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.
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.


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 HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 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.
Phillips
Lawrence S
LS
Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA. medlsp@emory.edu
Ziemer
David C
DC
Doyle
Joyce P
JP
Barnes
Catherine S
CS
Kolm
Paul
P
Branch
William T
WT
Caudle
Jane M
JM
Cook
Curtiss B
CB
Dunbar
Virginia G
VG
El-Kebbi
Imad M
IM
Gallina
Daniel L
DL
Hayes
Risa P
RP
Miller
Christopher D
CD
Rhee
Mary K
MK
Thompson
Dennis M
DM
Watkins
Clyde
C
D000046:Academic Medical Centers / Q000458:organization & administration; D000328:Adult; D001741:Black or African American; D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D004704:Endocrinology / Q000193:education; D005260:Female; D005500:Follow-Up Studies; D006442:Glycated Hemoglobin; D006801:Humans; D006943:Hyperglycemia / Q000628:therapy; D007396:Internship and Residency; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D011446:Prospective Studies
D006442:Glycated Hemoglobin