USC tries novel approach to care

Dr. Sarah Ma goes over medications and dosages with diabetes patient Jose Navarro. , PHOTO COURTESY OF ANACLETO RAPPING

Jose Navarro regularly trekked to the drugstore after being diagnosed as a diabetic seven years ago. In a sign of transformation in the local fight against diabetes, the pharmacist is now coming to him.

On a recent day, Sarah Ma, a 28-year-old USC clinical pharmacist, set up shop at Navarro’s kitchen table in Santa Ana.

She checked Navarro’s blood pressure and blood sugar, examined his feet for cuts or infection, and refilled his monthly pillbox. On previous visits, she had changed the hour he took some medications, altered some doses and discontinued other medications.

She inspected the refrigerator. “I see carrots, eggs, beets, cheese and yogurt that I haven’t seen before,” she said, delighted.

Ma began working closely with Navarro in October. He feels much better, so he’s less of a candidate for an emergency room or expensive hospitalization.

It also means an important new tool is emerging in the effort to contain diabetes, which afflicts one in 10 adults in Los Angeles County, one in 14 in Orange County, and can lead to amputations, blindness or death. Direct medical spending on the disease in Los Angeles County alone tops $6 billion annually.

More broadly, it also means that pharmacists in California may be on a path to a much larger role in patient care and in controlling health care costs.

Ma is part of a three year, $12-million study run by the USC School of Pharmacy and funded by the federal Centers for Medicare and Medicaid Services. Several teams from the school, including professional and student pharmacists, have fanned out to test whether patients at safety net clinics in Los Angeles and Orange counties will benefit if pharmacists' scope of practice expands into territory normally handled by physicians, including greater autonomy in filling prescriptions and more direct contact with high-risk clients.

The early results are impressive:

• Almost nine of 10 patients who had out-of-control blood pressure saw their readings drop below hypertension levels and remain there within 45 days of working with the pharmacy teams, according to Steve Chen, an associate professor of pharmacy at USC and a developer of the study.

• Similarly, diabetes patients whose blood sugar levels had been too high were twice as likely to have them under control within six months if they worked with a pharmacist team.

• In the program’s first 11 months, pharmacists corrected 19,696 medication problems among 1,993 patients, an astonishing 9.9 medication problems per patient.

• More than 2,000 of those problems – including excessive dosing, duplication and drug interactions – were potentially dangerous to patients.

• Study coordinators project a 25 percent decrease in hospitalizations for the estimated 6,000 patients in the project.

The results are preliminary and unpublished; the study will continue into next year. When the research is published, it is likely to add to the debate over how to contain medical costs.

The study began in 2012 at five clinics run by AltaMed Health Services Corp. in underserved neighborhoods in El Monte, West Covina, Boyle Heights, Pico Rivera and Huntington Beach.

Three-person USC teams – a clinical pharmacist, a pharmacy resident and a pharmacy technician – became primary caregivers for hypertension and blood pressure patients, and others with chronic illnesses. They increased clinic visits and made house calls as needed. The study has since been expanded to 11 AltaMed clinics in Los Angeles and Orange counties.

Lobbyists for pharmacists in Sacramento pointed to the study as they successfully argued last year for bumping up pharmacists’ authority. A California law that went into effect in January codified a new class of “advanced practice pharmacists” who can enter collaborative agreements with physicians to start, change or discontinue medications, and help manage chronic diseases.

At the outset, many AltaMed doctors were rankled by the pharmacy teams.

“Quite frankly there was a fair amount of anxiety up front from physicians,” said Dr. Michael Hochman, AltaMed’s director of innovation. The idea that pharmacists could take charge of a drug regimen was a particular concern.

“One question I got frequently was, ‘Why did I go to medical school?’” Hochman said.

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