A controlled trial of web-based diabetes disease management: the MGH diabetes primary care improvement project.

OBJECTIVE: To test effects of a web-based decision support tool, the diabetes Disease Management Application (DMA), developed to improve evidence-based management of type 2 diabetes. RESEARCH DESIGN AND METHODS: We conducted a group randomized controlled trial of 12 intervention and 14 control staff providers and 307 intervention and 291 control patients with type 2 diabetes in a hospital-based internal medicine clinic. Providers were randomly assigned from May 1998 through April 1999 to have access to the DMA (intervention) or not to have access (control). The DMA displays interactive patient-specific clinical data, treatment advice, and links to other web-based care resources. We compared patients in the intervention and control groups for changes in processes and outcomes of care from the year preceding the study through the year of the study by intention-to-treat analysis. RESULTS: The DMA was used for 42% of scheduled patient visits. The number of HbA(1c) tests obtained per year increased significantly in the intervention group (+0.3 tests/year) compared with the control group (-0.04 tests/year, P = 0.008), as did the number of LDL cholesterol tests (intervention, +0.2 tests/year; control, +0.01 tests/year; P = 0.02) and the proportions of patients undergoing at least one foot examination per year (intervention, +9.8%; control, -0.7%; P = 0.003). Levels of HbA(1c) decreased by 0.2 in the intervention group and increased by 0.1 in the control group (P = 0.09); proportions of patients with LDL cholesterol levels <130 mg/dl increased by 20.3% in the intervention group and 10.5% in the control group (P = 0.5). CONCLUSIONS: Web-based patient-specific decision support has the potential to improve evidence-based parameters of diabetes care.

Comparison of hyperglycemia, hypertension, and hypercholesterolemia management in patients with type 2 diabetes.

PURPOSE: Cardiovascular disease is the leading cause of death in patients with type 2 diabetes. We compared hyperglycemia management with the management of the cardiovascular disease risk factors hypertension and hypercholesterolemia in a cohort of type 2 diabetes patients. SUBJECTS AND METHODS: We randomly selected 601 patients with type 2 diabetes seen at the outpatient practices of an academic medical center and assessed the care they received during an 18-month period. We compared proportions of patients who had hemoglobin A(1c) (HbA(1c)) levels, blood pressure, or total cholesterol levels measured; who had been prescribed any drug therapy if HbA(1c) levels, systolic blood pressure, or low-density lipoprotein (LDL) cholesterol levels exceeded recommended treatment goals; and who had been prescribed greater-than-starting-dose therapy if these values were above those of treatment goals. RESULTS: Patients were less likely to have cholesterol levels (76%, n = 455) measured than HbA(1c) (92%, n = 552) levels or blood pressure (99%, n = 595; P <0.0001 for either comparison). The proportion of patients that received any drug therapy was greater for above-goal HbA(1c) (92%, n = 348) than for above-goal systolic blood pressure (78%, n = 274) or LDL cholesterol (38%, n = 82; P <0.0001 for each comparison). Similarly, patients whose HbA(1c) levels were above the treatment goal (80%, n = 302) were more likely to receive greater-than-starting-dose therapy, compared with those who had above-goal systolic blood pressure (62%, n = 218) and LDL cholesterol levels (13%, n = 28; P <0.0001). CONCLUSION: In this cohort, hypercholesterolemia and hypertension were managed less aggressively than was hyperglycemia. Given the prevalence of cardiovascular disease in patients with type 2 diabetes, increased screening for hypercholesterolemia and more aggressive drug therapy for hypercholesterolemia and hypertension are needed.

Health care resource utilization associated with a diabetes center and a general medicine clinic.

OBJECTIVE: Studies have proposed that the features of diabetes clinics may decrease hospital utilization and costs by reducing complications and providing more efficient outpatient care. We compared the health care utilization associated with a diabetes center (DC) and a general medicine clinic (GMC). DESIGN: Retrospective cohort study. SETTING: An urban academic medical center. PATIENTS/PARTICIPANTS: Type 2 diabetes patients (N = 601) under care in a DC and GMC before March 1996. MEASUREMENTS AND MAIN RESULTS: We compared baseline patient characteristics and outpatient care for the period of March 1996 to August 1997. Using administrative data from March 1996 to October 2000, we compared the probability of a hospitalization, length of stay, costs of hospitalizations, the probability of an emergency room visit, and costs of emergency room visits. Diabetes center patients had a longer mean duration of diabetes (12 years vs 6 years, P <.01), more baseline microvascular disease (65% vs 44%, P <.01), and higher baseline glucose levels (hemoglobin A1c 8.6% vs 7.9%, P <.01) than GMC patients. Diabetes center patients received more intensive outpatient care directed toward glucose monitoring and control. In all crude and adjusted analyses of hospitalizations and emergency room visits, we found no statistically significant differences for inpatient utilization or cost outcomes comparing clinic populations. CONCLUSIONS: Diabetes center attendance did not have a definitive positive or negative impact on inpatient resource utilization over a 4-year period. However, DC patients had more severe diabetes but no greater hospital utilization compared with GMC patients. Clear demonstration of the clinical and financial benefits of features of diabetes centers will require long-term controlled trials of interventions that promote comprehensive diabetes care, including cardiovascular prevention.