Rural Family Medicine Clinic Research Articles

Effectiveness of a health literacy intervention to improve diabetes outcomes in rural family medicine clinics: a randomized pragmatic trial

Effectiveness of a health literacy intervention to improve diabetes outcomes in rural family medicine clinics: a randomized pragmatic trial

Can You Hear Me Now? Patient Perceptions of Telehealth in a Rural Primary Care Population.

Background: The COVID-19 pandemic significantly increased telehealth adoption. Rural communities experience challenges relating to telehealth, including a shortage of clinicians, low health literacy, mistrust of medicine, and limited technology access, yet rural perceptions have not been a subject of robust study. The setting of this study was a rural Midwestern family medicine clinic within an academic health system. Methods: Surveys were given to all patients of age 18 or older visiting the clinic over a one-week period. Those who expressed interest were contacted for a semistructured interview. Descriptive statistics and chi-square testing were used to analyze survey results for significant relationships, while interview transcripts were analyzed for themes. Results: Of respondents, 27% indicated prior telehealth use and were more likely to prefer telehealth visits (p = 0.03). Perceptions of telehealth were sorted into themes, including scope of care, convenience, and technology. Telehealth was preferred for discussing test results or mental health. Barriers such as travel time and transportation access favored telehealth. Although more convenient, telehealth was found to be less effective for relationship building. The absence of physical examination during phone visits was a concern. Phone visits were more prevalent due to failure of video-based technology. Conclusions: Despite the potential to address these unique challenges in rural communities, telehealth acceptance is poor. Barriers such as accessibility of technology can be improved through governmental and health systemwide measures. Future work can help develop interventions that counter negative perceptions of telehealth while increasing interest and uptake in rural communities.

Effects of Academic Detailing, Panel Management and Mailed Multi-Target Stool-DNA Testing on Colorectal Cancer Screening.

Academic detailing, patient-panel management, and mailed, stool-based testing have each been utilized to increase colorectal cancer (CRC) screening in rural clinics. The effectiveness of combining these interventions to increase CRC screening during COVID-19 restrictions was unclear. We explored the effects of a multi-component intervention including academic detailing, active patient panel management, and mailed MT-sDNA testing on colorectal cancer screening in our rural family medicine clinic. Baseline interventions included EMR-based provider alerts and mailed patient reminders. Our intervention (March-May 2020) and follow-up periods (June-August 2020) coincided with the initial COVID-19 surge, giving us the opportunity to observe the effects of our intervention during COVID-19 restrictions. A total of 407 patients were eligible and overdue for colorectal cancer screening. Our clinic's CRC screening rate increased significantly after intervention (69.7%) as compared with before (64.3%) (P = <0.01; 95%CI = 5.39-5.4). Our clinic's CRC screening rates increased significantly during the initial 3 months of the COVID-19 surge (67.8%) compared with the same period the prior year. (62.3%) (P = .003; 95%CI = 3.4-7.6). Our CRC screening rates increased after intervention (69.7%) compared with our regional health system (67%) (P = <0.01; 95%CI = 2.6-2.77). Our weekly stool-based CRC screening increased (94% increase) compared with other health systems nationally (61 to 83% decrease). A multi-component intervention, including academic detailing, panel management, and mailed MT-sDNA testing, can lead to significant increases in CRC screening in a rural family medicine clinic, empowering providers to maintain an effective CRC screening outreach during COVID-19 related restrictions.

Improvement in Clinical Outcomes and Access to Care With Pharmacist-Led Chronic Care Management Services at a Rural Family Medicine Clinic

Background: Chronic care management (CCM) can significantly impact the management of chronic diseases in rural patient populations. To date, few practice models have addressed its impact on clinical outcomes and access to care in rural practice settings. Objective: Implement a sustainable pharmacist-led CCM practice model while tracking clinical outcomes and healthcare access at a rural, medically underserved family medicine clinic. Methods: This study retrospectively examined data from the clinic’s CCM program from October 2020 through May 2021 and included total clinical encounters at three- and 6-months intervals, as well as changes in clinical outcomes like A1c and systolic blood pressure (SBP) at three- and 6-months intervals. Results: Over an 8-month period, 46 patients were enrolled in pharmacist-led CCM services. Those with a CCM encounter or office visit within 3 months of enrollment showed a mean A1c reduction of 1.07% after 3 months (95% CI −1.70 to −.44, P = .0016), while those with an encounter or office visit within 6 months of enrollment displayed a mean A1c reduction of 1.64% after 6 months (95% CI −2.35 to −.92, P < .001). There was a 73.8% increase in total clinical encounters in the 6 months after CCM enrollment compared to the 6 months preceding it, signifying increased access to care. Conclusion: Patients with CCM encounters or office visits within the first 3-6 months experienced statistically significant reductions in A1c. Moreover, total clinical encounters markedly increased in the 6 months after enrollment, allowing for more frequent engagement between ambulatory pharmacists and traditionally challenging rural patients.

Evaluation of quality measure attainment with pharmacist-delivered Medicare annual wellness visits

BackgroundMedicare is required to fully cover annual wellness visits (AWVs) to increase access to preventive care. As health care converts to pay for performance models, clinical quality measures have increasing importance. Few studies have investigated the effect of pharmacist-delivered AWVs on clinical quality measure attainment in a rural family medicine (FM) clinic setting. ObjectivesThe primary objective of this study was to evaluate attainment of clinical quality measures for pharmacist-delivered AWVs compared with physician-delivered AWVs (usual care). Secondary objectives included assessment of the number and type of drug therapy problems (DTPs) identified by pharmacists during AWVs. MethodsThis single-center retrospective cohort study was conducted within an FM clinic located in southwest Georgia. Two cohorts were created according to the provider of AWVs during 2017: pharmacist or physician-usual care. Data on quality measure eligibility, attainment, and DTPs (for the pharmacist group only) were collected through electronic chart review. Descriptive statistics were used to characterize variables, and chi-square (or Fisher exact where appropriate) tests to compare the proportion of clinical quality measures attained between groups. ResultsAmong 334 delivered AWVs, pharmacists performed 68.6%. Approximately 62% of pharmacist and usual care visits were female with mean ages of 72 (SD +/− 9.1) and 62 (SD +/− 13.9) years, respectively. Pharmacist-delivered AWVs had statistically significant greater quality measure attainment in the following categories: advance care planning, osteoporosis cardiovascular screenings, and Tdap vaccinations compared with usual care (P < 0.05). Usual care had statistically significant greater quality measure attainment for diabetes screening. Seventy-five DTPs were identified in the pharmacist group, with the majority being related to adherence (39%). ConclusionPharmacist-delivered AWVs had greater quality measure attainment in several areas than usual care. Furthermore, increased quality measure attainment may assist in meeting benchmarks set by payers to ensure ongoing reimbursement of these services.

Pharmacist‐led phone call initiative targeting hemoglobin A1c levels in patients with uncontrolled diabetes

AbstractPurposePharmacist‐led telemedicine initiatives have been shown to lower hemoglobin A1c (HbA1c) levels compared with usual care, but few studies have targeted patients with uncontrolled diabetes in the rural setting. The purpose of this study was to evaluate the impact of a pharmacist‐led diabetes telemedicine initiative on HbA1c in patients with uncontrolled diabetes at a family medicine clinic in rural North Carolina.MethodsPharmacists implemented a telemedicine initiative to help manage patients with uncontrolled diabetes at a large, rural family medicine clinic. Adult patients with uncontrolled diabetes were identified through a generated report or by provider referrals. Pharmacy residents called each patient and documented type of interventions, demographic information, and HbA1c results. Patients were followed within a time period of 18 months (September 2018‐March 2020).ResultsA total of 64 patients were successfully contacted by the telemedicine program. The patients were primarily non‐Hispanic, white patients (50% female) with type 2 diabetes on insulin. The most common interventions that patients received included general education (68.8%), scheduling labs (51.6%), insulin titration (51.6%), and facilitating medication access (50.0%). For patients who had been in the telemedicine program long enough to have had an HbA1c lab completed post‐contact (n = 46), there was a significant reduction of 1.15 in mean HbA1c (t = −3.5, P &lt; .01) compared with their initial HbA1c prior to receiving phone calls.ConclusionA pharmacist‐led diabetes telemedicine program was associated with a reduction in HbA1c for patients with uncontrolled diabetes in a rural family practice.

Response: Re: Effects of Implementing a Comprehensive Opioid Reduction Protocol on Overall Opioid Prescribing Among Patients with Chronic, Non-Cancer Pain in a Rural Family Medicine Clinic: A Controlled Crossover Trial

To the Editor: We appreciate Dr. Gase’s drawing attention to the patient’s experience during opioid reduction. We agree with the importance of functional assessment, longitudinal followup,* and treating the whole person. However, we believe that Dr. Gase, and the medical community in general,

Diabetes-Related Patient Outcomes through Comprehensive Medication Management Delivered by Clinical Pharmacists in a Rural Family Medicine Clinic.

Two clinical pharmacy faculty members from a college of pharmacy provide comprehensive medication management in a rural family medicine clinic. The data was assessed for patients with diabetes managed by the pharmacists from 1 January 2017 through to 31 December 2019 to determine the service’s impact on patient outcomes. The primary outcome of this study is the change in the goal attainment rates of the three clinical goals of hemoglobin A1c, blood pressure, and appropriate statin therapy after pharmacist intervention. A total of 207 patients were included. At baseline, the patients had an average of 1.13 of the three goals met, improving to an average of 2.02 goals met after pharmacist intervention (p < 0.001). At baseline, 4.8% of the patients had met all three clinical goals, improving to 30.9% after pharmacist intervention (p < 0.001). There were significant improvements for the individual goal attainment rates of hemoglobin A1c (24.15% vs. 51.21%, p < 0.001), blood pressure (42.51% vs. 85.51%, p < 0.001), and appropriate statin therapy (45.89% vs. 65.70%, p < 0.001). This data adds to the evidence supporting the integration of clinical pharmacists into primary care clinics to improve patient outcomes related to diabetes.

Effects of Implementing a Comprehensive Opioid Reduction Protocol on Overall Opioid Prescribing Among Patients with Chronic, Non-Cancer Pain in a Rural Family Medicine Clinic: A Controlled Cross-over Trial.

The opioid crisis presents many challenges for family practice providers in rural communities who treat patients with chronic non-cancer pain (CNCP). Unfortunately, evidence for effective opioid reduction strategies is sparse. We evaluated the effects of implementing a comprehensive opioid reduction protocol on overall opioid prescribing among patients with chronic non-cancer pain in our rural family medicine clinics. We compared mean daily milligrams morphine equivalent (MME) prescribed to patients with CNCP in our rural family medicine clinic (n = 93) with another matched clinic (n =93) after implementation of our comprehensive protocol. We also compared mean daily MME prescribed to our patients with CNCP before and after implementation of the protocol. In a subsequent cross over phase, we examined the effects of the protocol when applied to the original control group patients. Mean daily MME in the intervention clinic (29.77) was significantly lower than the control clinic (93.2) after the intervention (t = 6.03; P < .00). Mean daily MME in the intervention group was significantly lower after implementation of the protocol (29.77) than before the protocol (MME 80.34) (t = 5.889; P < .00). After crossover, the mean daily MME was significantly lower (14.34) in the original control group than prior to the cross over intervention (85.68); (t = 8.19; P = .00). Our comprehensive opioid reduction protocol led to significant reductions in opioid prescribing in our rural family medicine clinics. Future studies should include important qualitative outcome measures such as patient function.

In the Name of Family Medicine: A Nationwide Survey of Registered Names of Family Medicine Clinics in Taiwan.

Family medicine is officially a specialty, but is often not regarded as a specialty by the general public. Past studies have usually investigated the opinions of medical students and resident physicians regarding family medicine, whereas few have focused on practicing family physicians themselves, especially in terms of analyzing how they represent themselves. This study aimed to investigate the patterns of clinic names to better apprehend whether general practitioners see themselves as being on an equal footing with other medical specialists. The registered names, medical specialties, and levels of urbanization of all clinics of Western medicine in Taiwan were collected. For clinics of each specialty, we examined whether their names contained the corresponding specialty designation. For example, a family medicine clinic was checked to determine whether its name contained the term “family medicine” or its abbreviation. The naming of family medicine clinics was then compared with that of clinics with other specialties. Of the 9867 Western medicine clinics included in this study, two-thirds (n = 6592) were single-specialty clinics. In contrast to the high percentages of single-specialty clinics of other specialties with specialty-containing names (97.5% for ophthalmology, 94.8% for dermatology, and 94.7% for otolaryngology), only 13.3% (132/989) of the family medicine clinics had such names. In addition, the urban family medicine clinics had a higher proportion (15.2%, 74/487) of specialty-containing names than the suburban (12.6%, 44/349) and rural family medicine clinics (9.2%, 14/153). Overall, a low percentage of family medicine clinics in Taiwan included “family medicine” in their names. This issue of professional identity deserves further qualitative investigation.

Barriers and solutions to implementing a pragmatic diabetes education trial in rural primary care clinics

IntroductionThe purpose of this report is to describe barriers and solutions to the implementation and optimization of a pragmatic trial that tests an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care in rural primary care clinics. MethodsThe two-arm pragmatic trial has been implemented in six rural family medicine clinics in Arkansas. It tests a self-management education and counseling intervention for patients with type 2 diabetes compared to enhanced usual care. Barriers and solutions were identified as issues arose and through interviews with clinic directors and clinic administrators and a focus group, interviews, and tracking reports with clinic health coaches who delivered the intervention. ResultsBarriers to optimizing enrollment, intervention delivery, and data collection were addressed through targeted education of and relationship building with leadership, changing enrollment oversight, and ongoing training of health coaches. ConclusionsSuccessful implementation and optimization of this pragmatic clinical trial in rural primary care clinics was achieved through establishing common goals with clinic leadership, minimizing demands on clinic staff and administration, frequent contact and ongoing support of health coaches, and collaborative troubleshooting of issues with delivering the intervention.

Impact of a Student Pharmacist Pilot Focused on the Transitions of Care Process From Emergency Department Visits to Family Medicine Follow-Up in a Rural Patient Setting

Introduction: Few would argue that emergency department utilization volumes do not tax the health system. Currently, there is not a process defined by Centers for Medicare and Medicaid Services for transitioning this patient population back to their primary physicians following emergency department visits. Resource limitations in a rural family medicine setting create barriers to dedicate focus on this important transitional care management from urgent care visits to primary care office. Objective: To describe a novel pilot process for transitional care management from the emergency department utilizing pharmacy student extenders to overcome resource limitation at a rural family medicine clinic and establish follow-up primary physician contact. Methods: From a master list provided, student pharmacists proactively telephoned patients and reviewed medication changes while assisting with scheduling follow-up appointments at the patient’s primary physician clinic. Results: The result of these efforts increased the communication with patients and resulted in a 26% (10/38) increase in follow-up appointments scheduled with a total increase of an additional 7 patients adhering to follow-up transitional appointment. Conclusion: This approach utilizing student extenders is a feasible and sustainable process that can increase patient contact when resources are limited, while serving as an educational tool for next generation providers.

Sugar-Sweetened Beverage Intake in a Rural Family Medicine Clinic.

Sugar-sweetened beverages (SSBs) are a major source of calories, and are associated with adverse health outcomes. Because the majority of studies are undertaken in urban areas, the rural intake of SSB presents a significant gap in current knowledge. The objective of our study was to assess SSB intake in a rural primary care clinic. The Beverage Intake Questionnaire is a 15-item self-reported questionnaire and has been extensively validated to assess habitual SSB consumption. The survey was administered to adult primary care clinic patients presenting for routine care over a 6-week period at a clinic in a rural central Nebraska community (population < 1,000). Survey participants (n = 121) were primarily white with an average age of 61 years (SD = 18.0) and an average body mass index (BMI) of 29.9 kg/m2 (SD = 7.5). Participants consumed an average of 1.05 SSBs per day (SD = 1.3), and 33.5% of respondents consumed one or more SSBs per day. The average daily caloric intake from SSBs was 153 Kilocalories (Kcals) compared the national average intake of 145 Kcals. The most commonly consumed caloric beverages, based on Kilocalories consumed, were 100% juice and regular soda. SSB consumption was not related to with BMI. In a rural primary care clinic, the daily consumption of SSB by patients was found to be a noteworthy source of calories, with no significant difference in consumption across BMI categories. Mitigation of SSB consumption by rural primary care clinicians is imperative for optimizing health.

Patient Body Mass Index (BMI) Knowledge in a Rural Primary Care Population.

Body mass index (BMI) is a traditional method of measuring obesity and an accepted quality measure in many health systems. However, little is known about how patients' understanding of BMI has progressed/changed in the last several years. The primary purpose of this study was to determine the change in patients' knowledge of BMI and weight-related risk factors. A secondary outcome of this study was to determine the incidence of physician discussion about BMI with the patient. We administered an anonymous survey to primary care patients in 33 rural family medicine clinics in 2013 and 2017. The survey included 8 questions regarding BMI knowledge and 5 demographic questions. A total of 573 patients completed the survey. There were 345 participants from 2013 and 238 from 2017. The sample included more women than men. There was no significant difference in age or proportion of comorbidities across the 2 survey years. Compared with year 2013, more survey participants from year 2017 knew that BMI stood for "body mass index" (71.1% vs 61.2%, P = .02) and understood what medical concerns were related to BMI (65.5% vs 50.7%, P = .0005). The percentages of participants who reported that their doctor ever discussed BMI with them went up from 20.1% to 28.7% (P = .02). In this cross-sectional cohort study, it was found that patients' knowledge about BMI and weight-related risk factors has increased modestly. However, despite the increase in patients' knowledge and discussions about BMI with their primary care physician, there was not a decrease in BMI. Future studies are needed to provide more detailed information about the discussion between patients and providers in relation to the patient's personal weight status.

Assessing the Effect of Pharmacist Care on Diabetes-Related Outcomes in a Rural Outpatient Clinic: A Retrospective Case-Control Study.

The care of diabetic patients in rural areas is complicated by factors such as poor health literacy, cultural barriers, and primary care provider (PCP) shortages. Integrating pharmacist care in diabetes management in these settings may increase access to care and improve patient outcomes. To evaluate differences in diabetes-related outcomes in patients with type 2 diabetes (T2DM) managed by a pharmacist diabetes clinic compared with patients only managed by PCPs in a rural family medicine clinic. This was a retrospective case-control study. The primary outcome was achievement of hemoglobin A1C (A1C) reduction ≥0.5%. Secondary outcomes included average A1C reduction, achievement of A1C goal, angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) use, statin use, blood pressure control, and frequency of nephropathy screenings. Patients ≥18 years old with an A1C ≥7% were eligible. Cases included patients established with the pharmacist diabetes clinic. Cases were matched to controls in a 1:1 ratio based on PCP, age (±5 years), gender, and race. A total of 21 pharmacist-managed patients met inclusion criteria. Cases were significantly more likely to experience an A1C reduction ≥0.5% (odds ratio = 7.51; 95% CI = 1.54-36.61; P < 0.01). Statistically significant improvements were also noted for ACE inhibitor/ARB use, statin use, and nephropathy screenings among cases. Patients managed by a pharmacist diabetes clinic were more likely to experience improved diabetes-related outcomes, including A1C reduction ≥0.5%. Pharmacist care, when added to standard care, can improve outcomes for patients with T2DM in rural areas.

Improving the Undiagnosed Rate of Diabetes Mellitus Using a Point-of-Care A1C Device

Aim: To determine the undiagnosed rate of diabetes and prediabetes in a high-risk rural population. Over 8% of the American population has diabetes mellitus. Portions of the country with the greatest prevalence include rural, underserved areas in the South. Despite its wide-spread prevalence 7 million are unknowingly living with the condition. Early detection allows for prevention of long-term disease complications. Methods: Patients at a rural family medicine clinic were prospectively pre-evaluated according to the American Diabetes Association’s criteria. Eligible adults were offered free point-of-care hemoglobin HbA1c screening. Results: Sixty-one percent (n=69) were unknowingly living with chronic hyperglycemia; 50% (n=57) had an HbA1c between 5.7% and 6.4%. Average HbA1c values for patients with euglycemia, prediabetes, and diabetes were 5.34%, 5.91%, and 6.88%, respectively. Body mass index (p=0.001) and age (p=0.0003) were statistically significant contributors to HbA1c. Conclusion: Systematically screening asymptomatic adults for diabetes is important. Using a convenient point-of-careHbA1c device facilitated diagnosis and further articulated the incidence of diabetes and prediabetes in a rural underserved population. In turn, early diagnosis and intervention allows patients to incorporate daily healthy behavioral strategies which can delay the diagnosis or slow the progress of diabetes and ultimately improve morbidity and mortality.

An Advanced Registered Nurse Practitioner-Community Pharmacist Team-Based Approach to Managing Hypertension in a Rural Community Pharmacy

Purpose: To evaluate the implementation of an Advanced Registered Nurse Practitioner (ARNP) – community pharmacist team-based collaborative model for managing hypertension in a rural, Midwestern, community pharmacy and family medicine clinic using the core functions of the patient centered medical home model (PCMH).&#x0D; Methods: Thirteen patients with uncontrolled hypertension, 5 of who were newly diagnosed, were referred to the pharmacist by the ARNP. The pharmacist rechecked the patient’s blood pressure (BP) every 2 weeks after referral and made drug therapy change recommendations to the ARNP if the patient was not below goal.&#x0D; Results: Following the intervention, the average SBP and DBP decreased 24 mmHg and 12mmHg, respectively. The pharmacists made 21 recommendations (dose increase (11), add a medication (6), change a medication (2), and addition of an adherence tool (2)), 100% of which were accepted by the ARNP.&#x0D; Conclusion: A team-based approach to managing hypertension in a rural community pharmacy and family medicine clinic was an effective way to lower blood pressure. In addition, the core functions of the PCMH model can be delivered in a small family medicine practice. Creating specific expectations for each member of the team prior to referring patients improved the efficiency of the intervention.&#x0D; &#x0D; Type: Original Research

Complementary and alternative medicine use by visitors to rural Japanese family medicine clinics: results from the international complementary and alternative medicine survey.

BackgroundThere is growing interest in the use of complementary and alternative medicine (CAM) throughout the world, however previous research done in Japan has focused primarily on CAM use in major cities. The purpose of this study was to develop and distribute a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) to assess the use of CAM among people who visit rural Japanese family medicine clinics.MethodsUsing a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q), a cross-sectional survey was conducted in three rural family medicine clinics. All patients and those accompanying patients who met inclusion criteria were eligible to participate. Data were entered into SPSS Statistics and analyzed for use by age, gender, and location.ResultsOf the 519 respondents who participated in the project, 415 participants reported CAM use in the past 12 months (80.0%). When prayer is excluded, the prevalence of CAM use drops to 77.3% in the past year, or 403 respondents. The most common forms of CAM used by respondents were pain relief pads (n = 170, 32.8%), herbal medicines/supplements (n = 167, 32.2%), and massage by self or family (n = 166, 32.0%). Female respondents, individuals with higher levels of education, and those with poorer overall health status were more likely to use CAM than respondents without these characteristics. Only 22.8% of CAM therapies used were reported to physicians by survey participants.ConclusionsThese data indicate that CAM use in rural Japan is common. The results are consistent with previous studies that show that Japanese individuals are more interested in forms of CAM such as pain relief pads and massage, than in mind-body forms of CAM like relaxation and meditation. Due to the high utilization of certain CAM practices, and given that most CAM users do not disclose their CAM use to their doctors, we conclude that physicians in rural Japan would benefit by asking about CAM use during patient interviews, and by familiarizing themselves with the potential benefits and risks of commonly used CAM modalities.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6882-14-360) contains supplementary material, which is available to authorized users.

Frequency of Monitoring Hemoglobin A1C and Achieving Diabetes Control

The American Diabetes Association recommends measuring hemoglobin A1C levels (A1C) at least semiannually in diabetic patients who have stable glycemic control and quarterly in patients whose therapy has changed or who are not meeting glycemic goals. These guidelines were based on expert consensus without reference to actual clinical data. The main objective of this study was to assess association between meeting a target A1C level of <7% and adherence to monitoring guidelines. Secondary objectives were to determine the proportion of diabetic patients in the authors' practice who met the A1C monitoring guidelines and to assess whether meeting the target A1C level is associated with other information easily abstracted from patients records, namely age, gender, and types of therapy. This study employed a case control design. Records of 193 type 2 diabetic patients seen over a 6-month period in a rural family medicine clinic were analyzed. Assessment of diabetes control was based on the most recent A1C level, with <7% considered controlled. Adherence to guidelines was assessed by determining frequency of testing during the preceding 12-month period. Ninety-eight patients (51%) adhered to the American Diabetes Association guidelines on frequency of monitoring A1C. Median levels of adherent and nonadherent patients differed significantly (6.5 vs 7.3, P < .001, Mann-Whitney test). Logistic regression analysis showed that "diabetes control" based on the A1C level is positively associated with adherence to the guidelines, negatively associated with intensity of therapy, and not associated with gender or age. This study supports the usefulness of American Diabetes Association practice guidelines on the frequency of monitoring A1C levels in diabetic patients.

Monetary Value of a Prescription Assistance Program Service in a Rural Family Medicine Clinic

To quantify the monetary value of medications provided to rural Alabamians through provision of pharmaceutical manufacturer-sponsored prescription assistance programs (PAPs) provided by a clinical pharmacist in a private Black Belt family medicine clinic during 2007 and 2008. Patients struggling to afford prescription medications were referred to a clinical pharmacist by the physician or nurse practitioner for medication assistance evaluation. Once patients were deemed eligible, the pharmacist assisted in the PAPs completion process, maintained detailed records, and aided in recovery of refills. Patients paid $5 per application to cover office supply costs. An annual retrospective review was performed each December to evaluate the monetary value of free medications provided to patients during this 24-month period. One hundred forty-two applications were completed, enrolling 31 patients in 22 PAPs. Patients received $138,400 worth of medications; the clinic collected $710 in fees. Antihypertensive, antidepressant, lipid-lowering, antiplatelet, and proton pump inhibitor medications were most frequently prescribed and represented 74% of the total monetary value of free medications provided to patients. Clopidogrel (Plavix) and esomeprazole (Nexium) were the most commonly requested medications, representing 16% of the monetary value. PAPs offer an avenue to obtain medications when cost may lead to non-adherence. PAP services helped rurally isolated Alabamians receive needed therapies they otherwise likely would not have purchased. Similar programs offering assistance services for merely cardiovascular products would provide a substantial public health impact. Providers interested in initiating similar services should identify a program coordinator, designate a private location for patient interviews, and develop systems to ensure patients receive their PAP medications.