title: Use of an Electronic Medical Record (EMR) to Identify Glycemic Intensification Strategies in Type 2 Diabetes.
abstract: BACKGROUND
  Current treatment guidelines for type 2 diabetes (T2D) recommend individualized intensification of therapy for glycated hemoglobin (A1C) ≥ 7% in most patients. The purpose of this investigation was to explore the ability of an electronic medical record (EMR) to identify glycemic intensification strategies among T2D patients receiving pharmacologic therapy.
  
  
  METHODS
  Patient records between 2005 and 2011 with documentation of A1C and active prescriptions for any diabetes medications were queried to identify potential candidates for intensification based on A1C ≥ 7% while on 1-2 oral diabetes medications (ODM). Patients with follow-up A1C values within 1 year of index A1C were grouped according to intensification with insulin, GLP-1 receptor agonists (GLP-1RA), a new class of ODM, or no intensification. Changes in A1C and continuation of intensification therapy were determined.
  
  
  RESULTS
  A total of 4921 patients meeting inclusion criteria were intensified with insulin (n = 416), GLP-1RA (n = 68), ODM (n = 1408), or no additional therapy (n = 3029). Patients receiving insulin had higher baseline (9.3 ± 2.0 vs 8.3 ± 1.2 vs 8.3 ± 1.3 vs 7.6 ± 1.0%, P < .0001) and follow-up A1C (8.1 ± 1.6 vs 7.5 ± 1.2 vs 7.6 ± 1.3 vs 7.2 ± 1.1%, P < .0001) despite experiencing larger absolute A1C reductions (-1.2 ± 2.1 vs -0.8 ± 1.4 vs -0.7 ± 1.4 vs -0.3 ± 1.1%, P < .0001). Patients receiving GLP-1RA were more obese at baseline (BMI: 33.6 ± 7.1 vs 37.7 ± 6.1 vs 33.7 ± 6.8 vs 32.9 ± 7.1 kg/m(2), P < .0001) and follow-up (BMI: 33.9 ± 7.3 vs 36.6 ± 6.1 vs 33.8 ± 7.0 vs 32.4 ± 7.0 kg/m(2), P < .0001) despite experiencing more absolute weight reduction. Insulin was the most and GLP-1RA the least likely therapy to be continued.
  
  
  CONCLUSIONS
  An EMR allows identification of prescribing practices and compliance with T2D treatment guidelines. Patients receiving intensification of glycemic medications had baseline A1C >8% suggesting that treatment recommendations are not being followed.
authors.affiliation: Division of Endocrinology, University of Pittsburgh, Pittsburgh, PA, USA mtk7@pitt.edu.
authors.forename: Mary T
authors.initials: MT
authors.lastname: Korytkowski
authors.affiliation: Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Maria
authors.initials: M
authors.lastname: Brooks
authors.affiliation: Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Manuel
authors.initials: M
authors.lastname: Lombardero
authors.affiliation: Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Dilhari
authors.initials: D
authors.lastname: DeAlmeida
authors.affiliation: UPMC, Pittsburgh, PA, USA.
authors.forename: Justin
authors.initials: J
authors.lastname: Kanter
authors.affiliation: Lehigh Valley Health Network, Diabetes and Endocrinology, Allentown, PA, USA.
authors.forename: Vasudev
authors.initials: V
authors.lastname: Magaji
authors.affiliation: Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Trevor
authors.initials: T
authors.lastname: Orchard
authors.affiliation: Division of Endocrinology, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Linda
authors.initials: L
authors.lastname: Siminerio
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000378:metabolism; D001794:Blood Pressure; D015992:Body Mass Index; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D057286:Electronic Health Records; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D054539:Medication Therapy Management / Q000458:organization & administration; D008875:Middle Aged; D009765:Obesity / Q000150:complications; D012189:Retrospective Studies; D015431:Weight Loss; D000097789:Glucagon-Like Peptide-1 Receptor Agonists
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; D000097789:Glucagon-Like Peptide-1 Receptor Agonists
keywords: electronic health records; hospital information systems; hypoglycemic agents; type 2 diabetes mellitus