Management of diabetic patients in a primary care setting can be improved by an intervention aimed at physicians

With the rate of diabetes skyrocketing to epidemic proportions, researchers at Emory University have found that management of diabetic patients in a primary care setting can be improved by an intervention aimed at physicians.

The intervention was individualized to each physician's record of action when patient glucose levels were high, and featured regular feedback on their performance. Feedback on performance improved the physicians' use of therapy, and led to lower glucose levels in their patients. Glucose levels are closely linked to the likelihood of developing diabetes complications such as kidney failure or blindness. The results of this three-year study will be published in the Archives of Internal Medicine.

"This study reaffirms the importance of correcting what we call 'clinical inertia' -- the failure of health care providers to intensify therapy appropriately when clinically indicated," says Lawrence S. Phillips, MD, professor of medicine in the Division of Endocrinology, Emory University School of Medicine and senior author on this paper. "We found that feedback on performance given to primary care physicians decreased their clinical inertia, and as a result, the glucose levels in their patients improved -- the patients became healthier."

The research was made possible by a unique partnership of generalists with specialists, aimed at improving the care of patients that the specialists did not see. The partnership differs from typical consultations where specialists see patients directly. The researchers focused on the primary care setting because most patients with diabetes are managed by generalists in such settings.

In the study, 345 primary care practitioners at Emory (internal medicine residents -- medical doctors still in training) were randomized either to be controls (no intervention) or to receive interventions aimed at their behavior -- either computerized reminders with patient-specific recommendations for changes in therapy; physican-specific feedback on their performance given by endocrinologists in five-minute, face-to-face meetings every two weeks; or both reminders and feedback on performance. When patients' glucose (blood sugar) levels were high during patient visits, physician behavior was categorized as did nothing, did anything (any intensification of therapy) or did enough (if intensification met recommendations). More than 4,000 patients participated in the study.

At baseline, physicians did anything for 35 percent of visits and did enough for 21 percent of visits. During the study, intensification increased more in the two groups receiving feedback on performance than for the other two groups. After three years, physician behavior in the reminders and control groups returned to baseline, whereas improvement with feedback alone or feedback plus reminders was sustained. Analysis showed that feedback on performance contributed independently to the likelihood that a physician would intensify therapy when clinically indicated, and that intensification contributed independently to improved glucose levels.

"To improve diabetes outcomes -- complications, death, and cost P it's critical that we find better ways to manage the disease." explains Dr. Phillips. "This research study showed the importance of recognizing the problem of clinical inertia, and developing interventions which can help overcome this problem. The feedback on performance intervention helped providers to intensify therapy more frequently when clinically indicated, to intensify therapy enough to make a clinical difference, and to bring patients with high glucose levels back for early return visits. The study worked because it succeeded in three key dimensions P identifying the problem, using an intervention which targets the problem, and focusing on specific, important behaviors to improve."

Diabetes is the sixth leading cause of death in the United States, and the major cause of kidney failure, blindness, and nontraumatic leg amputation in adults. Diabetes is also a major contributor to U.S. health care costs, according to Dr. Phillips. "In 2002, diabetes accounted for 11 percent of U.S. health care costs P 1 out of every 9 health care dollars is touched by diabetes. Diabetes also accounts for 30 percent of Medicare costs. We must find a more efficient and effective way to control this epidemic," says Dr. Phillips. "These study findings should help us to manage diabetes better in the primary care settings where most patients receive their management."

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