Pharmacist-managed Clinic Research Articles

Effects of pharmacists’ interventions on patient outcomes in an HIV primary care clinic

The effects of pharmacists' interventions on patient outcomes in an HIV primary care clinic were studied. All study participants were referred to a pharmacist-managed drug optimization clinic (DOC) in a county-based HIV primary care clinic between November 1, 2003, and September 30, 2004. Patients were eligible for study participation if they were 18 years of age or older and gave informed consent to participate. Pharmacists' interventions were categorized as follows: patient education, addition of a medication, dosage adjustment, discontinuation of a medication, and interpretation of viral-resistance tests. Changes in baseline CD4+ T-lymphocyte counts and viral load were also measured over the study period. Toxicities related to highly active antiretroviral therapy were recorded and graded from 0 to 4, with 0 indicating no toxicity and 4 indicating severe toxicity. Study participants used a standardized survey to measure their own health-related quality of life. Changes in CD4+ lymphocyte counts and viral load were analyzed using Student's t test and analysis of variance. Toxicity grades were analyzed using the Wilcoxon signed-rank test. A total of 34 patients completed the study. Pharmacists made a total of 253 interventions, most of which were categorized as patient education. The mean CD4+ lymphocyte count increased from baseline levels by 54 +/- 78 cells/mm3 over the study period (p < 0.0002). The mean +/- S.D. reduction in circulating viral load over the study period was 1.02 log10 copies/mL ( p < 0.004). HIV-infected patients who were managed by pharmacists in a DOC demonstrated significant improvement from baseline in their CD4+ lymphocyte counts, viral loads, and drug-related toxicities.

Pharmacist’s role in managing anemia in patients with chronic kidney disease: Potential clinical and economic benefits

Barriers to the treatment of anemia in patients with chronic kidney disease (CKD), the role of pharmacists in screening patients for anemia and developing guidelines for the use of anemia therapies in patients with CKD, the goals of and considerations in developing pharmacist-managed anemia management clinics, and the potential benefits of these clinics are described. The complexity of patients with CKD, patient nonadherence to the treatment regimen, a shortage of nephrologists, and a lack of familiarity with clinical practice guidelines and recommendations for treating anemia in these patients are possible barriers to the treatment of anemia. Pharmacists can play a role in improving the treatment of anemia in patients with CKD by screening for anemia, developing guidelines for the use of anemia therapies, and providing patient education to promote adherence to the treatment regimen. The optimal upper limit for hemoglobin concentration during treatment with erythropoietin-stimulating agents (ESA) in patients with CKD remains to be determined, but it should not routinely exceed 13.0 g/dL. Extended dosing of darbepoetin alfa and the new agent continuous erythropoiesis receptor activator appears effective. Iron status often is not assessed in patients with CKD because of difficulty interpreting iron laboratory values and identifying iron deficiency. The usefulness of iron supplementation is not limited to patients with iron deficiency. The intravenous (i.v.) or oral route of administration may be used for iron supplementation in predialysis patients and peritoneal dialysis patients, but the i.v. route is recommended for hemodialysis patients. Adverse effects and drug interactions limit the use of oral iron supplements. Administration of parenteral iron is time consuming and accompanied by concerns about iron accumulation and uncertainty about the optimal maximum serum ferritin concentration. Improved access to care and clinical outcomes and reduced costs have been documented in pharmacist-managed anemia management clinics. Pharmacists can help overcome barriers to treating anemia in patients with CKD. Clinical and economic benefits are associated with pharmacist-managed anemia management clinics.

Pharmacist‐Managed Vaccination Program Increased Influenza Vaccination Rates in Cardiovascular Patients Enrolled in a Secondary Prevention Lipid Clinic

To determine whether a vaccination program in a pharmacist-managed secondary prevention lipid clinic increased influenza immunization rates in a high-risk population, and whether age or gender disparity existed among those vaccinated. Retrospective chart review. Large, multispecialty, group practice. A total of 476 and 266 patients seen at clinic visits during the 2003-2004 and 2004-2005 influenza seasons, respectively. Immunization rates were compared before (2003-2004 influenza season) and after (2004-2005 influenza season) the implementation of the influenza vaccination program; chi2 analysis was used for all statistical inferences. Vaccination rates increased significantly from 39% to 76% (p<0.0001) after program implementation. No before-after difference in rates was noted based on gender. Before implementation, patients younger than 65 years were less likely versus those aged 65 years or older to receive the influenza vaccine (29% vs 58%, p<0.0001). Age disparity in vaccination rates was eliminated after initiation of the program. The pharmacist-managed program increased influenza vaccination rates in high-risk patients with cardiovascular disease in advance of the newly published secondary prevention guidelines. Age-related differences in the vaccination rates were eliminated after program implementation.

Evaluation of a pharmacist-managed hepatitis C care clinic

A description of an effort to create a more time, labor, and cost-efficient method for the management of patients with hepatitis C virus (HCV) infection in Department of Veterans Affairs (VA) hospitals is provided; this pilot study also revealed the outcomes of a pharmacist-managed clinic for these patients in comparison to established standards of care. A retrospective analysis was performed on data obtained from patients who were referred to the clinic between October 2002 and March 2004 and who had a clinical pharmacist as their primary treatment provider. The patients' medical records were searched for demographic information, disease characteristics, treatment information, treatment and safety information, and virological response. Thirty-one patients were evaluated, and 27 were offered antiviral therapy in the hepatitis C care clinic between October 2002 and March 2004. Of the 27 patients who had sufficient data for analysis, there was a sustained response rate of 63% (17 of 27) overall after treatment with peginterferon and ribavirin combination therapy. Only 3 patients (11%) stopped therapy early secondary to adverse effects, whereas 8 (30%) were managed with growth factors. VA patients managed by a clinical pharmacist for the treatment of chronic HCV infection demonstrated similar treatment outcomes compared with the results from earlier studies with VA patients managed with traditional care. Further studies are warranted to investigate the role of the pharmacist in the management of patients with HCV infection.

Evaluation of patient and provider satisfaction with a pharmacist-managed lipid clinic in a Veterans Affairs medical center

Patient and provider satisfaction with a pharmacist-managed lipid clinic in a Veterans Affairs medical center were assessed. All patients at Louis Stokes Cleveland Veterans Affairs Medical Center who were referred to a pharmacist-managed lipid clinic for drug therapy management were mailed a questionnaire addressing overall satisfaction with care provided by the lipid clinic. Chart reviews were performed for patients completing the questionnaire to ascertain lipid-lowering medications used, changes in serum cholesterol levels, and achievement of low-density-lipoprotein (LDL) cholesterol goal. Health care providers referring patients to the lipid clinic were sent an anonymous electronic questionnaire to assess provider satisfaction with the clinic. Responses to the questionnaire were rated on a Likert scale (strongly agree, somewhat agree, neutral, somewhat disagree, strongly disagree). A paired t test was used to assess the percent change in lipid values, and chi-square analysis was used to evaluate the achievement of each patient's LDL cholesterol goal. Surveys were sent to 224 patients and 104 providers. A total of 105 patients (47%) and 49 providers (47%) completed the questionnaire. Most patients and providers expressed satisfaction with the clinic, with 91.4% of patients and 87.8% of providers indicating that they were strongly or somewhat satisfied with the care provided by the pharmacist-managed clinic. Attainment rates of goal LDL cholesterol levels increased from 8.6% at baseline to 53.3% at discharge or the most recent measurement (p < 0.001). Most patients and providers were satisfied with the services provided by the pharmacist-managed lipid clinic. The clinic helped improve patients' LDL cholesterol, total cholesterol, and triglyceride levels.

Development and clinical outcomes of pharmacist-managed diabetes care clinics

The development and outcomes of two pharmacist-managed diabetes care clinics (DCCs) are described. Retrospective data analysis was performed to determine the outcomes for patients with type 2 diabetes mellitus who were treated in two pharmacist-managed DCCs. Primary outcome measures included changes in glycosylated hemoglobin (HbA(1c)), fasting plasma glucose, body mass index, low-density-lipoprotein (LDL) cholesterol, high-density-lipoprotein cholesterol, triglycerides, and blood pressure and documented annual retinal and micro-albumin screening. Secondary outcome measures included the use of aspirin and kidney-sparing agents and annual screening for thyroid-stimulating hormone. Data from 113 patients in the DCCs were analyzed. After one year, the mean reduction in HbA(1c) levels was 1.3%, with a mean HbA(1c) of 7.8%. HbA(1c) goals were based on the institution's HbA(1c) normal range of 4.1-6.5%. Compared with baseline, over one third of patients met the HbA(1c) and blood pressure goals of <7.5% and <130/80 mm Hg, respectively. Mean LDL cholesterol concentration decreased from 110 to 94 mg/dL. The mean concentration of triglycerides decreased from 243 to 178 mg/dL. Mean systolic blood pressure decreased from 136 to 132 mm Hg. Whereas the national average for uncontrolled diabetes (HbA(1c) > 9.5%) was 36.9%, only 3.5% of patients at the pharmacist-managed DCCs had uncontrolled diabetes. Attainment rates of LDL cholesterol goals and annual retinal and microalbumin screenings were significantly higher in clinic patients compared with national averages. Three-year postclinic inception data revealed similar favorable outcomes, most notably an average HbA(1c) of 7.6% and 55% of patients meeting their target HbA(1c) goal of <7.5%. Compared with national averages, DCCs managed by clinical pharmacists achieved higher screening rates and attained treatment goals more often.

Positive benefits of a pharmacist-managed hypertension clinic in Nigeria

The aim of this study was to determine whether the provision of further practice-based support by pharmacists will bring about improved outcomes for blood pressure (BP) control in middle-aged and elderly Nigerian hypertensive patients managed with combination diuretics (amiloride hydrochloride 5 mg+hydrochlorothiazide 50 mg) and/or methyl dopa at the primary care level. This was a 1-year prospective, randomized cohort study of the outpatients of a state comprehensive health centre in South-western Nigeria. Free primary health services including free drugs were provided for all patients. The study population comprised 51 Nigerian patients with uncomplicated hypertension aged 45 years or more, with a 0.2-3.0-year history of hypertension, registered at the Comprehensive Health Centre, Ife between October 2002 and March 2003. They were invited into the pharmacist-managed hypertension clinic and followed for the study period. Participating pharmacists counselled for current medication, personalized goals of lifestyle modification stressing weight loss and/or increased activity, increased patient awareness by providing relevant education about hypertension and associated/related diseases, adjusted drug therapy to optimize effectiveness and minimize adverse events, utilized treatment schedules that enhanced patients' adherence to therapy, and monitored treatment outcomes between enrollment and return visits. Patient satisfaction and the number of treatment failures within 6 months post enrollment were compared with retrospective data from our earlier study involving physician-managed patients under a similar setting. Uncontrolled BP reduced from 92 to 36.2% by 10.15+/-5.02 days after enrollment. Treatment failures were observed at 5.9% of the total return visits (n=184) within 6 months. Pharmacist-managed hypertension clinics can improve BP control, reduce treatment failure and increase patient satisfaction.

Outcomes from an Outpatient Smoking-Cessation Clinic

To determine the success of an outpatient smoking-cessation clinic by assessing smoking abstinence rates and factors associated with lower abstinence rates. We also sought to determine whether smoking abstinence rates differed among various smoking-cessation products. Patients were referred by primary care providers to a pharmacist-managed smoking-cessation clinic. Patients received tailored behavioral counseling, educational materials, and drug therapy consisting of sustained-release (SR) bupropion; nicotine patch, inhaler, or nasal spray; or combination therapy. Patients were monitored by phone or clinic visit for 6 months, if possible. Outcomes assessed were abstinence (both point prevalence and continuous abstinence) and adverse effects. Patients lost to follow-up were assumed to be smoking. Over 2 years, 198 patients were enrolled in the program. At the initial visit, 35.4% received the patch, 32.8% bupropion SR, 18.2% a combination of patch plus inhaler, 9.6% inhaler alone, and fewer than 5% other therapies. At 6 weeks, a statistically significant difference was observed in continuous abstinence rates between the nicotine patch versus bupropion SR groups (22.9% vs 7.7%, p=0.02) and between the combination patch-inhaler versus bupropion SR groups (25% vs 7.7%, p=0.02). However, this difference was not significant beyond the 6-week visit. A trend toward higher abstinence rates was noted at 6 weeks in the nicotine patch-inhaler versus the other treatment groups, possibly suggesting the need for more intense treatment regimens with combination therapy. Point prevalence abstinence rates after 12 weeks were 18.6%, 15.4%, 22.2% and 21.1% respectively, for the patch, bupropion SR, patchinhaler, and inhaler alone treatment groups. The corresponding continuous abstinence rates were 10.0%, 3.1%, 11.1%, and 10.5%. Although statistically significant differences between products were noted at 6 weeks, no sustained difference in smoking abstinence rates was observed between products. At 6 months, point prevalence and continuous abstinence rates were small, but the decline in success noted over time and the limited overall success rates are consistent with rates for the United States. Our findings suggest that when smokers are assisted in quitting, initial contact as well as follow-up evaluation and monitoring must be intense and sustained to increase the likelihood of successful abstinence. Tobacco dependence is clearly a chronic condition warranting repeated treatment and monitoring until continuous abstinence is achieved.

Treating Veterans for Helicobacter Pylori Infection: Retrospective Evaluation of Long-term Outcomes

Purpose This study documented the long-term outcomes of patients treated in a pharmacist-managed Helicobacter pylori (HP) clinic. Background An HP clinic was created in 1996 at a Veterans Affairs (VA) hospital. Patients received clarithromycin/amoxicillin-based therapy according to the clinic protocol. Clarithromycin use was restricted to treatment of HP infection. Metronidazole was used instead of amoxicillin in penicillin allergic patients. Results at 1 year showed that 53% of the patients were able to discontinue chronic heartburn therapy. Outcomes beyond 1 year were not established. Methods The electronic records of patients treated at the HP clinic from June 1996 to March 2001 were evaluated. Patients with at least 2 years of follow-up information were included. Baseline demographic and long-term outcome data were collected. Discontinuation rate, failure rate, and need for retreatment were evaluated. Results Of 229 patients treated during the period studied, at least 2 years of data was available for 198 individuals. Of these, 177 were men and 21 were women. Three of the 198 patients (1.5%) were unable to complete antibiotic therapy. Five patients (2.5%), two of them women, failed an initial course to eradicate HP. After treatment with bismuth-based therapy, four of these five patients showed documented eradication of infection. Forty-four percent of patients were off chronic therapy at the time of last review. Conclusions A pharmacist-managed HP treatment clinic can facilitate discontinuation of chronic acid suppressive therapy in more than a third of patients. A low treatment failure rate — below the national average for clarithromycin-based regimens — was found in our population.

Pharmacist-managed pain clinic at a Veterans Affairs Medical Center.

Pharmacist-managed pain clinic at a Veterans Affairs Medical Center.

A literature review of cardiovascular disease management programs in managed care populations.

(1) To review the literature on cardiovascular disease management programs in managed care populations, (2) compare the rigor of the studies and their findings by disease state, and (3) posit directions for future research. A total of 20 studies conducted in managed care populations were reviewed: 5 in patients with congestive heart failure (CHF), 9 in hypertensive patients, and 6 in hyperlipidemia and/or coronary artery disease (hyperlipidemia- CAD) patients. Management of CHF involved multifaceted programs that included the participation of multiple health care professionals, patient and physician education, promotion of intensive drug therapy and lifestyle modifications, and close patient monitoring. The most common CHF management strategies were case management and physician education, with an emphasis on close patient monitoring. Hypertension and hyperlipidemia-CAD intervention programs focused on chronic outpatient management and regular follow-up, with an emphasis on self-management skills. These programs were managed through regular and periodic interventions, including pharmacist-managed clinics and automated provider notices. Many of the studies employed "before-after" comparisons in the absence of a truly experimental design and posed significant limitations due to variations in the outcomes measured, lack of transparent disease severity stratification, and variation across types of managed care organizations. A number of cardiovascular disease management strategies in the literature reported promising results. Many of the multidisciplinary CHF disease management programs were more complex than were programs for hypertension and hyperlipidemia-CAD, due, at least in part, to the nature and severity of the disease. A lack of agreement on appropriate economic and clinical outcomes for evaluating the effectiveness of cardiovascular disease management strategies is readily apparent.

Effectiveness of an Amiodarone Protocol and Management Clinic in Improving Adherence to Amiodarone Monitoring Guidelines

Objective: To determine whether adherence to suggested monitoring parameters improved as a result of the development and implementation of an amiodarone protocol and management clinic. Adverse effects from amiodarone therapy were also evaluated to ascertain whether the Amiodarone Management Clinic (AMC) better identified adverse events as a result of improved monitoring. Methods: A retrospective review of charts of patients with an active amiodarone prescription was conducted. Patients were identified as enrolled in the AMC (intervention) or as receiving standard medical care (control) by nonpharmacist practitioners. Compliance with recommended monitoring parameters, including the presence of interacting medications and associated drug concentration or international normalized ratio (INR), was assessed for all patients and then compared between groups. Type and frequency of adverse effects were determined for both groups. Results: Two hundred twenty-five charts were reviewed; 154 and 71 patients were assigned to the intervention and control groups, respectively. One hundred one (66%) patients in the intervention group were considered compliant with thyroid function monitoring compared with 26 patients (37%) in the control group (p &lt; 0.0001). One hundred six (69%) and 27 (38%) patients in the intervention and control groups, respectively, were deemed compliant with liver function monitoring (p &lt; 0.0001). Intervention patients taking warfarin were more likely to have blood drawn for INR assessment; however, there was no difference in values between groups. Seventy-six patients had a documented adverse effect from amiodarone, 68 of whom were from the intervention group (p &lt; 0.0001). Conclusions: Many patients receiving amiodarone are not managed according to published guidelines. Implementation of a pharmacist-managed protocol and clinic significantly improved compliance with 2 of the 3 parameters needing continuous monitoring. Although more adverse effects were documented for intervention patients, it is unclear whether the AMC actually improved the event detection rate.

Glycemic control and medication compliance in diabetic patients in a pharmacist-managed clinic in Hong Kong

Glycemic control and medication compliance in diabetic patients in a pharmacist-managed clinic in Hong Kong

A Comparison of Orlistat Use in a Veteran Population: A Pharmacist-Managed Pharmacotherapy Weight-Loss Clinic versus Standard Medical Care

Objective: To determine whether a pharmacist-managed pharmacotherapy weight-loss clinic using orlistat is beneficial in promoting weight loss and reducing cardiovascular risk. Methods: A retrospective review of the records of all veterans receiving orlistat was conducted. Patients were assigned to 1 of 2 treatment groups: those enrolled in the pharmacist-managed pharmacotherapy weight-loss clinic (intervention) or those receiving standard medical care (control). Changes in weight and body mass index (BMI) at 6 months were compared with baseline measures. Treatment success, defined as a weight loss of ≥5% of initial body weight, was determined. The impact of weight loss on cardiovascular risk factor reduction was compared within each group. The prevalence of adverse drug reactions was also assessed and compared. Results: Forty-seven patients were included in the analysis: 18 and 29 in the intervention and control groups, respectively. Intervention patients lost a mean ± SD of 5.0 ± 6.0 kg by 6 months compared with 2.2 ± 4.7 kg for the controls (p = 0.109). BMI significantly decreased for all patients independent of group assignment (intervention, p = 0.006; control, p = 0.026), yet a between-group comparison revealed no difference (p = 0.140). Five patients (28%) in the intervention group were considered treatment successes versus 4 (14%) in the control group; however, this was not a significant difference (p = 0.274). Total cholesterol and glycosylated hemoglobin were significantly decreased in intervention patients, while control patients demonstrated significant improvement only in total cholesterol. There was no difference in adverse reaction occurrence between groups (p = 0.995). Conclusions: Patients enrolled in the pharmacist-managed pharmacotherapy weight-loss clinic lost twice as much weight, and twice as many were considered treatment successes compared with control patients. Intervention patients demonstrated improvement in several cardiovascular risk factors.

A pharmacist-managed clinic for treatment of latent tuberculosis infection in health care workers.

A pharmacist-managed clinic for treating latent tuberculosis infection (LTBI) in health care workers (HCWs) is described. The hospital-based clinic was begun in 1993 after a review showed that only 0.8% of HCWs at the institution who were prescribed isoniazid for LTBI completed it. The goals of the clinic are to improve HCWs' adherence to LTBI treatment, enhance outcomes, and minimize adverse drug reactions. The clinic is staffed by a pharmacist, a medical resident, and a nurse. If an employee is diagnosed with LTBI, he or she is referred to the clinic, where the pharmacist conducts an initial assessment and provides information on medication available for treatment. The worker is then scheduled for monthly follow-up visits with the pharmacist for the first three months of LTBI therapy, during which the pharmacist evaluates treatment adherence and potential adverse effects. Thereafter, the pharmacist interviews the patient monthly by telephone until therapy is complete. HCWs are allowed only a one-month supply of medication with each refill. From June 1993 through June 1997, of 131 employees who started treatment, 122 (93%) completed it. From June 1997 through December 2001, annual therapy completion rates ranged from 90% to 100%. No cases of active tuberculosis have been reported in treated patients, and only nine adverse drug reactions were reported for the 1997-2001 period. A pharmacist-managed clinic substantially improved rates of treatment completion among HCWs with LTBI.

A primer for developing pharmacist-managed clinics in the outpatient setting.

Pharmacist-managed clinics exist in many practice settings, such as physician offices, hospital-based outpatient clinics, and pharmacies. This article is intended to serve as a primer for pharmacists who wish to establish clinical pharmacy services in these settings. Recommendations for beginning this process are delineated. Information on building initial support, developing a needs assessment analysis, selecting the focus of new clinical services, developing a detailed clinic proposal, and marketing new services is provided. In a comprehensive review of how to develop a clinic proposal, the purpose, background information, proposed clinic structure, implications, assessment, billing issues, financial summary, and resources requested are discussed. Opportunities for financial compensation in various practice settings, such as the physician outpatient clinic, hospital-based outpatient clinic, and community pharmacy, are also reviewed.

Pharmacist-Managed Lipid Clinics: Development and Implementation in the Canadian Forces

Pharmacist-Managed Lipid Clinics: Development and Implementation in the Canadian Forces

Treatment of Very High Triglycerides with Fish Oils: A Review of 2 Cases

Objective: To report 2 cases of serum triglycerides &gt;1000 mg/dL (i.e., very high serum triglycerides) in which fish oil was used because of treatment failure or intolerance with conventional therapeutic modalities. Case Summary: Two individuals with a history of serum triglycerides &gt;1000 mg/dL were referred to a pharmacist-managed lipid clinic by their primary-care provider because of either treatment failure or intolerance to conventional therapeutic modalities. Fish oils were used in lieu of and in addition to conventional treatment modalities in cases 1 and 2, respectively. Both cases demonstrated that fish oil, at doses ranging from 1 to 6 g/d, decrease triglyceride levels to a degree similar to conventional measures. Both patients tolerated fish oil well; however, increases in liver transaminases were observed. Discussion: Published studies have shown that fish oil can reduce elevated plasma triglycerides by an average of 30–52% in subjects with borderline-high (150–199 mg/dL) to high (200–499 mg/dL) triglycerides. Both of our cases reflect similar results in patients with very high triglycerides. Although fish oil has not been reported to induce hepatotoxicity, both of our patients experienced an increase in transaminases while on fish oil therapy. Whether fish oil truly causes hepatic injury remains to be elucidated. Conclusions: Fish oil supplementation is effective and generally well tolerated in patients with very high triglycerides and can be used as either alternative or adjunctive therapy when conventional treatment modalities become ineffective or intolerable.

A retrospective cohort analysis of the clinical effectiveness of a physician-pharmacist collaborative drug therapy management diabetes clinic.

The glycemic control of patients with diabetes in a physician-supervised, pharmacist-managed primary care clinic was compared with that of patients receiving standard care in the same health care system. We retrospectively analyzed the glycemic control of 87 men with type 1 or type 2 diabetes whose diabetes-related drug therapy was managed by clinical pharmacists compared with a control group of 85 similar patients whose care was not augmented by clinical pharmacists. Primary outcomes were differences in fasting blood glucose (FBG) and glycosylated hemoglobin (A1C) levels between groups. Secondary outcomes were relative risk (RR) for achieving an A1C of 7% or below, frequency of diabetes-related scheduled and unscheduled clinic visits, and frequency of hypoglycemic events. The study group had 864 clinic visits and the control group had 712 between October 1997 and June 2000. No statistical differences were noted in FBG or A1C between groups. The RR of achieving an A1C of 7% or below was significantly higher in the study cohort (RR 5.19, 95% confidence interval [CI] 2.62-10.26). The frequency of hypoglycemic events did not differ between groups. The mean +/- SD frequency of unscheduled diabetes-related clinic visits/patient/year was higher in the control group (1.33 +/- 3.74) than in the study group (0.11 +/- 0.46, p = 0.003). Pharmacist-managed diabetes care was effective in improving glycemic control and was not associated with an increased risk for hypoglycemic events or unscheduled diabetes-related clinic visits.

Pharmacist-managed clinics optimise treatment in CAD

Pharmacist-managed clinics optimise treatment in CAD