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 Table of Contents  
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 155-161

Effect of hospital pharmacist counseling on clinical outcomes of type 2 diabetes mellitus outpatients

1 Department of Pharmacy, Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
2 Department of Public Health Nutrition, Public Health Faculty, Universitas Indonesia, Depok, Indonesia

Date of Submission31-Mar-2019
Date of Acceptance09-Jun-2019
Date of Web Publication16-Oct-2019

Correspondence Address:
Dr. Rani Sauriasari
Department of Pharmacy, Faculty of Pharmacy, Universitas Indonesia, Depok
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrpp.JRPP_19_67

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Objective: In Indonesia, the role of a hospital pharmacist in pharmaceutical care is still limited or even absent. This study aimed to determine whether counseling by a pharmacist could improve medication adherence, controlling the glycemic status, lipid profile, and blood pressure of type 2 diabetes mellitus (T2DM) outpatients. Methods: We conducted an interventional study at RSUD Kota Depok, a secondary public hospital, Indonesia, from April to October 2018. Counseling was given three times during the 4-month study. The study design was quasi-experimental with pretest-posttest group design on 77 respondents divided into intervention group (IGs) (n = 39 people) who received counseling and booklets from the hospital pharmacist and control group (CG) (n = 38 people) who were only given the booklets. We measured adherence with the Medication Adherence Questionnaire and conducted blood tests for fasting blood glucose (FBG), postprandial blood glucose (PPBG), glycosylated hemoglobin A1, lipid profiles (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and TG), and blood pressure measurements. Findings: In the IG, adherence parameters such as HbA1c and lipid profile improved, whereas in the CG, there were no statistically significant changes in clinical parameters and even nonadherence score increased (P = 0.008). IG showed statistically significant improvement in medication adherence, in parameters such as FBG, PPBG, and HbA1c, compared to CG. Based on the Chi-square test, IG also showed a statistically significant improvement in the number of controlled FBG (P = 0.05) and HbA1c (P < 0.001) compared to CG. In addition, a multivariate analysis showed that counseling by hospital pharmacist was 2.764 times (95% confidence interval [CI]: 1.096–6.794) and 9.964 times (95% CI: 3.434–28.917) better than no counseling in improvement of FBG and HbA1c, respectively. However, the significance disappeared after adjusted by type of medicine, duration of diabetes mellitus drug use, and medication adherence. Conclusion: Hospital pharmacist counseling is an important and significant factor in improving FBG and HbA1c levels of T2DM outpatients.

Keywords: Clinical outcomes, diabetic patient, hospital pharmacist, Indonesia, medication adherence

How to cite this article:
Hening WN, Sartika RA, Sauriasari R. Effect of hospital pharmacist counseling on clinical outcomes of type 2 diabetes mellitus outpatients. J Res Pharm Pract 2019;8:155-61

How to cite this URL:
Hening WN, Sartika RA, Sauriasari R. Effect of hospital pharmacist counseling on clinical outcomes of type 2 diabetes mellitus outpatients. J Res Pharm Pract [serial online] 2019 [cited 2021 Jul 30];8:155-61. Available from: https://www.jrpp.net/text.asp?2019/8/3/155/269287

  Introduction Top

Indonesia is a country where one in three adults has diabetes and one in three deaths is related to diabetes in this region. Diabetes mellitus (DM) is classified into two categories, type 1 and type 2 diabetes, in which type 2 DM (T2DM) is most common due to lifestyle and genetic factors.[1] Counseling as a part of clinical pharmacy services aims to optimize the results of therapy, minimize the risk of adverse drug reactions, and increase cost-effectiveness, which further increases the safety of drug use for patients.[2]

Pharmacists act as a liaison between patients and other health providers by conducting pharmaceutical service programs, especially in terms of education and ensuring patients' adherence to diabetes treatment and treatment programs.[3] The program includes nonpharmacological diabetes education; pharmacological interventions including treatment counseling; and strategies for improving adherence, avoiding drug interactions, and adjusting the treatment.[4]

Diabetes is a chronic disease that requires long-term treatment; thus, patient adherence will have an impact on the success of therapy. A comprehensive reduction in risk factors for cardiovascular disease, including blood pressure and lipid control other than blood glucose, is very important in preventing the development of cardiovascular disease in diabetic patients, as well as for preventing microvascular complications.[5] Education and support for patient's self-management are very important to prevent acute complications and reduce the risk of long-term complications.[6]

The study aims to evaluate the impact of counseling delivered by the researcher who is a hospital pharmacist in an Indonesian secondary hospital. Counseling was given three times on three topics namely diabetes and its management, diabetes mellitus management during Ramadan fasting, and management for acute and chronic complications. We also determined variables on the controlled condition from glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and postprandial blood glucose (PPBG) for glycemic control; lipid profiles including total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglyceride (TG); and also blood pressure measurements at the end of the study (posttest).

  Methods Top

This was a prospective quasi-experimental study with pretest-posttest design. This study obtained ethical clearance from the Ethics Committee of the Faculty of Medicine, University of Indonesia (No. 040/UN2.F1/ETIK/2018). Informed consent was obtained from the individuals before participation. The study was conducted at the Depok City General Hospital (RSUD Kota Depok), West Java, Indonesia, from April to October 2018.

The sample in this study was T2DM outpatients that met the inclusion and exclusion criteria, using consecutive sampling method.[7] The minimum number of samples required was 64. To avoid dropping out, the number of samples was increased by 20% to 78 samples. The study inclusion criteria were T2DM patients who used pharmacological therapy at least 2 months earlier, T2DM outpatients, those aged ≥20 years, individuals who undergo fasting during Ramadan, and those who were willing to be respondents in the study. The study exclusion criteria included pregnant and lactating female patients, those taking birth control drugs, those having other endocrine diseases that are not associated with DM, those with mental illness, who are illiterate, and those who have experienced blood loss or recently transfused and underwent hemodialysis.

The participants were divided into two groups, namely control group (CG) who did not receive pharmacist intervention but only received booklets and intervention group (IG) who received pharmacist intervention, booklets, and counseling. The participants received a questionnaire titled “Sociodemography and Therapy for Type 2 Diabetes Mellitus Patients” and Medication Adherence Questionnaire (MAQ) and underwent measurement of HbA1c, FBG, and PPBG levels, as well as measurements of lipid profile and blood pressure to assess treatment adherence, at the beginning and at the end of the study. Counseling was done three times for 4 months except during Ramadan.

Data were analyzed using Statistical Package for the Social Sciences, version 22.0; IBM Corp,© Copyright IBM Corporation and other(s) 1989, 2013. P < 0.05 was considered statistically significant. The data were presented as mean ± standard deviation [SD]. Differences between pretest and posttest were compared using the Chi-squared test, Pearson's exact test, dependent t- test if the data are normal; if the data are not normally distributed, they were analyzed using Wilcoxon signed-rank test. The differences between CG and IG were analyzed using independent t-test, if the data are normally distributed, and Mann–Whitney test if the data are nonnormally distributed. A multivariate analysis was conducted using binomial logistic regression test.

  Results Top

A total of 81 patients were enrolled in this study and were divided into two groups: IG (40 patients) and CG (41 patients). Seventy-seven patients completed the study [Figure 1].
Figure 1: Flowchart of participants selected for this study

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The baseline characteristics of the respondents are shown in [Table 1]. The results showed that there were no statistically significant differences in baseline characteristics between the IG and CG (P > 0.05). The majority of respondents were nongeriatric, in the age range between 41 and 60 years old comprising 38 people (49.4%), with an average age of 58.65 ± 10.1 years (mean ± SD). The majority of participants were female (48 people, 63.2%), had a secondary level of education (31 people, 40.3%), and were homemakers (40 people, 51.9%).
Table 1: Baseline demographic and clinical characteristics

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There were no significant differences in clinical characteristics between IG and CG, except for the types of DM drugs used. Medication adherence was assessed using the MAQ questionnaire that has been validated in Bahasa Indonesia. Both groups at pretest showed comparable medication adherence.

The results of the clinical outcomes of glycemic control measurements (HbA1c, FBG, and PPBG), lipid profiles (TC, HDL, LDL, and TGL), and blood pressure are summarized in [Table 2], and the clinical outcome conditions are summarized as proportions in [Table 3]. IG showed a significant improvement on adherence, in parameters such as HbA1c, TC, HDL-cholesterol, LDL-cholesterol, and TG. In contrary, CG showed a decrease in medication adherence parameters, but no change on all the clinical parameters.
Table 2: Comparison of clinical parameters in both groups

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Table 3: Clinical outcomes in category

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When the posttest results in IG were compared to those of CG, it was reported that adherence, in terms of FBG, PPBG, and HbA1c, was better in IG than CG (P < 0.05). In terms of medication adherence, the level of adherence improved after intervention in IG (P = 0.006). In contrary, there was a decrease in medication adherence (P = 0.008) in CG [Table 2].

  Discussion Top

According to the International Diabetes Federation DM map, nearly half of the 4 million people who died of diabetes in 2017 are under 60 years of age.[8] Two previous studies in China and Malaysia showed similar results as the average age of diabetic patients was <60 years. The research showed that DM patients were mostly female (59.1%), and T2DM patients in China on an average have secondary education (60.80%) and are unemployed (59.29%).[9],[10]

The mean body mass index of the patients in both groups was in overweight criteria. The pathophysiology of DM does not only involve insulin and glucose but interference with fat metabolism can also cause T2DM. Excess triglycerides (TGL) in the stomach adipose tissue cause central obesity. Subcutaneous fat has a high basal lipolysis level. The accumulation of visceral fat causes an increase in free fatty acids, causing a buildup of ectopic fat. In the end, it causes the accumulation of ectopic TGL in the muscles, liver, heart, and pancreatic β-cells, which results in insulin resistance at the systemic level by interfering with insulin secretion and insulin signaling.[11]

The IG tends to have a good lifestyle in terms of physical activity. The participants from IG mostly work as housewives that make them sweat every day not because of doing sports but because they undergo their own physical activities by doing household chores such as sweeping, mopping the floor, washing clothes with hands, and carrying their children or grandchildren so that they meet the criteria for physical activity according to the American Diabetes Association (ADA) standard.[12]

Physical activities carried out in accordance with the recommendation (150 min/week) can activate the enzyme pathway in insulin receptors (e.g., adenosine monophosphate-activated protein kinase-AMPK) and protein kinase B substrate to increase glucose transport in skeletal muscle. They may also increase the use of fat reserves as an energy source, and increased performance of mitochondria in the skeletal muscle can increase cell sensitivity to insulin. Muscle contraction as a response to the body during physical activity can increase glucose uptake in cells without using insulin. This activity is thought to involve several major proteins including AMPK, protein kinase C, Ca2+/calmodulin-dependent protein kinase, and mitogen- AMPK, and act as a substrate for 160 kDa (AS160).[13]

This study showed different results from previous studies conducted by Osterberg and Blaschke. Both IG and CG were shown to have behavioral changes, becoming more compliant because each respondent in both groups continued to feel supervised by health professionals during the study period. This symptom is commonly known as white-coat adherence, a result of interactions with health practitioners so that patients tend to improve their habits in taking medicine 5 days before and after they meet health practitioners.[14] Counseling is related to adherence (P = 0.006) [Table 2]. The group that received counseling had a higher proportion of adherence than controls. Improvement in adherence might be due to an increase in the respondent's understanding as a result of education provided through counseling.

Labrador Barba et al. stated that one of the main requirements in order to achieve treatment compliance is by increasing patients' knowledge about their disease and treatment. The majority of respondents understood the importance of taking medication and recognized the importance of getting adequate information about their illness, comorbidity, and benefits of the medicine. In addition, patients' involvement in the selection of the therapy can also increase their adherence to the therapy they undergo, especially patients on insulin therapy.[15]

Research conducted by Shao et al. showed that additional services provided by pharmacists in the form of counseling can improve medication adherence and clinical outcomes of glycemic control, lipid profile, and blood pressure.[10] Similar finding has been proven in a study in Malaysia that the involvement of pharmacists in patients' treatment can improve compliance, HbA1c, and quality of life of the patients.[9] Vella and Azzopardi conducted research in Malta, where patients were given pharmacist intervention in the form of counseling and leaflets, and showed that there was an increase in the adherence of respondents after the intervention. In addition, improved the awareness of the treatment they undergo could decreased missed medicine taken.[16]

The categorization of clinical outcomes in a controlled–uncontrolled form in this study was based on the ADA guidelines. [Table 2] summarizes that the difference in PPBG between IG and CG was not significant and IG's HbA1c decreased at posttest. The mean results of FBG and HbA1c in both groups were significantly different post test. The mean of HbA1c decreased in small amount (by 0.39%). The results were similar to a study conducted in China, where the decrease in the mean of HbA1c was only 0.9%, possibly because the condition of IG's HbA1c before intervention tended to be close to normal (7.29 ± 1.35).[10]

A systematic review of 118 studies by Chrvala et al. showed that the reduction of the mean of HbA1c as a result of diabetes self-management education (DSME) was 0.57%. Improvement of HbA1c was experienced by 61.9% of patients who received DSME compared to those who did not. Decreases were getting better in the study where the total interaction time between educators and patients over the study was more than 10 h.[17] At the end of the study, there was an increase in the proportion of respondents in the IG with controlled HbA1c conditions of 69.2% compared to before-the-pharmacist intervention of 56.4% (P < 0.05).

There was no significant difference in lipid profile between IG and CG. However, lipid profile changed in IG, as shown by the decrease of TC, LDL, and triglycerides, and an increase in HDL value (P < 0.05). The higher lipid profiles may also be due to the fact that majority (62.3%) of the respondents were female. According to Gupta et al.,[18] the average value of lipid profiles in females tends to be higher than that in males.

There was no significant difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) between IG and CG. SBP and DBP also did not change in each group [Table 2]. The effect of pharmacist's counseling and other independent variables on FBG and HbA1c was analyzed using binomial logistic regression. Bivariate analysis was performed for each independent variable on the dependent variable before performing mutivariate analysis. The results showed that counseling and the type of drugs used by respondents influence the FBG levels. Whereas in HbA1c, the type of the drug was the main factor that affected, while counseling along with other factors as a controlling factor for these changes [Table 4]. In the case of FBG, the IG was 2.764 times more likely to show FBG-controlled results than the intervention without counseling. Whereas in HbA1c, the IG was 9.964 times greater, which showed controlled results than the intervention without counseling.
Table 4: Multiple regression analysis on the influencing factors of fasting blood glucose and glycated hemoglobin

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In line with the results of this study, Shao et al. conducted research in China which showed that there is a linear relationship between HbA1c values and patient medication adherence as a result of pharmacist intervention in the form of counseling in a 6-month period.[10]

Nazir et al., in a study conducted in Pakistan, looked at the relationship between HbA1c levels, knowledge, and treatment adherence to DM patients and reported that HbA1c has a negative and insignificant relationship with diabetes-related knowledge (r = −0.036, P = 0.404) and medication adherence (r = −0.071, P = 0.238). Lack of knowledge related to diabetes among patients results in poor adherence to treatment and ultimately causes poor glycemic control. The causes of poor knowledge or inaccurate understanding of the diseases suffered include the lack of time to interact with medical practitioners, lack of counseling about their illnesses, and various sources of alternative medicine referrals that provide wrong information about DM, whereas the causes of medication noncompliance include poor knowledge; lack of understanding and concern for the illness; and the inability to access health services, which leads to differences in services, facilities, and treatment received by patients. This study suggests that future studies shall be conducted to look at the main causative factors that can affect glycemic control.[19] The present study results showed that pharmacist counseling has a significant effect on improving patient's clinical outcomes and glycemic control of FBG and HbA1c.

  Authors' Contribution Top

Wiwiet Nurwidya Hening participated in design, literature search, clinical studies, data analysis, statistical analysis, manuscript preparation, manuscript editing; Ratu Ayu Dewi Sartika participated in design, definition of intellectual content, statistical analysis, manuscript editing and manuscript review; Rani Sauriasari participated in concept, design, definition of intellectual content, statistical analysis, manuscript editing and manuscript review.

Financial support and sponsorship

This work was funded by the International Indexed Publication for Final Project UI Students (PITTA UI).

Conflicts of interest

There are no conflicts of interest.

  References Top

Al-Goblan AS, Al-Alfi MA, Khan MZ. Mechanism linking diabetes mellitus and obesity. Diabetes Metab Syndr Obes 2014;7:587-91.  Back to cited text no. 1
Ministry of Health of the Republic of Indonesia. Standard of Pharmaceutical Services at Hospitals. Jakarta: RI Ministry of Health; 2016.  Back to cited text no. 2
Pousinho S, Morgado M, Falcão A, Alves G. Pharmacist interventions in the management of type 2 diabetes mellitus: A systematic review of randomized controlled trials. J Manag Care Spec Pharm 2016;22:493-515.  Back to cited text no. 3
Collins C, Limone BL, Scholle JM, Coleman CI. Effect of pharmacist intervention on glycemic control in diabetes. Diabetes Res Clin Pract 2011;92:145-52.  Back to cited text no. 4
World Health Organization. Global Report on Diabetes. World Health Organization; 2016.  Back to cited text no. 5
American Diabetes Association. Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes. American Diabetes Association; 2018. Available from: http://www.diabetes.org/newsroom/press-releases/2017/american-diabetes-association-2018-release-standards-of-medical-care-in-diabetes.html?referrer=https://www.google.co.id. [Last accessed on 2018 Jan 05].  Back to cited text no. 6
Mathieson K. Making sense of biostatistics: Types of nonprobability sampling. J Clin Res Best Pract 2014;10. Available from: https:// firstclinical.com/journal/2014/1410_Biostatistics64.pdf. [Last accessed on 2018 Jan 05].  Back to cited text no. 7
International Diabetes Federation. IDF Diabetes Atlas. 8th ed. Brussels: International Diabetes Federation; 2017.  Back to cited text no. 8
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Labrador Barba E, Rodríguez de Miguel M, Hernández-Mijares A, Alonso-Moreno FJ, Orera Peña ML, Aceituno S, et al. Medication adherence and persistence in type 2 diabetes mellitus: Perspectives of patients, physicians and pharmacists on the Spanish health care system. Patient Prefer Adherence 2017;11:707-18.  Back to cited text no. 15
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Gupta A, Tyagi V, Virmani S. Evaluation of pattern of dyslipidemia and its association with obesity in type 2 diabetes mellitus. J Contemp Med Res 2015;2:1432-5.  Back to cited text no. 18
Nazir SU, Hassali MA, Saleem F, Bashir S, Aljadhey H. Disease related knowledge, medication adherence and glycaemic control among patients with type 2 diabetes mellitus in Pakistan. Prim Care Diabetes 2016;10:136-41.  Back to cited text no. 19


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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