Outcomes/Effectiveness Research

Interventions for primary care providers improve management of diabetes

Diabetes care is most often provided in the primary care setting, and proper management of diabetes generally results in improved outcomes for the patient. However, glycated hemoglobin (HbA1c) or blood sugar levels are rising in patients with diabetes. While poor blood sugar control could be due to patient noncompliance with treatment recommendations, it is also possible that health care providers could be failing to initiate or intensify therapy appropriately—a problem known as "clinical inertia."

Three studies supported in part by the Agency for Healthcare Research and Quality (HS07922) examined interventions intended to overcome clinical inertia and whether these interventions improved blood sugar control. The first reveals that providing feedback to internal medicine resident primary care providers improves blood sugar control. The second found that providing feedback on performance to medical resident primary care providers both improved provider behavior and resulted in lower HbA1c levels in patients with diabetes. A third study indicates that feedback from an endocrinologist on residents' management practices can improve blood sugar control in their patients. All three studies are summarized here.

Miller, C.D., Ziemer, D.C., Doyle, J.P., and others (2005, Autumn). "Diabetes management by residents in training in a municipal hospital primary care site (IPCAAD 2)." Ethnicity & Disease 15, pp. 649-655.

The Improving Primary Care of African Americans with Diabetes (IPCAAD) study is a randomized, controlled trial that attempts to translate endocrinologist approaches to diabetes to the primary care setting by partnering endocrinologists with generalists to improve diabetes care. In this 7-week study prior to the initiation of the IPCAAD interventions, the investigators observed the diabetes management practices of internal medicine residents in a hospital primary care clinic.

They found that residents' patients with type 2 diabetes often did not achieve national standard of care goals, even though many were receiving medication for their condition, suggesting a need to intensify therapy. For example, the HbA1c goal (less than 7 percent) was met in only 39 percent of patients, and LDL cholesterol and systolic blood pressure goals (less than 100 mg/dL and 130mm Hg, respectively) were met in only 25 percent of patients. In contrast, HDL cholesterol was at goal (greater than 40 mg/dL for men and 50 mg/dL for women) in 51 percent of patients, triglycerides at goal (less than 200 mg/dL) in 85 percent, and diastolic blood pressure (less than 85 mm Hg) in 77 percent of patients.

An average of 53 percent of the patients had urine protein screening for diabetic-related kidney damage over the course of a year. Also, only 39 percent of patients took aspirin to reduce their risk of heart disease and stroke. Clinical skills and attitudes developed in residents are likely to carry over into later practice. Thus, local diabetes educators may need to work with medical faculty to develop new ways to improve post-graduate medical education in diabetes management, suggest the researchers.

Ziemer, D.C., Doyle, J.P., Barnes, C.S., and others (2006, March). "An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting." Archives of Internal Medicine 166, pp. 507-513.

In this IPCAAD study, 345 internal medicine residents who treated patients with diabetes were randomly assigned to either a control group or an intervention group. Residents in the intervention group received one of three types of interventions: computerized reminders that provided patient-specific recommendations at each visit; feedback on their performance every 2 weeks; or both computerized reminders and feedback.

When the patient's blood sugar level exceeded 150 mg/dL (equivalent to an HbA1c level of 7 percent), a change of therapy was indicated. Resident management was divided into three categories: "did nothing" (meaning no steps were taken to increase the patient's medication or add a new diabetes medication); "did anything" (meaning that some steps were taken, but less than recommended); or "did enough" (meaning that the steps taken were as great as those recommended by an algorithm to improve blood sugar control).

At baseline, when a change in therapy was indicated, residents "did anything" for 35 percent of visits and "did enough" for 21 percent of visits. During the intervention period, residents who received the feedback alone or the feedback plus reminders intensified therapy more often for their patients than did residents who received reminders alone and the control group. After 3 years, resident behavior returned to baseline measures among those who received reminders alone and the control group; however, the improvement seen in residents who received feedback or feedback plus reminders was sustained: 52 percent "did anything" and 30 percent "did enough."

Additional analysis showed that intensification of therapy by providers, promoted by feedback on performance, contributed significantly to better glycemic control. The researchers concluded that performance feedback given to medical resident primary care providers improved their behavior—helping to overcome their "clinical inertia"—and lowered blood sugar levels in their patients.

Phillips, L.S., Ziemer, D.C., Doyle, J.P., and others (2005, October). "An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site." Diabetes Care 28(10), pp. 2352-2360.

Failure to intensify therapy in patients with diabetes when it is clinically indicated (for example, when glucose levels are high) is a problem known as clinical inertia. Clinical inertia affects management of disorders such as diabetes, hypertension, and dyslipidemia. This IPCAAD study found that utilizing feedback from endocrinologists aimed at overcoming the clinical inertia of internal medicine residents improved glycemic control in patients with diabetes.

The investigators randomized 4,138 patients with type 2 diabetes seen at a hospital primary care clinic by 345 internal medicine residents to a control group or 1 of 3 experimental groups. Patients were followed for an average of 15 months.

Endocrinologists provided residents in one group with hard copy computerized reminders that provided patient-specific recommendations for diabetes management at the time of each patient's visit. They gave the second group of residents face-to-face feedback on their diabetes management performance for 5 minutes every 2 weeks. They emphasized the importance of achieving ADA goals and taking action to adjust medication when values were abnormal during visits. The endocrinologists provided the third group with both reminders and feedback.

Patients in the feedback plus reminders group had 0.6 percent improved HbA1c and final HbA1c of 7.46 (the goal is less than 7 percent). This was significantly better than the control group (0.2 percent change and a final HbA1c of 7.84 percent). Changes were smaller with feedback only and reminders only. Over a 2-year period, overall glycemic control improved at the intervention site, but did not change in other primary care sites.

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