title: Impact of population management with direct physician feedback on care of patients with type 2 diabetes.
abstract: 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.
authors.affiliation: General Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA. rgrant@partners.org
authors.forename: Richard W
authors.initials: RW
authors.lastname: Grant
authors.forename: Hope E
authors.initials: HE
authors.lastname: Hamrick
authors.forename: Christine M
authors.initials: CM
authors.lastname: Sullivan
authors.forename: Anil K
authors.initials: AK
authors.lastname: Dubey
authors.forename: Henry C
authors.initials: HC
authors.lastname: Chueh
authors.forename: Enrico
authors.initials: E
authors.lastname: Cagliero
authors.forename: James B
authors.initials: JB
authors.lastname: Meigs
mesh_terms: 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