title: Improving combined diabetes outcomes by adding a simple patient intervention to physician feedback: a cluster randomized trial.
abstract: 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.
authors.affiliation: Department of Epidemiology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. weitzman@bgu.ac.il
authors.forename: Shimon
authors.initials: S
authors.lastname: Weitzman
authors.forename: Sheldon
authors.initials: S
authors.lastname: Greenfield
authors.forename: John
authors.initials: J
authors.lastname: Billimek
authors.forename: Tabenkin
authors.initials: T
authors.lastname: Hava
authors.forename: Pesach
authors.initials: P
authors.lastname: Schvartzman
authors.forename: Ezra
authors.initials: E
authors.lastname: Yehiel
authors.forename: Howard
authors.initials: H
authors.lastname: Tandeter
authors.forename: Sophia
authors.initials: S
authors.lastname: Eilat-Tsanani
authors.forename: Sherrie H
authors.initials: SH
authors.lastname: Kaplan
mesh_terms: 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
chemical_list: D008078:Cholesterol, LDL; D006442:Glycated Hemoglobin