Impact of population management with direct physician feedback on care of patients with type 2 diabetes.
OBJECTIVE
Population-level strategies may improve primary care for diabetes. We designed a controlled study to assess the impact of population management versus usual care on metabolic risk factor testing and management in patients with type 2 diabetes. We also identified potential patient-related barriers to effective diabetes management.


METHODS
We used novel clinical software to rank 910 patients in a diabetes registry at a single primary care clinic and thereby identify the 149 patients with the highest HbA(1c) and cholesterol levels. After review of the medical records of these 149 patients, evidence-based guideline recommendations regarding metabolic testing and management were sent via e-mail to each intervention patient's primary care provider (PCP). Over a 3-month follow-up period, we assessed changes in the evidence-based management of intervention patients compared with a matched cohort of control patients receiving usual care at a second primary care clinic affiliated with the same academic medical center.


RESULTS
In the intervention cohort, PCPs followed testing recommendations more often (78%) than therapeutic change recommendations (36%, P = 0.001). Compared with the usual care control cohort, population management resulted in a greater overall proportion of evidence-based guideline practices being followed (59 vs. 45%, P = 0.02). Most intervention patients (62%) had potential barriers to effective care, including depression (35%), substance abuse (26%), and prior nonadherence to care plans (18%).


CONCLUSIONS
Population management with clinical recommendations sent to PCPs had a modest but statistically significant impact on the evidence-based management of diabetes compared with usual care. Depression and substance abuse are prevalent patient-level adherence barriers in patients with poor metabolic control.
Grant
Richard W
RW
General Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA. rgrant@partners.org
Hamrick
Hope E
HE
Sullivan
Christine M
CM
Dubey
Anil K
AK
Chueh
Henry C
HC
Cagliero
Enrico
E
Meigs
James B
JB
D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities; D001291:Attitude of Health Personnel; D015331:Cohort Studies; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D010820:Physicians; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration*; D012042:Registries; D012984:Software