Improving combined diabetes outcomes by adding a simple patient intervention to physician feedback: a cluster randomized trial.
BACKGROUND
Research on synergistic effects of patient targeted interventions combined with physician-targeted interventions has been limited.


OBJECTIVE
To compare a combined physician-patient intervention to physician feedback alone on a composite outcome of glycemic, lipid and blood pressure control.


METHODS
In this cluster study 417 patients with adult-type 2 diabetes from four primary care clinics were randomized to receive either a physician-only intervention or a combined physician-plus-patient intervention. Physicians in all clinics received diabetes-related quality performance feedback during staff meetings. Patients at combined-intervention clinics also received a letter encouraging them to remind their doctors to address essential aspects of diabetes care at the next visit. At 1 year follow-up, outcome measurements included hemoglobin A1c, low density lipoprotein-cholesterol and systolic blood pressure: namely, the proportion of patients with HbA1c 9%, LDL <130 mg/dl and SBP <140 mmHg both as separate outcomes and combined.


RESULTS
After adjusting for patient characteristics and baseline measures, follow-up levels of HbA1c (7.5% vs. 7.8%, P = 0.09), LDL (104.7 vs. 110.7 mg/dl, P < 0.05) and SBP (135.6 vs. 139.9, P = 0.10) were marginally better for combined-intervention patients compared to physician-only intervention patients. Significantly more patients in the combined-intervention (38.8%) than physician-only intervention (24.2%) met all three targets (HbA1c (9%, LDL (130 mg/dl and SBP <140 mmHg) as a single combined outcome (adjusted odds ratio 2.4, P < .01).


CONCLUSIONS
Compared to physician-feedback alone, a dual intervention combining a patient letter with physician feedback produced modest improvements in glycemic, lipid and blood pressure control individually, but substantial improvement in a combined measure of these three outcomes together. Using composite outcomes may detect meaningful improvements in the management of complex chronic disease.
Weitzman
Shimon
S
Department of Epidemiology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. weitzman@bgu.ac.il
Greenfield
Sheldon
S
Billimek
John
J
Hava
Tabenkin
T
Schvartzman
Pesach
P
Yehiel
Ezra
E
Tandeter
Howard
H
Eilat-Tsanani
Sophia
S
Kaplan
Sherrie H
SH
D000368:Aged; D001794:Blood Pressure; D008078:Cholesterol, LDL / Q000097:blood; D003142:Communication; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D005246:Feedback; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D008297:Male; D010817:Physician-Patient Relations; D016896:Treatment Outcome
D008078:Cholesterol, LDL; D006442:Glycated Hemoglobin