in place in order for clinical pharmacists to fully engage in patient care and improve the medication therapy outcomes of patients with type 2 diabetes mellitus. Future multicenter, prospective randomized controlled studies recruiting a large number of sample from a diverse population are warranted in order to confirm the generalizability of our results.