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An Endocrinologist-Supported Intervention Aimed at Providers Improves Diabetes Management in a Primary Care Site

Improving Primary Care of African Americans with Diabetes (IPCAAD) 7

¹ Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
² Division of General Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
³ Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
⁴ Department of Medicine, Mayo Clinic, Scottsdale, Arizona
⁵ Eli Lilly, Indianapolis, Indiana
⁶ Department of Educational Psychology and Special Education, Georgia State University, Atlanta, Georgia

Address correspondence and reprint requests to Lawrence S. Phillips, MD, General Clinical Research Center, Emory University Hospital, Room GG-23, 1364 Clifton Rd., Atlanta, GA 30322. E-mail: medlsp{at}emory.edu

OBJECTIVE—Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes.

RESEARCH DESIGN AND METHODS—A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient’s visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both.

RESULTS—Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA_1c (A1C) with feedback + reminders (A1C 0.6%, final A1C 7.46%) were significantly better than control (A1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001).

CONCLUSIONS—Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.

Abbreviations: ADA, American Diabetes Association • GEE, generalized estimating equation • IPCAAD, Improving Primary Care of African Americans with Diabetes • sBP, systolic blood pressure

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