Intervention Directed at Primary Care Providers Improves Outcomes

Endocrinologist-supported intervention improved primary care diabetes management.

Interventions directed at primary care providers and supported by endocrinologists improved the management of diabetes among primary care physicians and lowered HbA1c, blood pressure and LDL cholesterol levels among diabetic patients. The interventions were aimed at fighting a problem known as ‘clinical inertia.’

“Clinical inertia is a common problem in management of disorders that cause considerable morbidity and mortality in the United States: diabetes, hypertension and dyslipidemia. It is not due to a lack of knowledge, but reflects instead inadequacies in the structure of care,” said Lawrence Phillips, MD, professor of medicine, division of endocrinology at Emory University.

Phillips and colleagues undertook a study to see if specialist-supported interventions could improve diabetes management among primary care physicians. Researchers observed more clinical inertia and higher HbA1c levels at the general medicine primary care clinic at Grady Memorial Hospital in Atlanta than at the associated diabetes specialty clinic.

“Differences in apparent clinical inertia might be due to the reluctance of primary care providers to intensify therapy for patients who seem unmotivated, but we believe the differences also reflect prior quality-improvement efforts in the specialty clinic that reduced clinical inertia and lowered HbA1c levels,” the researchers wrote.

The hypothesis that endocrinologist-supported interventions may reduce clinical inertia was tested in the Improving Primary Care of African Americans with Diabetes (IPCAAD) study.

A total of 345 residents participated. They treated 4,138 patients with type 2 diabetes from July 1999 through December 2002. Baseline levels of LDL cholesterol, blood pressure and HbA1c were measured in all patients at enrollment and were followed to the end of the study. Physicians were randomized to a control group, a computerized-reminders group, a feedback-on-performance group or to a group receiving both feedback and reminders.

Computerized reminders consisted of recommendations for management of hyperglycemia, hypertension and dyslipidemia. These reminders took into account specific patients’ medications and goals in order to recommend changes in dosing or medications and were provided at the time of patient visits.

Feedback sessions consisted of approximately five minutes of discussion with an endocrinologist every two weeks. “The sessions specifically avoided consultative advice on management,” the researchers wrote. “Instead, feedback was based on IPCAAD report cards that showed individual provider actions or outcomes of the patients seen by that provider, but did not identify specific patients.”

Statistically significant improvement of HbA1c levels was found in the feedback and reminders group vs. the control group (0.6% vs. 0.2%). Improvements in HbA1c were also greater in the feedback-only group (0.4%) and the reminders-only group (0.3%), but these values were not statistically different from the control group.

Systolic blood pressure also showed a statistically significant improvement in the feedback and reminders group (–3.4 mm Hg) as well as the feedback-only group (–3.2 mm Hg). LDL cholesterol showed statistically significant improvement in all intervention arms, but the greatest change was found in the feedback and reminders group (–18 mg/dL).

Among patients in the feedback and reminders group, 56% attained their ADA treatment goal for HbA1c, compared with 49% of the control patients.

Feedback-only patients showed similar results to the combination group, while only 47% of patients in the reminders-only group reached their goal.

To correct for the possibility of contamination between the various intervention arms, researchers also examined outcomes in other primary care sites outside of the study population, and found significantly lower HbA1c levels among patients at the study site.

Dr. Lawrence Phillips, stated that, "Our study showed that an intervention aimed at providers – emphasizing provider action when indicated, but not providing knowledge per se – improved HbA1c levels and also blood pressure to a lesser extent.”

“LDL cholesterol didn’t differ among the intervention arms, probably because management is much easier, not requiring repeated action by the provider – just add a statin and it’s done.”

Phillips LS, Ziemer DC, Doyle JP, et al. And endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site. Diabetes Care. 2005;28:2352-2360.

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DID YOU KNOW:
50 million people will be living with diabetes in 2025. The Institute for Alternative Futures has projected that if the rate of diabetes continues unchecked, 50 million people will be living with the disease in 2025—more than double the current number of people with diabetes. The total direct and indirect costs of diabetes will also double in 2025, totaling $351 billion. If the system remains unchanged, the urrent number of devastating consequences of diabetes will more than triple, resulting in 70,000 cases of blindness, more than 119,000 case of kidney failure, and 239,000 lower extremity amputations. Barriers to Chronic Disease Care in the United States of America: The Case of Diabetes and its Consequences