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patients, or 63.1%); this was followed by Malayalam for six Details are presented in Table 3.
patients (31.5%) and by English for one patient (5.2%). The median knowledge score of the test group on the day of
discharge was 14; this was significantly higher than the knowl-
Time Required for Counseling edge score on the day of admission (P = .003). Similarly, the me-
Most patients (12 [63.1%]) were counseled for a period of dian knowledge scores during the first and second follow-up
30 to 60 minutes during the initial visit with the pharmacist. Of evaluations were significantly higher (P < .001) than on the day
the remaining patients, four (26%) were counseled for more of admission (P < .001). Details are provided in Table 4.
than an hour. Patients were also counseled on the subsequent Knowledge scores for the test group were significantly higher
days of their hospital stay based on their requirements. In gen- at the first follow-up visit (P = .004) and at the second follow-up
eral, the most time was devoted to elderly patients, patients visit (P = .000), compared with the corresponding values for the
using insulin therapy, and patients receiving multiple drugs. control group. However, no such differences were observed in
the attitude/practice scores.
Medications There was no significant correlation between the proportion
Figure 1 shows the drugs for which the test group had of subjects who answered the knowledge questions correctly
received detailed counseling. Most of the test patients (13 and those who answered the behavioral questions appropri-
patients, 68.4%) were using insulin, followed by: ately, as determined by Pearson’s correlation coefficient (.325).
Patients may have been counseled by the treating physician,
• metformin (e.g., Glucophage, Bristol-Myers Squibb) nurses, relatives, and other patients and might have obtained
(10 patients, 52.6%). diabetes-related information from other sources. This could be
• glibenclamide (five patients, 26.3%). a confounding factor, and we did not account for it during the
• other sulfonylureas (five patients, 26.3%). study.
• pioglitazone (Actos, Eli Lilly/Takeda) (one patient, 5.2%).
• acarbose (Precose, Bayer) (one patient, 5.2%). DISCUSSION
Our study evaluated the impact of pharmacist-provided coun-
No patients were taking meglitinides. seling in terms of diabetic patients’ understanding of their dis-
ease, drug therapy, and lifestyle changes. We found that coun-
EVALUATION OF THE QUESTIONNAIRE AND THE seling by pharmacists was effective in improving patients’
EFFECT OF COUNSELING ON SCORES knowledge but not in improving their attitudes and practices.
The scores corresponding to the number of questions an- Because there was no correlation between attitude and practice,
swered correctly by the control patients and the test patients are we cannot assume that improved patient knowledge would
listed in Tables 1 and 2, respectively. result in appropriate behavior.
The median attitude/practice score of the test group on the Management of chronic disease is strongly linked to lifestyle
first follow-up visit was 5; this score was significantly higher than modifications. For effective disease prevention and treatment,
on the day of admission (P = .013). Similarly, the median atti- behavioral changes are required.
tude/practice score on the second follow-up evaluation was For patients with chronic diseases, home is usually the
5, and it was significantly higher than on the day of admission central site of managing the illness. This is true for diabetic
(P = .022), according to the Wilcoxon Signed-Rank test. How- patients who also need knowledge about their illness in order
ever, no such improvement was observed in the control group. to manage it effectively.17 The role of the pharmacist is especially
important in helping patients control chronic diseases like dia- A major objective of counseling is to improve patient compli-
betes. The pharmacist can monitor and track patients’ blood glu- ance. Several strategies may be taken to encourage the patient
cose levels. During contact with the pharmacist, patients can ask to adhere to therapy.19 Our study used patient information
questions that they might have been reluctant to ask their physi- leaflets to promote counseling. The leaflet was written in local
cians. In general, it is the pharmacists’ role to help diabetic pa- languages, which enhanced understanding among the patients.
tients to cope with their disease.18 A study by Hawkins and colleagues assessed the effectiveness
Every patient enrolled in our study was taking at least one of interventions by clinical pharmacists in managing hyperten-
drug as a part of a diabetes-management regimen, and the clin- sive and diabetic patients.20 The controls received conventional
ical pharmacist provided counseling according to OBRA recom- care by one physician; the test group of patients received care
mendations.6 The questions patients most commonly asked directly from a pharmacist and were closely monitored by a
about their medications had to do with the following: physician. The investigators noted an increase in patient satis-
faction and patient compliance with the treatment regimen for
• technique of insulin administration the test group. In our study, the pharmacist monitored the
• when to take oral hypoglycemic drugs (before or after patient chart for correct doses, drug interactions, and any
meals) needed dosage adjustments.
• management of hypoglycemia Patient involvement is of paramount importance for the suc-
cessful management of diabetes. Lifestyle changes are usually
Hypoglycemia is a common problem associated with dia- necessary; these include dietary adjustments, exercise, moni-
betes management. Pharmacists should emphasize the meth- toring of blood glucose levels at home, sometimes monitoring
ods used to detect and prevent hypoglycemia. In the study pop- urine changes, and following an appropriate drug regimen).21
ulation, insulin was the drug used in the majority of patients. Shilling conducted a program that utilized a pharmacist for
Table 1 Knowledge, Attitude, and Practice (KAP) Scores of the Control Group of Patients (C1–C27)
Table 2 Knowledge, Attitude, and Practice (KAP) Scores of the Test Group of Patients (T1–T9)
monitoring and treating diabetic patients in a 58-bed hospital.22 participants received information and training to improve com-
The study enrolled 193 diabetic patients; 50% of the patients pliance. These study findings indicated that the test group
were monitored for 19 months. The increased involvement of experienced fewer medication errors, fewer hospital admis-
the pharmacist resulted in better use of their abilities and more sions, and fewer changes in therapeutic regimens compared
time for physicians to spend with patients who had complica- with the control group.23
tions. Self-monitoring of blood glucose is considered a key element
In our study, we could not evaluate the amount of physicians’ in diabetes care, and it is widely recommended. This activity
time saved as a result of the increased pharmacist involvement; helps patients adjust their insulin dosage, diet, and exercise
however, it is clear that a period of physicians’ time was saved regimens, and it aids in detecting and preventing hypo-
as a result of the pharmacist’s clearly explaining instructions on glycemia.24
drug use to the test group of patients. A study conducted in South India on diabetic patients’ knowl-
Sczupak and Conrad assessed the effect of patient-oriented edge and beliefs about the disease and their practices in terms
pharmaceutical services on the treatment outcomes of ambula- of diet, medications, and self-monitoring of blood glucose levels
tory patients with diabetes mellitus.23 The test group was mon- revealed a large gap between knowledge and action. The find-
itored for drug therapy via a patient profile form, and the ings illustrate the need for increased efforts in the area of
patient education.25 In our study, patients were taught the
importance of self-monitoring.
Table 3 Effect of Patient Counseling in Terms of
It is essential to dedicate an appropriate amount of time to
Attitude and Practice Outcomes
achieve improved patient counseling. The amount of time spent
generally depends on factors such as a patient’s interest, the
Median ± Interquartile Range
number of medications needed, the seriousness of the patient’s
Day of Day of 1st 2nd condition, and the pharmacist’s work schedule. Lack of time is
Group Admission Discharge Follow-up Follow-up one of the barriers to providing counseling.26 It is also necessary
to spend more time counseling certain patient groups, such as
Test (n = 19) 4±3 4±3 5 ± 2* 5 ± 2†
those who need multiple drugs, those who have complicated
Control (n = 27) 5 ± 2 5±2 5±2 5±2
drug regimens, and the elderly. However, our study did not
*P = .013 compared with attitude/practice scores on the day of consider these factors to be barriers to providing counseling.
admission. The need for teaching diabetic patients about their illness is
†P = .022 compared to attitude/practice scores on the day of obvious, because the success of the diabetes treatment depends
admission. on lifestyle modifications in addition to the drug therapy. Patient
4. Diabetes, if not treated: 12. Regular urine tests will help in knowing:
o can lead to eye problems. o the status of liver function.
o can lead to kidney problems. o the status of kidney function.
o can lead to foot ulcers. o the control of diabetes.
o can lead to heart problems. o I don’t know
o all the above
o I don’t know 13. When was your last urine exam?
o one month ago
5. The most accurate method of monitoring diabetes is: o six months ago
o checking blood glucose levels. o one year ago
o checking urine sugar. o not done at all
o I don’t know
14. The important factors that help in controlling blood sugar
6. In a diabetic patient, high blood pressure can increase or are:
worsen: o a controlled and planned diet
o the risk of heart attack. o regular exercise
o the risk of stroke. o medication
o the risk of eye problems. o all the above
o the risk of kidney problems. o none
o all the above
o I don’t know 15. A regular exercise regimen will help in:
o increasing blood circulation.
7. A diabetic patient should measure his or her blood pres- o enhancing insulin action.
sure: o I don’t know
o once a year.
o once every six months. 16. Do you exercise regularly?
o once every two months. o Yes o No
o once every month.
o need not check at all If yes, how often?
o I don’t know o Every day o Once weekly o Once monthly
8. When was your blood pressure checked last? 17. Are you following a controlled and planned diet?
o one week ago o Yes o No
o one month ago
o two months ago If yes, how often?
o six months ago o Always o Sometimes o Rarely
o one year ago
continued on page 400
24. Are you aware of blood sugar levels falling below normal
when you are taking drugs?
o Yes o No