While the pandemic may be waning, the newly gained prominence of pharmacists has positioned them to take a more active role in diabetes management. In this virtual roundtable, retailers and suppliers discuss new approaches to helping people manage a condition affecting more than 37 million Americans, and the most exciting new technologies that can support that effort. They also explore ways to deal with prediabetes.
With pharmacists’ stature enhanced by their role during the pandemic, how can they become more actively involved in diabetes care?
SNOW: Pharmacists have a unique role in the health care system. In addition to their traditional responsibilities, pharmacists have the opportunity to work with patients to help improve adherence for their diabetes care plans. Pharmacists can also help educate patients about their disease and the goals for their treatment plan. Through these conversations, they can uncover issues that might be interfering with an effective plan and assess if the treatment plan is adequate. If not, the pharmacist can work with the patient’s managing physician to adjust the plan as needed.
EMMONS: The COVID-19 pandemic showed us that we are in a unique position to do even more to remove obstacles and improve access to health care, especially for those living in underserved communities. This is particularly important as it relates to access to our pharmacy teams. As one of the most accessible members of the patient’s health care team, our pharmacists are available to support patients in their health care journey, including ensuring access to and education around maintenance medications for chronic conditions like diabetes. Our pharmacists receive enhanced diabetes management training and continue to keep up to date with current guidelines by completing regular continuing education, which empowers individuals living with diabetes with the information they need to manage their health. We take a holistic approach with these patients to educate and support nutrition, exercise, and ensure they get regular checkups and screenings such as kidney screenings, diabetes eye exams, and foot exams.
KETTERLING: As the practice of pharmacy shifts towards providing value-based care, the opportunities for pharmacists to be directly involved in providing services to improve health outcomes are growing. Diabetes care and other disease state management can be provided through many of the MTM (medication therapy management) services pharmacists are currently providing. For example, a Comprehensive Medication Review (CMR) can include a focused assessment of the diabetes disease state. This may include going a step beyond a medication review to ensure therapeutic goals of therapy are being met. It may also include assessing for gaps in routine diabetic preventative screenings. Another example pharmacists can be more actively involved in diabetes care is by evaluating a patient’s entire immunization history when providing a routine vaccine, such as a COVID-19 booster or influenza vaccine, to identify gaps in key immunizations for diabetic patients.
KERLEY: Pharmacists are ideally positioned to help persons with diabetes and have been increasingly involved in diabetes care. Examples of pharmacist involvement include overall diabetes education, medication education/use, lifestyle changes, patient care plan/goal settings, self-management skills support, and self-monitoring of blood glucose. As regulations become more favorable, pharmacists can be involved in test-and-treat models through collaborative practice agreements. Pharmacists can serve as a bridge between a patient’s visits to their physicians and other providers to help ensure the continuity of care necessary to appropriately manage diabetes.
HOUSTON: Pharmacists have always been a great resource for patients — not only for dispensing medications but for answering health care-related questions and providing resources to their communities. Since the beginning of the COVID-19 pandemic, pharmacies have gone above and beyond on the front lines, providing continuous care to their communities. They helped curb the spread of coronavirus by providing timely guidance to their patients in-person and online and, of course, through their localized vaccination efforts. In fact, according to the CDC, as of May 4, more than 247.1 million doses have been administered and reported by pharmacies across programs in the United States, showing the critical role pharmacists are playing in the vaccine rollout.
Pharmacists have long provided services to support patients at risk for or managing diabetes. These services include screening patients at a higher risk for diabetes and having conversations about the importance of testing blood sugar and controlling diabetes. Many stores provide nutrition counseling and weight loss programs as well. Pharmacists are also assessing overall patient health status and adherence to their medication, which is inclusive of not just medications for diabetes but also health conditions such as high blood pressure and high cholesterol. Good Neighbor Pharmacy members have access to e-care plans and models of patient engagement, and these technology solutions help pharmacists capture key data points from health care interactions with patients including blood pressure, A1c, lab values and other critical information. The pandemic has just put a spotlight on how accessible neighborhood pharmacies are and the wealth of clinical knowledge that pharmacists have and provide to patients in their community every day. The key is continuing to illuminate that accessibility and clinical knowledge and ensuring communities know that applies to diabetes care as well — not just COVID support.
Social determinants of health can play a significant role in influencing a person’s ability to successfully prevent type 2 diabetes or manage their ongoing diabetes care with the goal of a better quality of life and preventing dangerous and costly complications. Over half of Good Neighbor Pharmacy members (52%) participating in the Federal Retail Pharmacy Program for COVID-19 vaccinations are located in communities with socially vulnerable populations where accessible health care is so critical. We know our independent customers are in locations that can really make a difference and support patients that may be at higher risk for diabetes or need support as they navigate and treat their disease.
LYONS: Since the pandemic began, community pharmacies haven been called upon multiple times to meet patients’ needs. As essential frontline health care workers, pharmacies kept their doors open during shutdowns to provide access to needed medications, modified workflows to keep patients and employees safe and added new patient care services to meet the new health care needs of their communities that COVID-19 created, especially when other providers weren’t accessible. Pharmacists provided education, testing, immunizations and critical access to medications at a time when their patients needed them the most.
These same skills are needed to impact the lives of patients living with diabetes. Pharmacists must continue to take an active role in each of their patient’s care as members of the patient’s health care team. Pharmacists provide self-care skills training and education, and help recommend the best diabetes supplies, equipment and safe over-the-counter treatment options. To be sure this can happen, pharmacists must be able to easily access adequate payment for diabetes care and education services. Barriers to billing need to be removed to ensure pharmacies can offer sustainable services.
ANDERSON: The pandemic increased peoples’ reliance on pharmacists, as traditional hospital settings were less available to folks when they needed medical advice, access to vaccines, and more. And specifically for people with diabetes and other underlying health conditions, the pandemic led to patients valuing their health more and thereby understanding the need for proper diabetes management.
As trusted health care professionals in the diabetes space, pharmacists can more actively support their customers with diabetes by helping to ensure that customers adhere to their medications, glucose monitoring and overall health. This could include lifestyle changes, weight management and mental health awareness.
For those with diabetes, developing a consistent routine that incorporates glucose monitoring is so important. That’s why partnering with their pharmacist and other members of their care teams more regularly is important for ensuring a more consistent continuum of care.
DUVALL: Pharmacists have many opportunities to be actively involved in diabetes care. The pandemic has highlighted their importance even more in the past two years. The first step is identifying opportunities within their patient base by talking with people with diabetes and understanding challenges and needs. Their resources and time are also important factors to consider in identifying opportunities and potential solutions. The next step is to improve their knowledge on not only diabetes medications and treatments but also overall diabetes management. Things like engaging in your local ADA chapter and APhA diabetes training program and investigating the CDCES certification process including the Core Concepts course are all worthwhile to consider, along with many others. A few other things to consider are capabilities of the dispensing software (e.g. — can nonadherent patients be identified, can messaging be implemented to engage pharmacy staff) and the scope of practice laws in each state including possible provider status and what that entails especially around payment for activities other than dispensing like injection technique training or POC testing. The first step though is just talking with people with diabetes about challenges, wants and needs.
SHINE: Pharmacists have always played a critical role in diabetes care, but their appreciation has been especially heightened during the pandemic. Pharmacists are the most accessible health care providers and are uniquely positioned to see a holistic view of the patient’s medication regimen — both what the patient is prescribed and how the patient is taking their medication. Pharmacists can continue to play an active role in diabetes care by evaluating the patient’s medication regimen, collaborate with the patient and their physician to establish goals for the patient, encourage lifestyle modifications, and identify and ease patient’s concerns about diabetes and barriers to achieving their goals.
AHMAD: COVID-19 has exacerbated the pressure on the Canadian Health Care System, and as a result, there is a growing backlog of patients that have gone undiagnosed or unmanaged since the beginning of the pandemic.
Our pharmacists are playing an active role in identifying these patients through point-of-care testing that is being offered in a subset of our locations. Pharmacists are also helping patients manage their diabetes care by offering them follow-up consultations to help the patient manage their disease optimally (e.g. — foot care, nutrition, travel, glucometer training, etc.). In addition, our pharmacists are offering blood pressure monitoring through our new PC Health Stations that provide users with a convenient method to verify their blood pressure and BMI reading. In the first 10,000 readings that have been completed thus far in 2022, we have 46% of readings considered high (above 140/90mmHg) and 61% of BMI readings have been over 26 and considered overweight.
These advancements are key to improving access to care and enable our pharmacists to drive better patient outcomes through preventive support.
What specific diabetes care and education programs are pharmacy operators deploying to take advantage of pharmacists’ accessibility and patients’ trust in them?
• Hypertension and hyperlipidemia management in diabetic patients.
• Monthly diabetic consultations including a CMR and monthly targeted reviews.
• Routine A1c testing.
• Monthly blood pressure screening.
• Prediabetes screenings.
• Prediabetes awareness material posted in pharmacies and consultation rooms.
• Screening and referring at-risk patients into state Medicaid MTM programs.
• Assessing insulin adherence and subsequently providing recommendations for therapy optimization.
• First fill diabetic therapy consultation programs.
Expanding diabetic management services helps make this level of care routine at the pharmacy. Patients recognize this, and it help builds their trust. Patient’s trust and willingness to work with their health care providers is key to improving health outcomes. Patient collaboration is what influences the results.
LYONS: Health Mart pharmacies play a huge role in increasing proactive efforts for both prevention and management of chronic diseases like diabetes through the following activities:
• Offer screening, testing and referral services for patients at risk of diabetes to ensure quicker treatment.
• Recommend appropriate over-the-counter medications that manage patient symptoms without interfering with their diabetes diagnosis.
• Conduct complete CMRs to optimize all therapies to safely achieve treatment goals and ensure affordability.
• Provide tailored education and individual self-care training sessions for glucose monitoring, blood pressure monitoring and injection technique.
• Support lifestyle change education focused on smoking cessation, weight loss, physical activity and coping skills.
• Partner to provide nutritional advice, resources and referrals to registered dietitians for medical nutritional therapy.
• Provide immunization assessments and needed vaccinations.
• Stock specialty diabetes supplies, including hypoglycemia treatments, testing supplies, diabetic socks/shoes and durable medical equipment.
AHMAD: The PC Health App and our Diabetes Clinic Days are just some of the various services and programs we offer to people living with diabetes. With many of our pharmacists being certified diabetes educators, they can offer their perspective not only as pharmacists, but as educators as well. This might involve support that happens beyond the pharmacy — for example, walking their patients through the fresh-food area of the store to help them better understand how to eat to support their condition. Our programs were specifically created to allow for a rounded approach to patient care and support.
KERLEY: Rite Aid has many tools available to patients — starting with the pharmacist. All Rite Aid pharmacists earn their Integrated Pharmacy Specialist Certificate, so they understand holistically how diet and lifestyle play a foundational role in a person’s health and wellness. Rite Aid is now an Accredited Provider of Continuing Pharmacy Education certified by the Accreditation Council for Pharmacy Education (ACPE). We’ve built on this knowledge by providing an ACPE course on diabetes to support our pharmacists’ interactions with customers with diabetes. To solidify recommendations and discussions from our pharmacists regarding diabetes as a focused health condition, these tips get spotlighted in a customer handout. We also offer additional clinical resources in-store, such as printable or QR codes for hundreds of videos about disease state management (Elsevier Patient Education Direct). Health Dialog, a Rite Aid subsidiary, runs our Medicine Support Team made up of health coaches that reach out to customers with diabetes directly to encourage and educate them about the importance of adherence.
EMMONS: Our pharmacy team members build strong relationships with patients in their communities to support medication adherence. We also use smart analytics to power personalized interventions that help improve adherence and patient outcomes by identifying patients who are most in need, then triggering interventions through the most appropriate channels, which enables personalized conversations. In underserved communities that we serve, we’ve observed a higher rate of diabetes and lower health outcomes. Our health equity diabetes program helps patients connect with our pharmacists to get information surrounding clinical guidelines, recommended lifestyle changes, and general tips to manage their diabetes. We’ve implemented this program, which takes a holistic approach to helping patients. Through comprehensive, personalized consultations, our pharmacists can uncover gaps in diabetes care and barriers to adherence and offer tailored solutions leading to improved health outcomes. We’re piloting enhanced screening services (e.g., HbA1c, blood pressure screenings) at the pharmacy to ensure guidelines are met to support prevention of common complications in diabetes. We also work with select payor partners to pilot comprehensive disease state management interventions centered around providing personalized consultations to select patients to educate and motivate them, to close gaps in care and resolve barriers to adherence.
DUVALL: There are several initiatives running at numerous retail pharmacies throughout the U.S., including point-of-care testing (e.g., A1c, hyperlipidemia), MTM and injection technique education. Some pharmacies have engaged with payers to look at HEOR opportunities and publish research. Retailers have the ability to analyze their data and identify opportunities they may be missing, particularly when it comes to adherence/persistence rates for insulin and injection supplies. It has always been relatively easy to identify medications that are dosed daily or weekly, but insulin and insulin supplies do not always match up to a true billable days’ supply.
ANDERSON: Your mention of pharmacists’ accessibility and patients’ trust are especially worth noting because people with diabetes usually see their pharmacists more often than other members of their health care team and may feel more comfortable with them.
These touchpoints with pharmacists and pharmacy operators typically include providing patient health screenings and A1c testing, as well as counseling on how to delay diabetes progression and improve diabetes management through proper diet and exercise. Many pharmacy operators also provide significant assistance to patients already living with diabetes by offering training on different methods and technologies for blood glucose monitoring.
And for those who are able to invest the time, pharmacists with accreditation to provide Medicare patients with Diabetes Self-Management Training, which is reimbursed by CMS, can become a truly trusted resource for their customers with diabetes.
All of this gives pharmacists and pharmacy operators more opportunities to reinforce the importance of staying on top of diabetes management in partnership with their customers.
HOUSTON: On a daily basis, pharmacists have comprehensive conversations with patients with many complex conditions, including diabetes, due to the trust these patients have in their local pharmacist. Many community pharmacists are certified in Diabetes Self-Management Education and Support (DSMES) and are equipped to provide a deeper level of education, including providing patients with after-hour education services and enhancing that trust by ensuring patients understand the importance of adherence to their diabetes medication, as well as other maintenance medications. Pharmacies have the ability to provide some health care screenings and, through education and awareness, encourage patients to stay current on all preventative care tests recommended for a patient with diabetes, such as eye exams and kidney function.
Pharmacists can also work with a diabetic patient and their prescribers on adding a statin, if needed. Pharmacists frequently confirm a patient’s comfort level testing their blood sugar and injecting insulin. As with any complex condition, understanding the condition as well as knowing how to better control it is critical to a patient’s well-being.
SNOW: In addition to programs centered on medications, pharmacists are now expanding their role to provide education on goals of treatment, new technologies and recommended screening tests.
What new diabetes care technologies are you most excited about?
DUVALL: It is not exactly one product or device that is most exciting but more of the reach with different technologies particularly in the continuous glucose monitoring (CGM) devices and continuous subcutaneous insulin infusion (CSII) products. CGM was initially used by patients with type 1 diabetes. Over the past few years, we have seen the CGM market grow across patient segments because of ease of use, decrease in cost, etc. What is exciting about CGM being more mainstream is the fact that more patients with diabetes can now have an idea how their blood glucose fluctuates throughout the day, during certain activities and after eating certain foods. Understanding these variations in blood glucose can assist greatly with treatment. Regarding CSII, again they were mainly used, and to some degree still today, by patients with type 1 diabetes. As manufacturers continue to assess the type 2 market, insulin usage by patients and the need for simpler devices, I believe the insulin pump market will expand its reach. Regardless of what technology is available, patients will still need to understand the diabetes basics and how to manage their disease — but hopefully technology can make that management a little easier.
AHMAD: I am most excited about our new PC Health Stations that are currently rolling out across Canada. These kiosks will allow users to measure their blood pressure, heart rate, weight, and provide a body mass index calculation — all while tracking their readings in the PC health app. By providing an easy-to-use tool to help identify concerns such as hypertension or obesity, we see a great opportunity for pharmacists to proactively engage and counsel patients. Additionally, the data collected can help to support those who are actively managing their diabetes or provide a longitudinal view for someone who may be at risk of developing diabetes. That means that we have a better chance of helping to prevent diabetes or slow the progression of the condition. It is crucial that people living with diabetes continue to receive routine care in order to avoid complications and increased health concerns. This is just one new tool that will allow our pharmacists to develop a more comprehensive and tailored plan for each of their patients.
LYONS: I’m most excited about alternative monitoring methods that allow patients less invasive alternatives to control their blood sugar. In addition, I’m excited to see more use of smart technologies in insulin pumps and CGM, which can help make the lives of patients living with diabetes easier. Many of the new technologies also allow real-time data to be shared with health care providers more easily, which will open more doors for team collaboration in the care of people with diabetes.
For example, connected glucose monitoring devices, blood pressure monitors, CGMs and insulin delivery devices can allow pharmacists to make better recommendations for medication adjustments, registered dietitians a greater ability to personalize nutritional plans, and physicians and other prescribers to ensure that all treatment goals are optimized, giving the patient more control and a better quality of life.
EMMONS: Patients have more options now than ever to use technology to manage their diabetes. As people continue to rely more on online tools to help address their health care needs, we are excited to see diabetes technology lean more into smart phone offerings and mobile apps to help patients more closely monitor their disease and help drive better outcomes. Beyond our pharmacists’ relationships with patients, Walgreens offers access to state-of-the-art health monitoring devices such as the Dexcom G6 and Abbott FreeStyle Lite CGM systems. Both systems provide patients with real-time glucose data, and the Dexcom G6 eliminates the need for finger pricks. Because of our strategic partnerships with these two major suppliers of CGM systems, Walgreens is the largest retail pharmacy chain that provides nationwide distribution of their devices, offering increased access to these important tools across the communities we serve. We also provide a 24/7 Pharmacy Chat option through our mobile app and website, giving patients easy access to personalized care and advice from Walgreens pharmacists. Patients can also use Walgreens Find Care to access in-person and virtual health care expertise and connect with local and national providers they trust, all through the convenience of the Walgreens mobile app or online at walgreens.com/findcare.
SNOW: I am most excited about CGMs and the recent progress in closed-loop insulin pump systems. These systems utilize blood glucose information from CGMs and advanced algorithms to actually instruct the insulin pump to provide the appropriate dose of insulin. These systems will result in better blood glucose control and also simplify the role of the patient, making this technology usable to more patients.
ANDERSON: There has been a lot of innovation happening around diabetes data management, digital therapeutics, new therapies and CGM over the last several years. But unfortunately, CGM is only used by a very limited segment of the population with diabetes.
That’s why it’s great to be able to bring a technology like automatic blood glucose monitoring — or ABGM — to the conversation, because it’s a technology that enables the entire population with diabetes to get in on the excitement around diabetes innovation.
ABGM represents innovation that understands the burdens that the vast majority of people with diabetes still face and gives those folks another way to meet their blood glucose testing needs. And I’m hoping we’ll see a lot more of that kind of innovation in the future — innovation with broad application across the category.
KETTERLING: Further utilization of CGMs, remote patient monitoring and opportunities to help manage diabetes through telehealth services, all of which provide pharmacists with additional resources to better manage diabetic patients beyond what they can utilize from dispensing systems and MTM services.
SHINE: Although CGMs are not necessarily new, I think we will continue to see increased adoption of these devices. Additionally, the idea of CGM use expanding beyond patients with diabetes — the idea that continuous glucose monitoring could become part of our general health monitoring for tracking sleep, steps, heart rate, etc. — is exciting. Applying CGM to additional uses could help the general population monitor their glucose levels and evaluate what foods cause glucose levels to spike and crash versus what foods or exercise helps to stabilize glucose levels. This could ultimately lead to prevention of diabetes in some cases, and even for those who still develop diabetes, could serve as a tool for better disease management.
KERLEY: With the variety of new technological innovations becoming available, these new devices hold promise for making diabetes easier to manage. Advances such as continuous glucose monitoring, are making the often-dreaded finger pricks a thing of the past, while closed loop systems help automate insulin delivery. Diabetes apps have emerged as valuable tools for people living with diabetes. It really comes down to the product that best meets the needs of the individual patient and helps make self-managing their health easier.
HOUSTON: Continuous glucose monitors, or integrated CGMs, are a way for patients to ensure they are monitoring their glucose levels more consistently without the need to test frequently via a finger stick. Adding consistency and a level of convenience is so important for patients with a very complex disease to manage. This science allows users to track their blood sugar over a period of time to analyze trends and help patients make informed decisions on food intake, physical activity and their medication. With the ability to connect to their smartphone devices and insulin pumps, this type of closed system can adjust insulin doses without the input from the patient, making it significantly easier for patients to have more autonomy, observe their disease and make any necessary changes. This is yet another area where pharmacists can help further educate patients who have questions or concerns on how and where to place their CGM.
To what extent is continuous glucose monitoring catching on versus fingersticks, and what are the implications for diabetes care?
EMMONS: Last year, nearly 2 million people with diabetes used a CGM, which is twice the number in 2019. While this is a small portion of the more than 37.3 million people currently living with the disease, this is encouraging because CGM enables patients to more conveniently monitor and address blood glucose fluctuations in real time. Through the real-time information on blood glucose levels, patients and their health care team can understand the dynamics of how their body reacts to factors such as different foods, stressors and medications.
ANDERSON: While CGM is an important development for a subset of people with diabetes, the reality is that there are still more than 27 million people diagnosed with diabetes in the U.S. that are not using CGM for one reason or another. That means more than 90% are currently using traditional fingersticks to check their glucose levels.
But traditional fingersticks (or blood glucose meters, BGMs) present barriers that hinder people from checking their glucose levels as often as recommended by their health care team. These barriers typically surround the complicated testing procedure, the need to carry multiple supplies, and the disruption it presents to everyday life. And, unfortunately, the BGM category has seen limited innovation over the years to address these barriers. People are clamoring for something much simpler that’s not being addressed by either CGM or traditional BGM.
I think that’s why we’re seeing so much interest in the arrival of truly automatic blood glucose monitoring, or ABGM. ABGM boils down blood glucose testing to just the push of a button, eliminating the need to handle separate lancets or test strips. It does this by integrating testing supplies for 10 tests into a single cartridge/drum that quickly pops into a monitor. This technology is satisfying a strong desire among people with diabetes for simple, convenient blood glucose testing.
Automatic blood glucose monitoring shares with CGM the ability to conduct sufficient glucose readings to detect patterns that show points in range and how glucose levels fluctuate throughout the day in response to different lifestyles and therapies. Automatic blood glucose monitoring is meaningful blood glucose monitoring.
SHINE: Continuous glucose monitoring has been around for quite some time and is catching on with both patients and providers. CGMs simplify blood sugar monitoring and management for patients since they are not required to stick their finger and automatically generate reports on how a patient’s glucose levels are trending, which allows both the patient and their providers to identify the ideal medication regimen. However, BGM is still relevant for a variety of reasons. There are still patients who simply prefer BGM over CGM and those who cannot afford a CGM device.
KETTERLING: Prescribing of CGMs has been increasing; however, many patients still utilize standard glucose monitors. It depends on the geography of the patient, the clinic/provider they see and the specific patient population. There are certainly providers and clinics/health systems that seem to have more confidence in prescribing CGMs and have made that a standard of their diabetes management practice. Additionally, patient age and length of diagnosis influences the use of CGM. It is important to meet the patient where they are at in terms of their comfort level in the type of blood glucose monitoring device they use. Ultimately, improved therapeutic outcomes can be achieved with consistent and accurate blood glucose monitoring. However, there is great opportunities for pharmacists to further intervene and deliver patient care through the use of CGM such as real-time monitoring and more accurate reporting to help influence therapy optimization.
LYONS: Many Health Mart community pharmacies are in rural or underserved areas, which results in lack of quality insurance and access. Due to those factors and cost, many patients don’t have the ability to take advantage of this technology. If more patients are able to take advantage of CGM, better glucose control, better patient outcomes and reduced health care costs are more easily attained.
SNOW: The market for this technology continues to grow, providing patients with greater amounts of information regarding glucose control, while freeing them from the painful need to stick their finger. However, interpretation of the information that comes from these devices can be complex both for users and for their providers. One of the significant implications is the need for better education and tools to interpret the information so that appropriate actions can be taken, resulting in better care. Without this knowledge, patients may find themselves armed with better technology but unable to turn that into better outcomes.
KERLEY: Recent advances in technology have made it possible to track blood glucose and other important information like never before. Since convenience is a key driver of behavior, these new tools can help patients monitor their disease more proactively (and less painfully). Unfortunately, insurance coverage can still be a barrier to individuals’ ability to utilize continuous glucose monitoring. Rite Aid pharmacists can help customers make sense of all that information and offer advice for how to act on the insights that new monitoring devices can provide.
AHMAD: In my opinion, continuous glucose monitoring is a strong tool because it better allows users to track and trend data that can assist them in managing their diabetes. Since fingersticks are a self-managed technique, they provide a less-rich data set to interpret. However, diabetes health management is so much more than just testing. It is comprised of many moving parts, such as medication, pharmacist support, life choices and self-management. The most important thing is that we are helping patients to prevent their condition from worsening and offering both in-person and virtual options for care.
The vulnerability of people with diabetes to more severe COVID cases helped raise awareness of the need for diabetes management. With the pandemic waning, is there a danger that diabetes and the danger of its complications will slip under the radar?
KERLEY: Pharmacists are a tremendous resource for community health — whether helping end the pandemic through vaccinations or helping manage chronic conditions like diabetes. Due to accessibility and the frequency in which they see patients, community pharmacists are available to counsel, educate and increase awareness of diabetes — thereby helping their patients lead healthier lifestyles. Pharmacists are one of the first resources customers engage with questions and can direct customers to their primary care provider or other resources if diabetes complications are a concern.
SHINE: I do not believe that will happen. I think health care providers are even more acutely aware of the complications of diabetes, especially if left uncontrolled. The pandemic also helped raise awareness for patients, which I think gives health care providers a great opportunity to discuss the importance of controlling the disease with the patient and allows them to work in tandem to identify how to best accomplish this for each patient at an individual level.
SNOW: I don’t believe that the issue of the seriousness of diabetes and risk of complications will diminish as the pandemic wanes. The challenge, though, is to turn this attention into actionable items that result in better care for people with diabetes. The danger is that lessons learned over the past couple of years regarding access to care, remote monitoring and alternative approaches to care will not continue to have a major role. If we revert back to the same processes for care that existed prior to the pandemic, then that will be a squandered opportunity.
HOUSTON: In some regions, pharmacists are the first line of contact for health-related concerns. Effective communication between pharmacists and patients is crucial for optimizing patient health outcomes and mitigating risk. When these relationships are strong between patient and provider, patients are more likely to remain adherent to their medications and ultimately stay healthy.
There is also the complexity of patients and health care impacts, such as recognizing the number of patients that have not only diabetes but the risk of other health complications as well. For this reason, pharmacies have a continuous focus on adherence to all medications, not just diabetes, and continue to partner with patients so they understand the importance of adherence, both short term and long term. There are adherence gaps, particularly to diabetes medication, and this further proves the need to continually provide patient education and reinforcement. Pharmacists fill the health care gaps in their neighborhoods and play an integral role in their communities. Whether that’s offering low-cost immunizations or equipping a community to face a pandemic, independent pharmacies are uniquely qualified to serve local diabetes patients through their expansive disease management capabilities.
KETTERLING: As a result of the heightened awareness around the need for diabetic management, new clinical programs focusing on diabetes care were developed and implemented and/or existing programs were re-initiated during the pandemic. With a more focused effort, the impact pharmacists have made on patient diabetic outcomes is better understood. With that, I suspect that diabetic management programs will be maintained and even further expanded.
AHMAD: We know as a result of the pandemic, people living with diabetes and chronic conditions experienced a disruption in care. Lockdowns, decreased physical activity and unhealthy dietary changes significantly impacted the well-being of Canadians. I believe that we should always be focusing on each individual patient’s condition and their needs living with diabetes. We know that there is a progression with diabetes, meaning that a patient’s condition and treatment plan will change over time and severe events can occur when people don’t get the care and support that they need. With the pandemic waning it’s incredibly important that patients continue to monitor and manage their diabetes with the support of their health care providers.
EMMONS: Over the course of the pandemic, the guidance provided by the Food and Drug Administration and the Centers for Disease Control and Prevention (CDC) around COVID-19 vaccines has changed. People get confused, or they think something is wrong, when guidance changes with COVID-19, but we have to remember that we are learning about this virus as additional data becomes available. The protection COVID-19 vaccines provide decreases over time, especially for certain groups of people. For this reason, the CDC recommends everyone age 5 years and older stay up to date with their vaccines, which includes getting boosters when eligible, for the best protection against COVID-19. The risk of getting very sick from COVID-19 is likely to be lower among people with diabetes if the condition is well managed. People with diabetes who do not manage their chronic condition well and experience fluctuating blood sugars are generally at risk for several diabetes-related complications. A recent study also shows that COVID-19 can leave behind a legacy of chronic illnesses — especially diabetes. People who get COVID-19 have a greater risk of developing diabetes up to a year later, even after a mild SARS-CoV-2 infection, compared with those who never had the disease. As your question suggests, with our nation transitioning into a “controlled pandemic” stage, we could be more likely to lose focus on understanding diabetes the diabetes management. For these reasons and others, diabetes management continues to remain top of mind for our pharmacists. Our pharmacists continue to focus on improving access, adherence and outcomes for individuals living with this chronic condition. We are committed to helping millions of people live healthy lives with diabetes, as our purpose is to champion the health and well-being of every community in America.
LYONS: I do see a risk that many of the lessons that the COVID-19 pandemic taught us, including the increased health risks for people with diabetes, could slip away if we fail to learn from what we saw and take action for change. That means all stakeholders — including patients, health care providers, public health officials, community leaders and elected officials — need to do the work to take the lessons to heart and create changes that are needed. For decades we have all seen national statistics for diabetes that showed an overall unawareness of the disease and poor control. When the COVID-19 virus arrived, the effects on all vulnerable patients were devastating and life changing for many families. However, the more severe COVID-19 cases in people with diabetes we saw were often in those whose diabetes was not well controlled. We can change that.
Now is the time to change those statistics that have been published over the years and act to improve the health of all people living with prediabetes and diabetes. Pharmacists are in a perfect position to impact this by providing meaningful education for prevention and control, plus monitor and collaborate with other members of the health care team to optimize therapies and other treatments. By leveraging the locations of pharmacies in the centers of their communities, we can reach more people, both diagnosed and undiagnosed to provide ongoing support. The critical aspect comes back to structuring reimbursement models to include options for patients to receive care from their pharmacists.
DUVALL: The danger of the complications of diabetes not being front and center has always been a concern whether or not it is overshadowed by a pandemic. Like with other disease states such as hypertension, complications of diabetes may happen over the long term. Part of diabetes education is addressing micro and macrovascular complications. Framing those conversations in a way that hits home to the patient with diabetes is essential. Examples are linking complications to preparing for retirement or routine maintenance on your car to avoid problems later. With COVID-19, I think the development of complications was accelerated exponentially. Diabetes does not necessarily cause complications, but uncontrolled diabetes contributes to complications.
Is there a sense that working from home and presumably less exercise and more overeating have increased the prevalence of diabetes and prediabetes? If so, how can that be addressed?
DUVALL: One could look at it that way … being home more could lead to a more sedentary lifestyle and overeating. However, one could look at it the opposite way. There is now more time in the day to choose healthy behaviors without the need to commute, stop for breakfast/coffee, go out for lunch, etc. With the absence of these activities, there is now more time to exercise, meal plan/prep, etc.
However, can most jobs be done from home? Working from home was not an option for many people during COVID-19 and is still not an option now. While there was a huge focus on health care workers, and rightfully so, during COVID-19 communities still rely on the important work of those in manufacturing, transporting goods, servicing groceries, etc. Diabetes is a highly self-managed disease. Technology will come and go. Diet fads are not sustainable, and regardless of one’s working situation whether pre-, during or post-COVID-19 it still comes down to behavioral change, management and motivation.
SNOW: There is definitely a concern about the rising prevalence of diabetes and prediabetes. This problem has been documented over the past few decades and changes that occurred during the pandemic, such as working from home with greater risk of overeating and less activity, has only exacerbated the problem. In the short term a greater emphasis by the health care system on healthier lifestyle choices is certainly important. In the longer term, we also need to begin to address some of the structural issues that also contribute to the problem. For example, the increase in diabetes prevalence also corresponds to a time when we shifted our method of movement away from walking and public transportation to a greater dependence on the automobile. By doing so we removed a major source of exercise from our daily lives. Reexamining how people get from home to work, shopping, etc., and making more exercise-dependent options available, such as walking and bicycling, may provide some longer-term solutions for the need to increase activity levels.
EMMONS: There were 1.4 million new cases of diabetes in 2019, and there are more than 37.3 million people currently living with the disease. These factors and others are why it is so important for us to continue to lean into a more holistic approach to improve the health and lives of those we serve. Complex, chronic conditions like diabetes necessitate programs that support the many needs of patients. This includes access to screenings such as HbA1c or blood pressure at one of the most accessible and trusted resources — the community pharmacy.
SHINE: It is hard to say if working from home will equate to less exercise and more overeating and therefore an increased prevalence of diabetes and prediabetes. Some may argue that working from home allows more time for exercise and healthier eating habits. Employees who work from home no longer have a commute, which may allow them to better fit exercise into their schedule. Working from home may also allow individuals to eat healthier due to not needing to meal prep in advance to be able to pack a lunch. There will, of course, be individuals who have a more sedentary lifestyle. In these instances, the patient’s health care team can design an exercise regimen that encourages them to move more. These regimens will vary based on the individual needs of the patient and may be focused on encouraging small improvements/wins with exercises such as walking, stretching, etc. to help kickstart behavior change. The same can be said for healthy eating habits — helping patients focus on taking a consistent, healthier choices approach versus an extreme diet change, which may ultimately lead to longer-lasting habits.
LYONS: I think there is a great likelihood that the shutdowns and mandated working from home actions that occurred during the pandemic could translate to a more sedentary lifestyle and poorer eating habits, both of which are known to contribute to the onset of prediabetes, diabetes and other chronic conditions. Other behaviors that rose during the pandemic — such as increased alcohol consumption and loss of social connections — lead to depression and other mental conditions which can also contribute to increased health risks.
With any change in behavior that causes negative effects, offering easy strategies to offset or reverse the negative behavior are needed. To address the new lifestyles that many are experiencing, employers, community groups and families need to also change to help make healthy habits a priority. Individuals need more options and ways to access education programs, wellness tips and fun, interactive physical activity programs. For example, app-based step-tracking programs can allow employees across the country to enter a race. Virtual platforms can allow multiple community members to join support groups without leaving their homes. Educational and motivational daily tips can be delivered via text message to give employees daily engagement. Overall, employees must feel empowered to take time to prioritize their health. Other activities in the community or group involvement, and regular check-ins with health providers would also help.
ANDERSON: Researchers have found that work-from-home environments are associated with an increase in sedentary behavior. Medical research has also shown that COVID-19 lockdowns have resulted in significant increases in glucose levels and BMI in patients with type 2 diabetes.
While people should always check with their own health care professionals for medical guidance on exercise, there are medical and exercise experts suggesting a range of strategies to reduce sitting time and increase physical activity.
Some note the benefits of wearable devices to help monitor and set goals for physical activity, set reminders to stand and increase movement, and even incorporate game strategies for physical activity. They even emphasize how built-in social communities can help people stay accountable with exercise. Pharmacists can provide suggestions for engagement with these.
Like all of us, people with diabetes are having to find ways to realign their daily lives during the pandemic so they can maintain healthy habits that will keep their blood glucose levels and other important health indicators on target. As always, that will continue to include habits around exercise and activity, eating, medication regimens, and regularly keeping tabs on glucose levels.
For the latter, that can mean turning to strategies that help people check their blood glucose consistently, so they’re regularly in touch with where their glucose levels are at. Adopting new technologies like automatic blood glucose monitoring — or ABGM — can help by making it as simple, quick and convenient as possible for people to check their blood glucose levels without interrupting their day.