Trial of Decision Support to Improve Diabetes Outcomes

Diabetes is an independent risk factor for the nation's first and third leading killers and the leading cause of kidney failure and adult blindness. Evidence-based guidelines exist for control of glycemia (A1c levels), lipid abnormalities (LDL levels), hypertension (HBP), kidney and eye disease, yet gaps exist between what can be achieved and current performance. Competing approaches to improvement include disease management and patient empowerment, both of which can be facilitated by electronic medical records (EMR)-centered decision support.

Aims and Methods: The investigation was a 2-year cluster-randomized trial of 22 primary care practices, 197 PCPs, and their 13,000 adult diabetics across two health systems experienced in using the same commercial EMR system. Four clusters of similar practices will be assigned randomly to EMR-based disease management (EMR-DM 2). web portal-based patient empowerment (EMR-PE), both approaches (EMR-Both), or EMR alone.

Our Aims were to: 1) compare the incremental effects of our interventions on primary outcomes (quality of care/patient safety, and utilization), adjusting as necessary for baseline prognostic differences, adjusting for clustering and using an intention-to-treat analysis; 2) estimate intervention effects in pre-specified sub-groups: 3) describe specific features of patients and PCPs that are associated with different types and levels of adoption of our interventions; and 4) describe general and intervention-specific unintended consequences of our interventions.

Significance: The results of this investigation are of critical value to providers and their patients with chronic illnesses, to payers and insurers, to policymakers, and to those seeking to better understand EMR-based decision support - its adoption, and its usefulness for improving quality and safety in patient care.

CCF Partnership: CCF investigators Harris, Miller, and Jain collaborated on all aspects of this project. CCF led the components of the study related to patient empowerment utilizing the MyChart clinical application currently being deployed at CCF.