Improving HbA1c and Diabetes Preventative Screening Measures in Spanish-Speaking Patients With Clinical Pharmacist Care: A Quality Improvement Initiative

Abstract

Purpose:

To evaluate the impact of clinical pharmacist interventions on HbA1c and adherence to diabetes preventative screenings among Spanish-speaking adults with uncontrolled type 2 diabetes.

Methods:

This retrospective evaluation of a quality improvement initiative included Spanish-speaking adults with baseline HbA1c of 8% or greater who received at least 1 clinical pharmacist visit at a Federally Qualified Health Center. Outcomes included changes in glycemic control and timely preventive care screenings (diabetic eye exam, diabetic foot exam, urine albumin-to-creatinine ratio [UACR] test, and statin use), analyzed using logistical regression and McNemar’s test.

Results:

Among 70 included patients, the mean age was 55.6 years, with 65.7% of patients identifying as female and 62.9% having Medicaid insurance. The baseline mean HbA1c was 11.0%. Within 12 months, 40 patients achieved HbA1c <8% (Cochran’s Q₅ = 142.88, P < .0001). Gender and insurance status were significant predictors of success. The odds of a timely diabetic eye exams (odds ratio [OR]: 8.67, 95% confidence interval [CI]: 2.66-44.74, P < .0001), foot exams (P < .0001), and UACR tests (OR: 4.80, 95% CI: 1.80-16.11, P = .0008) increased.

Conclusion:

Spanish-speaking patients exposed to clinical pharmacist care observed significant improvements in glycemic control and timely preventative care screening.

Introduction

Type 2 diabetes mellitus (T2D) affects over 38 million people in the United States (U.S.) and remains a leading cause of morbidity and mortality. ¹ Poor glycemic control contributes to the development of serious microvascular complications and other complications. Minoritized populations, including Hispanic adults, are disproportionately impacted, facing a higher burden of diabetes-related complications. ² Unfortunately, individuals who identify as Hispanic also experience multiple health disparities related to poor access to health services and other factors related to social determinants of health (SDOH). ³ Patients with limited English proficiency (LEP), such as Spanish-speaking patients, experience even greater barriers.

Despite national guidelines emphasizing the importance of preventative microvascular screenings for people with diabetes, these services are often underutilized in underserved populations.^4-6 As such, timely access to evidence-based preventative screenings are critical in reducing the risk of vision loss, amputations, and kidney disease. ⁷ Clinical pharmacists play an increasingly important role in chronic disease management; however, there is limited research describing interventions among Spanish-speaking patients with LEP, particularly regarding adherence to guideline-recommended screenings for preventing diabetes-related microvascular complications.^8,9

Comprehensive medication management (CMM) is a pharmacist-delivered, patient-centered approach to optimizing medication use and improving health outcomes in collaboration with the patient and the health team. ¹⁰ Prior research has demonstrated the positive impact of pharmacist-led CMM in diabetes care on lowering HbA1c and reaching comprehensive diabetes care goals.^11-13 Clinical pharmacists are exceptionally positioned to address SDOH by providing comprehensive patient care through CMM. As accessible health care providers, clinical pharmacists collaborate interprofessionally and play an important role in determining the services needed to address SDOH. ¹⁴ Health care settings like Federally Qualified Health Centers (FQHCs) provide crucial safety net services for minoritized populations who are uninsured or underinsured. In California, a large proportion of Hispanic Medicaid enrollees receive primary care services at FQHCs. ¹⁵ Clinical pharmacists in FQHCs increase patient access to necessary care, medications, and resources, which ultimately leads to improved health outcomes. However, existing reimbursement challenges hinder the expansion of clinical pharmacist care in these settings. ¹⁶

The objective of this evaluation was to evaluate the change in glycemic control among Spanish-speaking adults with uncontrolled T2D after receiving clinical pharmacist-led interventions at a FQHC. Further, this evaluation observed the change in adherence to guideline-recommended diabetes preventative screening measures after receiving clinical pharmacist care.

Methods

Setting

This quality improvement evaluation was conducted at a FQHC located in southern California. The site is a Patient-Centered Medical Home (PCMH) that provides comprehensive and culturally sensitive care to patients regardless of their ability to pay. Of the total patient population seen at this FQHC, 71% identify as Hispanic, 92% earn <200% of the federal poverty level, 84% have Medicaid, and 13% are uninsured. All members of the medical team spoke both Spanish and English, including primary care providers (4 FTE), the clinical pharmacy team (0.4 FTE), medical assistants, and patient service associates. Clinical pharmacy services were established in 2021 to address gaps in diabetes control due to barriers to medication access, adherence, and health literacy. Patients receive an automatic referral to clinical pharmacy services for diabetes management if their HbA1c is above 9% to target National Committee for Quality Assurance (NCQA) standards for glycemic status.

Each initial clinical pharmacy visit is scheduled for 60 min to review the patient’s history, reconcile medications, assess medication adherence, review self-monitored blood glucose (SMBG) values, discuss diet and exercise, complete point-of-care testing, complete diabetic foot examinations, order laboratory tests, and encourage preventative screenings such as a diabetic eye exam. The clinical pharmacist makes pharmacotherapeutic changes to the medication regimen (eg, initiate, change, or discontinue medications) according to a collaborative practice agreement (CPA). Key aspects of the visit include assessing medication adherence, enrolling patients in patient medication assistance programs when applicable, identifying cost-effective treatment alternatives, determining patient preferences in care, providing patient education on disease management, and utilizing shared decision-making when negotiating a care plan. Follow-up visits are conducted on a weekly, biweekly, or monthly basis depending on patient acuity, and typically vary between 30 and 60 min visits. The majority of appointments are completed in-person; however, telehealth visits are also offered according to patient availability and preference.

Design

This was a retrospective pre-post evaluation of a single center quality improvement initiative that evaluated a deidentified dataset. The institutional review board waived the need for ethics approval for this non-interventional evaluation. The anonymized dataset included patients who were at least 18 years old, identified Spanish as their preferred language, had a baseline HbA1c 8% or greater, and had at least 1 clinical pharmacist encounter between May 2023 and May 2025. Patients were excluded if only baseline HbA1c data was available without follow-up HbA1c values.

Outcomes

The primary outcome was the proportion of patients achieving HbA1c below 8% within 12 months of initiating pharmacist-led care, based on NCQA Healthcare Effectiveness Data and Information Set (HEDIS) glycemic control measures. ¹⁷ Secondary outcomes included time to achieving HbA1c below 8% at 3-month intervals from 3 to 15 months (±4 weeks), factors associated with achieving the HbA1c target, whether patients were up to date on diabetes preventative screening measures (ie, diabetic eye exam, diabetic foot exam, and urine albumin-creatinine ratio (UACR) tests) after establishing care with a clinical pharmacist compared with baseline, and the proportion of patients on appropriate statin therapy.

Data Analysis

Statistical analysis was done using R Statistical Software version 4.4.2 run on the RStudio platform.^18,19 HbA1c levels were obtained at baseline and around every 3 months thereafter for persons being followed by a pharmacist. Patients were considered as meeting the goal if they had a measured HbA1c below 8% at 3, 6, 9, 12, or 15 months (±4 weeks). Proportions that had achieved this goal were compared at baseline, 3 months, 6 months, 9 months, 12 months, and 15 months using a Cochran’s Q test with pairwise Mcnemar’s tests for post hoc comparisons using the false discovery rate to adjust for multiple comparisons.^20-22 Next, a multivariate logistic regression was performed to determine factors associated with achieving a goal of HbA1c below 8% within 12 months. Independent variables were selected a priori and included the number of pharmacist visits, subject’s gender, subject’s age, and the insurance status. Insurance status was compared to Medicaid insurance. A 2-sided P-value of <.05 was considered statistically significant. Preventative care measures were evaluated for the same study population at 2 time points, baseline (within 12 months prior to first clinical pharmacist visit) and follow-up (within 12 months prior to or 3 months after last clinical pharmacist visit occurring at 12 months or earlier if discharged). Diabetes preventative care measures included completion of diabetic retinopathy screenings, diabetic foot exams, and UACR tests, as well as prescription for statin therapy. Prescriptions for any statin therapy were determined by the medication list in the electronic medical record (EMR). The odds of patients up-to-date on diabetes preventative care measures after establishing care with a clinical pharmacist were compared with baseline using McNemar’s Test GraphPad QuickCalcs Web site. ²³

Results

A total of 70 patients met the inclusion criteria (Table 1). The mean age was 55.6 years old, with most patients identifying as female (65.7%) and having Medicaid insurance (62.9%). The baseline mean HbA1c was 11.0% and patients had a median of 8 clinical pharmacy visits (interquartile range [IQR]: 4-11) over the 12-month period.

Table 1.

Demographic and Healthcare Utilization Characteristics of Patients (N = 70).

Demographic or characteristic	Value
Age, mean years	55.6
Female gender, N (%)	46 (65.7)
Male gender, N (%)	24 (34.3)
Preferred Language
Spanish-Speaking, N (%)	70 (100)
Health Insurance
Commercial Insurance, N (%)	3 (4.3)
Medicaid Insurance, N (%)	44 (62.9)
Medicare Insurance, N (%)	3 (4.3)
Medicaid and Medicare Insurance, N (%)	3 (4.3)
Uninsured, N (%)	17 (24.3)
Number of visits with clinical pharmacist
Average number of pharmacy visits, N	7.9
Median number of pharmacy visits, N	8

Overall, 40 patients (57.1%) achieved an HbA1c below 8% within 12 months. Proportional changes in reaching the goal of HbA1c under 8% were statistically significant (Cochran’s Q₅ = 142.88, P < .0001), Figure 1. Among the 40 patients who achieved the primary outcome within 12 months, 32 maintained an HbA1c below 8% during follow-up. Proportional changes were significant at each 3-month increment compared to the prior 3 month period, at 3, 6, 9, 12, and 15 months, (P < .001, .001, .05, .05, and .05, respectively). Logistic regression identified that gender (χ²₁ = 7.75, P < .01) and insurance status (χ²₁ = 12.18, P < .05) were significant predictors of success (Figure 2). Data revealed that males were more likely than females to achieve HbA1c below 8% (odds ratio [OR]: 5.88, 95% confidence interval [CI]: 1.650-25.300). Achievement rates were also higher among uninsured patients compared with those insured by Medicaid (88% compared to 50% respectively; OR: 6.68, 95% CI: 1.50-48.95). Patient age and number of pharmacy visits were not significant predictors (Table 2).

Figure 1.

Percent of patients reaching HbA1c below 8% at 3, 6, 9, 12, and 15 months compared to baseline.

Figure 2.

Balloon plots for gender (A) and insurance status (B) as predictors of achieving HbA1c below 8%.

Table 2.

Multivariate Logistic Regression on Factors Associated With Achieving HbA1c <8% Within 12 Months.

Variable	N	Category/unit	Odds ratio (95% CI)	P-value
Number of pharmacy visits	70	Per visit increase	1.09 (0.95-1.26)	.21
Gender
Female	46	(Ref)	(Ref)	(Ref)
Male	24	Vs Female	5.88 (1.65-25.30)	.01
Insurance
Medicaid	44	(Ref)	(Ref)	(Ref)
Uninsured	17	Vs Medicaid	6.68 (1.50-48.95)	.02
Commercial	3	Vs Medicaid	NA	.99
Medi-Medi	3	Vs Medicaid	0.88 (0.03-15.99)	.93
Medicare	3	Vs Medicaid	3.33 (0.21-93.71)	.40
Age	70	Per year increase	0.98 (0.91-1.05)	.63

The odds of a timely diabetic eye exam (OR: 8.667, 95% CI: 2.656-44.738, P < .0001), diabetic foot exam (P < .0001), and UACR test (OR 4.800, 95% CI: 1.795-16.107, P = .0008) increased. The OR and CI could not be calculated for completion of timely diabetic foot exams because one of the discordant values was 0. The odds of patients taking a statin increased (OR: 9.000, 95% CI: 2.155-79.981, P = .0008). Diabetic eye exam completion rates improved by 37.1%, diabetic foot exams by 57.1%, UACR tests by 34.3%, and statin initiation by 25.7%. After 12 months of clinical pharmacist intervention, 68.6% of patients were up-to-date on diabetic eye exams, 67.1% on diabetic foot exams, 84.3% on UACR testing, and 91.4% of patients were on appropriate statin use. The majority of patients were taking a moderate-intensity statin (67.1%), with remaining patients who were taking a statin on a high-intensity statin.

Discussion

Spanish-speaking adults with uncontrolled T2D who had at least 1 visit with a clinical pharmacist observed improvements in glycemic control and timely diabetes preventative care screening rates. The majority of patients (80%) who achieved HbA1c below 8% maintained glycemic improvements during follow-up. Male gender and patients without insurance were more likely to achieve HbA1c below 8%. The limited sample size of patients identifying as male or lacking insurance coverage may have influenced the higher observed odds of achieving an HbA1c below 8%. Additionally, there was a disproportionately higher percentage of uninsured patients in the study population compared with the clinic population as a whole (24.3% vs 13%, respectively), with a lower percentage of patients in the study population with Medicaid (63% vs 84% of overall clinic population). The clinical pharmacist addresses barriers to medication access by enrolling uninsured patients in medication assistance programs. Consequently, uninsured patients may have greater access to a broader range of antidiabetic medications, such as GLP1-RA, SGLT2 inhibitors, and insulin, than before seeing the clinical pharmacist, contributing to the higher odds of achieving HbA1c below 8%. Once patients achieve glycemic control, they are discharged from clinical pharmacy services. Patients who required more pharmacy visits over the 12-month period may have achieved HbA1c control more slowly and faced greater challenges in attaining glycemic control.

In our evaluation, patients were also more up-to-date on completing diabetic eye exams, diabetic foot exams, and UACR monitoring by the end of the observation period. The majority of patients (91.4%) were on at least a moderate-intensity statin by the end of the evaluation period. These findings demonstrate the potential for clinical pharmacists to address crucial barriers to care in a Spanish-speaking patient population. This is especially relevant given the large burden of diabetes-related complications that Hispanic individuals face in comparison to non-Hispanic white counterparts. ²⁴ However, reimbursement challenges exist. Currently, clinical pharmacist visits are completed as co-visits for reimbursement purposes. Additionally, clinical pharmacist services are delivered through an academic partnership with a School of Pharmacy.

Prior research supports the role that clinical pharmacists play in diabetes management with improvements in HbA1c reduction, preventing hospital/emergency department visits, and cost savings.^25-27 Although several studies have shown that clinical pharmacist interventions can significantly improve glycemic control among predominantly Hispanic patient populations, the overall evidence remains mixed regarding their impact on HbA1c, microvascular complication severity, and other clinical parameters such as blood pressure, lipid levels, and body mass index (BMI).^12,28-30 In our evaluation, Spanish-speaking patients who attended at least 1 clinical pharmacist visit exhibited significant improvement in glycemic control and demonstrated improved adherence to guideline-recommended screenings for diabetes-related complications. The study population (N = 70) had a median of 8 visits with the clinical pharmacist over a 12-month period and included patients who were lost to follow-up or were discharged after 1 visit. Further, all members of the medical care team, including the clinical pharmacist, spoke Spanish and conducted the pharmacy visits in Spanish according to patient preference. Future research is needed to identify and examine the factors that contribute to improved clinical outcomes among Spanish-speaking patients receiving care from clinical pharmacists, such as frequency of visits, language concordance, or length of visits. This will aid in enhancing care delivery while minimizing the systemic gaps that Spanish-speaking patients often encounter.

Beyond glycemic control, our evaluation also found improvements in adherence to guideline-recommended diabetes preventative screening measures and statin therapy. Completion of diabetic eye and diabetic foot exams as well as UACR testing increased by 37.1%, 57.1%, and 34.3%, respectively. In a recent quality improvement study, a 5% increase in annual diabetes eye exam rates in patients with diabetes was seen with a pharmacist-led retina scan program. ³¹ To our knowledge, no prior literature has described changes in timely diabetes preventative care screenings in Spanish-speaking populations who receive clinical pharmacist care. Existing literature has shown that Hispanic patients receive diabetes preventative care screenings, including yearly foot exams and diabetic eye exams, at lower rates. ³² Clinical pharmacists provide CMM, diabetes education, and structured follow-ups. ³³ These elements combined create accessible care, which in turn can increase medication adherence and completion of guideline-recommended screenings.

Limitations include that this was a retrospective evaluation conducted at a single site that lacked a control group and included a small sample size. Consequently, the changes observed may not be attributable to clinical pharmacy interventions alone or generalized to other settings. Future research should include studies with a comparator group, as well as other LEP populations and settings. Additionally, studies that assess the absolute change in HbA1c value at each timepoint would be beneficial to evaluate within-group changes over time. Investigation into how pharmacists can identify and intervene on SDOH and how these interventions can influence diabetes outcomes may also be beneficial in guiding the development of pharmacist-led care in underserved populations. Still, these findings highlight the critical role pharmacists play in addressing care gaps, promoting adherence to evidence-based guideline recommendations, and improving health outcomes in underserved populations.

Conclusion

Among patients who received clinical pharmacist care, higher rates of reaching glycemic goals, completion of diabetes preventative care screenings, and use of guideline-recommended statin therapy were observed. These findings highlight potential opportunities for pharmacists to help close care gaps and reduce the risk of microvascular complications among Spanish-speaking adults with uncontrolled diabetes. Further research that examines the factors that contribute to improved clinical outcomes among Spanish-speaking patients receiving care from clinical pharmacists is needed.