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Regional business organizations can and should be leaders in the fight against health complications and soaring costs associated with diabetes, a key pharmacy group says.
Engaging employees with community resources to better control their conditions is the idea behind the Diabetes Ten City Challenge, a diabetes management program introduced last fall by the American Pharmacists Association (APhA) Foundation, which is partnering with local groups of large, self-insured employers.
"We want to challenge the current system in health care, which really is sick care," explains William M. Ellis, RPh, MS, CEO and executive director of the APhA Foundation. "We sense that there is some growing momentum from people looking for new answers."
HOW IT WORKS
In the program, which receives funding from pharmaceutical manufacturer GlaxoSmithKline, community pharmacists act as coaches to help people manage their diabetes, offering them education about setting goals, using medications properly, and tracking their condition with cholesterol tests, blood pressure readings, foot exams, and eye exams. Collaborative care teams of pharmacists, physicians, and diabetes educators consult with each other to improve patient care and are compensated for their time.
Employers have different methods for enrolling patients in the program. In some cases, pharmacy benefit managers help identify candidates for the challenge, according to Christine Whipple, executive director of the Pittsburgh Business Group on Health (PBGH), a Ten Cities Challenge participant. Elsewhere, employers post notices in the workplace, offering reduced copayments for medications and doctor visits for people who volunteer to participate.
The program tracks progress by measuring glycated hemoglobin (A1C) levels, patient satisfaction with pharmacy services, and cost savings for medical care, APhA says. Some recent evidence indicates this approach is effective.
An article in Pharmacotherapy showed that pharmacist-administered education and management of diabetes patients in South Carolina had a positive impact on A1C counts, control of blood pressure, and aspirin use.1 The specially trained pharmacists also helped patients reduce LDL cholesterol levels, the researchers reported.
Seventy-two patients (38%) experienced 
1% reduction in A1C. Average
blood pressure decreased from 141/79 to 135/75 mmHg, but average LDL levels
did not change significantly. Aspirin use increased from 34% to 73% at 1 year.
The program achieved the A1C and LDL values required to qualify for diabetes
recognition by the National Committee for Quality Assurance (NCQA), a private,
nonprofit organization committed to improving U.S. health care. Estimating a
savings of $820 for each 1% decrease in A1C, costs avoided were calculated as
$59,040.
The foundation's plan is to work closely with diabetes education centers in each challenge region, building a framework for collaborative alignment of various health care providers so that care is less fragmented, Ellis says.
To date, the APhA Foundation has signed up employer groups in just four locations for the Ten City Challenge. PBGH, which represents more than 1 million insured employees, is using the challenge as the launch vehicle for a wider disease management effort called Living-MyLife.
"It affords us the opportunity to get this program off the ground," Whipple says. "It gives us a chance to benchmark and learn from the experiences of other regions."
Also involved in the Diabetes Ten City Challenge is the Northwest Georgia Healthcare Partnership, which includes the carpet mills in and around Dalton, Ga. The most recent entries are the City of Milwaukee (Wisc.) and Hawaii Business Health Council (Oahu). "The Pacific Islander population is a particularly at-risk population," Ellis explains.
Ellis says the foundation will announce the rest of the 10 cities this spring. The Dalton, Ga., and Pittsburgh groups were to start delivering care under the program by late January. Preliminary results should be available by the end of 2006, and those regions will issue a 1-year progress report by spring 2007, according to Ellis.
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There will be no intercity competition, other than bragging rights. "They will be competing against their own baseline experience," Ellis says.
PHARMACISTS ON THE FRONT LINES
PBGH's Whipple reports that 10 employers had committed to participate in the diabetes challenge as of the beginning of the year, and those companies were to begin issuing invitation letters to selected workers by late January.
The organization began signing up pharmacist coaches in February and plans to start reporting preliminary data by fall. "[Pharmacists] will need to go through programs to be certified to work with diabetes patients," Whipple says.
Individuals will be able to select their own coaches. "These are their local, community pharmacists. They will not have to go out of their way," Whipple says.
"The pharmacist plays a role in being able to make contact with that
person on a more regular basis and also has input into their medications if
there are complications," says endocrinologist Jeffrey K. Russell, MD,
medical director of Mission St. Joseph's Diabetes Center in Asheville, N.C.
"Care for diabetes as well as other illnesses today is complicated;
there are so many potential sources for error and confusion that having more
people involved is a good thing." 
Setting the Standard: The Asheville Project
Pittsburgh's program—and, indeed, the entire Diabetes Ten City Challenge—is modeled after a successful diabetes management program in Asheville, N.C., and on a cholesterol management effort the American Pharmacists Association Foundation ran from 1996 to 1999.
"We follow clinical parameters to determine the success of the program, and those clinical numbers have gone from an average A1C of 8 at enrollment to an average of 6.8 for individuals who have been in the program 5 years. The goal is <7, as established by the American Diabetes Association," says Asheville Project coordinator Barry Bunting, PharmD, of Mission-St. Joseph's Health System. "Another clinical goal, for LDL, is that it is <100, and the group's average has consistently been <100."
The Pittsburgh Business Group on Health (PBGH) began to explore the idea of a diabetes program after bringing in John Miall, retired risk manager for the City of Asheville, to speak in 2004. "We wanted a strategy that correlates to the consumer aspect of health care," says Christine Whipple, PBGH executive director.
In Asheville, employers saved an average $918 per person during the first year of a patient's participation. Individuals save $400–$600 annually in waived co-pays—an option for employers. Over time, annual medical costs have decreased $1,622–$3,356 per patient, the foundation reports.
Employee absenteeism related to diabetes has fallen by half for those in the program, and employee satisfaction with pharmacist care reached 95%.
Footnotes
More information about how health care providers and employers can get involved in the Diabetes Ten City Challenge is available online at www.aphafoundation.org/CityChallenge/TenCityChallenge.htm.
References
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