A Community Pharmacist-Sponsored Diabetes Detection Program

A Community Pharmacist-Sponsored Dja~etes Detection Prograrri

Arthur C. Solomon, Stephen G. Haag and W. Arlyn Kloesel A community-wide pharmacist-sponsored diabetes detection drive was conducted for the purposes of (a) having as many undiagnosed diabetics as possible receive medical attention and (b) demonstrating that community pharmacies can serve as an excellent network for conducting community-wide health care programs. The program was sponsored by the Capitol Area Pharmaceu-

tical Association and the University of Texas College of Pharmacy at Austin and was endorsed by several area medical agencies and societies. After an intensive public advertising campaign, approximately 39,000 test kits were distributed, 25,000 of which were distributed at area community pharmacies. At the close of the drive, 22 individuals had been newly diagnosed as diabetic, a figure

considered to be well worth the effort. One of the most significant achievements of the drive was the demonstration that community pharmacies c;Jid indeed facilitate this ·mass screening program. Organizational and procedural aspects of the drive appeared to be applicable to other mass screening programs as welf. ·

Diabetes mellitus is generally accepted as one of the most serious health problems in the United States. The American Diabetes Association (ADA) estimates there may be as many as 10 million individuals-approximately five percent ·at the populationafflicted with the disease. 1 In individuals past age 60 prevalence may be as high as 10 percent. 2 It also has been estimated that perhaps one-third of all diabetics in the United States are presently undetected 1 and in need of medical attention. Unfortunately, the general public is frequently uninformed about the magnitude of the problem and fails to understand the severity of the disease and its associated complications. It is apparent that detection of the disease is a serious problem. Community-wide screening programs, where individuals have the opportunity to participate in personal testing, are an effective means of detecting undiagnosed diabetics. 3 •4 Although the primary objective of such programs is to identify previously undiagnosed diabetics, a successful diabetes detection program also should increase public awareness and understanding of the disease and inform physicians and allied health personnel of recent developments so they may continue to improve the care and treatment of their diabetic . patients. The pharmacist's role and responsibility toward the diabetic has been said to be more clearcut and important than toward any other group of patients. 5, During National Di~betes Detection Week,

1974, a community-wide diabetes detection drive was conducted in the greater Austin, Texas, vicinity by the Capitol Area Pharmaceutical Association (CAPA) and the l)niversity of Texas College of Pharmacy. The program was conducted in cooperation with the Austin-Travis County Health Department and was endorsed by the Travis County Medical Society and the South Texas affiliate of the American Diabetes Association. Based on figures provided by the local ADA chapter, there are approximately 18,000 diabetics in the greater Austin area, approximately 6,000 of whom are undetected. The program was undertaken to bring as many of these undetected diabetics as possible to medical attention. A primary intent in the program's design was to involve area pharmacists and pharmacy students. Further, it was intended that the program be conducted and evaluated in such a manner that the information gained could be useful to other pharmacy associations in organizing and conducting similar diabetes detection programs or related public service projects.

facts about the disease were aired on a popular contemp~xary radio station several days prior to the wee·k-long drive, followed by announcements of locations where test kits would be available during the week of the drive. Television coverage was obtained by providing local' stations with diabetes information video tapes purchased from the American Diabetes Association and aired as public service announcements. Further promotion was gained during the drive when selected pharmacists were interviewed on radio and television, and when one television station filmed an interview at a distribution site. Test kits were distributed to the public in a number of ways. Nearly every community pharmacy in the area participated in the drive and had test kits available in its prescription department. Bulk quantities of test kits were distributed to retirement centers by pharmacy students in an effort to reach elderly citizens. At the end of the week-long drive, distribution stations staffed by pharmacy students and pharmacists were e~­ tablished at eight major shopping centers. Approximately 25,000 kits were distributed through pharmacies, 7,000 through shopping center stations and 3,000 through retirement centers. No individual desiring a test kit was refused, although distributors attempted to limit distribution to high,.risk individuals whenever possible (Table 2, page 162). The screening method utilized in the drive was the Dreypak test kit available from the American Diabetes Association. The kit contains a chemically treated paper test strip, a set of instructions for performing the test and a return mail envelope. Following ingestion of a high carbohydr~te meal, subjects wetted the test strip with urine and mailed it to a testing center staffed by pharmacists and pharmacy students. The test was then completed at the testing center by placing a drop of glucose oxidase reagent

Arthur C. Solomon, MS. is Manager of Nuclear Pharmacy, Inc., Atlanta, Georgia 30329. Stephen G. Hoag, PhD, is Assistant Professor of Pharmacy, North Dakota State University, Fargo, North Dakota 58102. W. Arlyn Kloesel is a community pharmacist in Austin, Texas. Presented before the Academy of Pharmacy Practice, APhA Annual Meeting. San Francisco, Cal ifornia, April 21, 1975.

Vol. NS 17, No.3, March 1977

Method

Early in 1974 the Board of Directors of the Capitol Area Pharmaceutical Association decided to conduct the diabetes detection drive after reviewing a number of possible public service projects. Realizing that a project of this magnitude would require a great deal of organization, the Board appointed a steering committee of five pharmacists and one pharmacy student to carry out planning and organizational arrangements. The steering committee organized several subcommittees (Table 1, page 162) to carry out the various phases of the drive. Public awareness of diabetes and the detection drive was promoted through a variety of media. Radio sp'ots stating general

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A Community Pharmacist-Sponsored Diabetes Detection Program

Table 1. Gommittees for Organizing , Planning and Condu~ting Diabe-tes Detection Drives 1. Steering Committee* ·4. Test Kit :Pistribution 2. Finance Committee Committee 3. Publicity Committee 5. Testin·g Committee

did not report for follow-up testing, 10 had indicated a previous diagnosis of diabetes. Discussion

Table 3 (page 163) lists the data concerning test kits distributed, returned by mail and found positive for the presence of urine glucose. The finding of ·164 urine-positive tests represents 4:8 percent of .the 3,409 kits tested. As stated, these individuals were referred to the city-county health department for follo\N-UP testing. At the time of this writing, only 81 of the 164 had reported, and 29 of the 81 who reported w"ere found to have a positive blood glucose ( 130 mg percent or greater) . The age distribution of urine-positive individuals is given in Table 4 (page 163). Individuals who received the follow-up blood glucose screening test were questioned concerning a family history and I or previous diagnosis of diabetes. Of the 29 individuals who were bath urine- and blood gluco$e-positive, 17 confirmed a family history of the disease, and seven stated that they had previously been diqgnosed as diabetic. Of 'the 29 persons with positive urine and blood glucose response, 22 Were newly detected. Of 83 urine-positive subjects who

A significant result of the drive was the identification of 22 individuals, previously undetected, with abnormally high blood glucose. We felt that while this number of individuals was admittedly small, the detection of a single individual, previously undetected, would have made the drive worthwhile. ·A criticism of the urine screening process is the correlation between results of the urine ?nd blood screening tests. As mentioned, only 29 of 81 urine-positive persons were confirmed with positive blood glucose response. The reasons for the high number of false-positive urine tests were not entirely clear. It was felt that perhaps the greatest reason for the false-positive tests was the fact that pharmaci~ts conducting the tests were instructed to consider positive any test which was questionable. Since the test involved a color-change reaction, even faint changes were considered positive until proven otherwise by th~ follow-up blood test·. How~ver, we concluded that the mass~creening capability and the simplicity in the testing procedure validated our choice ·of method. Furthermore,· the second screening process carried out at the health department contributed to the validity of the design and results of the drive. Other criticisms of the drive may be centered on (a) the proportion of distributed kits which were returned by mail and . (b) the proportion of the individuals referred to the health department (urine-positive) who did, in fact, report for follow-up testing. That is, significant n~mbers of individuals received test kits but did not follow through with the test, and greater than half of those with positive urine glucose response failed toreceive the second screening test for blood glucose. ADA advises groups desiring to conduct detection drives that a 10 percen~ return of tests distributed is typical. In future detection drives, mechanisms should be sought to increase the number of both those persons returning strips for testing and those who obtain follow-up testing after initial positive response. At the time test kits are distributed the individual should be more thoroughly advised of the importance of following through. Announcements through the news media to encourage follow-through would be helpful. In comparison to other reported drives3 ·4

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Journal of the American Pharmaceutical Association

*l\llembers of the steering committee chaired or co-chaired each of the other committees.

Table 2. High-Risk Population Groups for · : Diabetes 5 1. Individuals past

3. Individuals with a family history of diabetes age 40 · 2. Obese individuals 4. Women who have borne large babies (nine lbs · or more) ·

on the test strip and observing for a color change. All individuals who submitted strips for testing received a letter informing them of the test results, positive or negative. Individuals with a positive response were instructed to report to the city-county health department for a free, follow-up blood glucose screening test. Those persons found to have · an · abnormally high bfood glucose concentration were then referred to · their private physicians. · · Results

Table 3. Urine Test Kit Distribution and Response Total number of test kits distributed Total number of test kits returned by mail for determination of urine glucose Total number of urine positive responses Total number of urine-positive persons receiving follow-up blood screening test

35 ,000

3,409 164

Age Group

Number of Subjects

19 and below 20-39 40 - 59 60 and over

17 39 45 63

Table 5. Diabetes Detection Drive Expenses 25,000 Dreypak Test Kits* 40,000 "STOP DIABETES" leaflets 400 "STOP DIABETES" posters 9 promotion video tapes Miscellaneous expenses**

$1,200.00 132.00 10.00 18.00 7 5.00 Total

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one of the most significant achievements of this drive was the demonstration that community pharmacies can serve as an excellent network for conducting mass screening programs for diabetics. The organizational and procedural aspects of the drive appear to be applicable to other mass screening programs as well. It is difficult to assess many of the intangible results of the drive;· especially the contribution to professional and public knowledge, educational value to students, promotion of professional unity and pride, and increased public awareness of the professional capabilities of the pharmacist. The program's success in terms of professional unity and pride was evidenced by the fact that greater than 98 percent of community pharmacies in the area served as distribution sites. Participation in the program was not limited to Capitol Area Pharmaceutical Association members. Indeed, an overwhelming majority of pharmacists in the area willingly participated. Member pharmacists, nonmember pharmacists and pharmacy students worked together in a united effort. An important goal of any health-related public service project is to increase public awareness of the problem. Specific efforts to assess public awareness of diabetes were not undertaken in our diabetes detection drive, but a number of subjective observations indicate favorable effects in this regard. Several community service organizations have volunteered to assist the Association in future diabetes screening attempts; many of the participating pharmacists have received inquiries from their patrons concerning future drives and numerous individuals have contacted the Association and the College of Pharmacy for advice on how they can test themselves for diabetes on a regular basis. Additionally, the observed public demand for test · kits following the publicity campaign indicated that many individuals

Vol. NS 17, No.3, March 1977

Table 4. Age Distribution of Individuals With Positive Urine Glucose Response

had become aware of diabetes and the detection drive. The Association obtained help from more than 150 pharmacy students from the University of Texas College of Pharmacy. Lectures on diabetes were scheduled to coincide with the drive. The students were eager, well informed and receptive to all inquiries concerning diabetes and its management. Many students expressed the opinion that the program had enabled them to observe the value of unity within a profession. Participation in the organizational and educational activities will hopefully encourage these students to organize similar public service projects and encourage their future support of professional associations. Another encouraging feature of the detection drive was its contribution to the rejuvenation of the Austin area affiliate of the ADA. This chapter had been dormant for a number of years and its officers viewed our drive as an opportunity to conduct a membership campaign. We can report that the Austin chapter is again very active, and pharmacy is now represented on the Board of Directors and several standing committees. The total cost of the detection drive is presented in Table 5 (above right) . .It should be noted that there would have been $750 additional expense if 1,500 Dreypaks had not been donated by the American Diabetes Association. The cost of the program described here is quite low and perhaps should not be considered typical. Much time and effort were donated by students and practitioners alike. As stated previously, the steering committee had responsibility for securing financial support for the project. It was decided to assess each of the 100 participating pharmacies a $5.00 fee to offset a portion of the test kit expense. An additional $685 was obtained through donations from wholesale houses and pharmacy chains. The remainder of the expense, $250,

$1.,435 .00

*An additional ·15,000 test kits were donated bY the American Diabetes Association. **Includes cost of printing reply letters, postage and testing_ reagents.

was absorbed by CAPA. Without the generous donations recei'(ed and the fine_cooperation of the participating pharmacies it would have been difficult for CAPA to support the project. Hqwever, members of the CAPA Board of Directors fe~l that the benefits of the drive far exceeded the expenses, and have indicated a desire to support future drives in the absence of outside support. Summary

The responsibilities of the pharmacist are no longer limited to the dispensing of medication. Consultation and education concerning disease states have become an important part of the pharmacist's service to the patient. The price-conscious consumer demands and deserves more than medication from his pharmacist. Statistical results obtained from detection drives are important and often impressive, but community public service projects such as diabetes detection drives also provide an excellent opportunity to demonstrate pharmacy knowledge and ·expertise. In addition to being a valuable public service, the program described was judged to be of immeasurable value to pharmacy in terms of knowledge gained, p_ublic image and professional pride. • References 1. Anon .: Facts on diabetes. ADA Newsletter, South Texas Affiliate, 1974. 2. Bondy, P. K. : Diabetes mellitus, in Cecil-Loeb textbook of medicine, Beeson, P. B., and McDermott, W., eds., W. B. Saunders Company, Philadelphia, Pennsylvania, 1970 p. 1645. 3. Orzeck, E A., Mooney, J. H. , and Owen, J. A.: Diabetes detection with a comparison of screening methods, Diabetes 20: 109, 1971 . 4. West, K. M.: Case history of a diabetes detection program in early disease detection, Halos and Associates, Miami, Florida, 1970, p. 33. 5. Shangraw, R. F., and Lamy, P. P.: Pharmaceutical aspects of the treatment of diabetes mellitus, J. Am Pharm Assoc. NS9: 117, 1969.

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