C-B4-03: EMR-based Clinical Decision Support System Improved Glucose and Blood Pressure Control in Adults With Diabetes.

Abstract

Context: Medical groups have invested billions of dollars in outpatient Electronic Medical Records (EMR), but few studies demonstrate a positive impact of EMR-based clinical decision support on clinically important patient outcomes. Objectives: To assess the impact of an EMR-based diabetes clinical decision support system on control of glycated hemoglobin (A1c), blood pressure (BP) and LDL Cholesterol (LDL) in adults with diabetes. Design, Setting, and Participants: The study was conducted from October 2006 to May 2007 in Minnesota. Eleven clinics with 41 consenting primary care physicians (PCP) and these physicians' 2556 diabetes patients were randomized either to receive or not to receive an EMR-based clinical decision support system designed to improve A1c, BP, and LDL in diabetes patients not at recommended clinical goals at the time of an office visit. Main Outcome Measures: Post-intervention levels of A1c, BP, and LDL controlling for pre-intervention levels. Results: Intervention group PCPs used the EMR-based decision support system at over 62.6% of all diabetes patient visits, and intensified drug therapy at 61.9%, 43.6% and 18.8% of visits with uncontrolled A1c, BP, and lipids, respectively. Intervention group diabetes patients had significantly better A1c (P=.014) and SBP (P=.035) but not LDL (P=.63) relative to patients of PCPs randomized to the control arm of the study based on general linear mixed models with a repeated time measurement to control for clustering. Additional analytic models that adjusted for patient age, gender, and co-morbidity showed similar results. Ninety-four percent of PCPs expressed satisfaction with the intervention, and moderate rates of use persisted for over a year after withdrawal of feedback and incentives to encourage use. Conclusions: An EMR-based diabetes clinical decision support significantly improved glucose control and BP control in adults with type 2 diabetes who were not at recommended clinical goals.

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CM&R 2010 : 1 (March)
48
HMORN 2009 – Selected Abstracts
C-B4-03:
EMR-based Clinical Decision Support System Improved Glucose and
Blood Pressure Control in Adults With Diabetes
Patrick J O’Connor, MD, MPH, HealthPartners Research Foundation; JoAnn
M Sperl -Hillen, MD, HealthPartners Research Foundation; William A Rush,
PhD, HealthPartners Research Foundation; Paul E Johnson, PhD, Carlson
School of Management, University of Minnesota; Jerry H Amundson, BS,
HealthPartners Research Foundation; Stephen E Asche, MA, HealthPartners
Research Foundation; Heidi L Ekstrom, MA, HealthPartners Research
Foundation
Context: Medical groups have invested billions of dollars in outpatient
Electronic Medical Records (EMR), but few studies demonstrate a positive
impact of EMR- based clinical decision support on clinically important
patient outcomes. Objectives: To assess the impact of an EMR -based
diabetes clinical decision support system on control of glycated hemoglobin
(A1c), blood pressure (BP) and LDL Cholesterol (LDL) in adults with
diabetes. Design, Setting, and Participants: The study was conducted from
October 2006 to May 2007 in Minnesota. Eleven clinics with 41 consenting
primary care physicians (PCP) and these physicians’ 2556 diabetes patients
were randomized either to receive or not to receive an EMR- based clinical
decision support system designed to improve A1c, BP, and LDL in diabetes
patients not at recommended clinical goals at the time of an office visit.
Main Outcome Measures: Post -intervention levels of A1c, BP, and LDL
controlling for pre- intervention levels. Results: Intervention group PCPs
used the EMR- based decision support system at over 62.6% of all diabetes
patient visits, and intensified drug therapy at 61.9%, 43.6% and 18.8% of
visits with uncontrolled A1c, BP, and lipids, respectively. Intervention group
diabetes patients had significantly better A1c (P=.014) and SBP (P=.035) but
not LDL (P=.63) relative to patients of PCPs randomized to the control arm
of the study based on general linear mixed models with a repeated time
measurement to control for clustering. Additional analytic models that
adjusted for patient age, gender, and co-morbidity showed similar results.
Ninety -four percent of PCPs expressed satisfaction with the intervention, and
moderate rates of use persisted for over a year after withdrawal of feedback
and incentives to encourage use. Conclusions: An EMR -based diabetes
clinical decision support significantly improved glucose control and BP
control in adults with type 2 diabetes who were not at recommended
clinical goals.
C-B4-04:
Personalized Physician Learning Intervention Improved Glucose
Control in Adults With Diabetes
JoAnn M Sperl -Hillen, MD, HealthPartners Research Foundation; Patrick J
O’Connor, MD, MPH, HealthPartners Research Foundation; William A
Rush, PhD, HealthPartners Research Foundation; Paul E Johnson, PhD,
Carlson School of Management, University of Minnesota; George Biltz, MD,
Carlson School of Management, University of Minnesota; Stephen E Asche,
MA, HealthPartners Research Foundation; Heidi L Ekstrom, MA,
HealthPartners Research Foundation
Context: Personalization of learning interventions using opinion leaders
improves care but is expensive. Automated methods to deliver personalized
learning interventions to physicians have not been widely studied or
rigorously evaluated. Objectives: To assess the impact of a computer- based
personalized learning intervention for primary care physicians designed to
improve control of glycated hemoglobin (A1c), blood pressure (BP) and LDL
Cholesterol (LDL) in adults with type 2 diabetes. Design, Setting, and
Participants: The randomized trial was conducted from October 2006 to
May 2007 in Minnesota. Eleven clinics with 40 consenting primary care
physicians (PCP) were randomized either to receive or not to receive a
simulated personalized learning intervention designed to improve A1c, BP,
and LDL in actual diabetes patients not at recommended clinical goals. Main
Outcome Measures: Post -intervention levels of A1c, BP, and LDL controlling
for pre -intervention levels and nesting of data. Results: Patients of
intervention group PCPs had significantly better A1c (P=.044), SBP
(P=.018), and DBP (P=.001), but not LDL relative to patients of PCPs
randomized to the control arm of the study based on general linear mixed
models with a repeated time measurement to control for clustering.
Additional analytic models that adjusted for patient age, gender, and
co-morbidity showed similar results. Nearly all PCPs were very satisfied
with the intervention, which most completed in fewer than three hours in split
sessions over one to two days. Conclusions: An inexpensive simulated
personalized physician learning intervention for primary care physicians
significantly improved glucose and BP control in adults with type 2 diabetes
who were not at recommended clinical goals.
PS2-19:
Validation of Self-Reported Diabetes From the Women’s Health
Initiative (WHI) Clinical Trials
Jody Jackson, RN, BSN, HealthPartners Research Foundation; Karen L
Margolis, MD, MPH, HealthPartners Research Foundation; Terese A DeFor,
MS, Health Partners Research Foundation; Feifei Wei, PhD, HealthPartners
Research Foundation; Cora E Lewis, MD, University of Alabama of
Birmington; Mara Vitolins, DrPH, Wake Forest University School of
Medicine; Denise E Bonds, MD, MPH, University of Virginia, Department of
Public Health Sciences and Medicine; Evelyn Whitlock, MD, Kaiser
Foundation Research Institute
Background: The Women’s Health Initiative (WHI) clinical trials offer a
wealth of data on patient outcomes including cancer, coronary heart disease,
and hip fracture, which were confirmed via medical record review. Diabetes
was self- reported, but was not validated by independent review. The literature
shows wide variations on the validity of self -reported diabetes in diverse
populations. Aims: To compare the rates of positive and negative predictive
values of self- reports of incident and prevalent diabetes during the WHI
trials. Methods: At four WHI field centers (Minneapolis MN, Winston-
Salem NC, Birmingham AL, Portland OR), all WHI trial participants with a
self -report of diabetes at baseline or follow -up were identified. A random
sample of participants who did not self -report diabetes was also identified.
Women were surveyed regarding details of their diagnosis and treatment of
diabetes. Medical records were obtained and reviewed for consenting
subjects using a standardized protocol based on documented treatment with
anti- diabetic medications, or physician diagnosis of diabetes supported by
laboratory measurements of glucose. Results: A total of 1280 eligible
subjects were available across the four sites. To date, subject information
from the Minneapolis field center has been collected and analyzed. Of the
295 eligible subjects contacted at the Minneapolis site, 227 (77%) consented
to participate and provided survey data. Medical records were obtained for
224 (57 prevalent, 81 incident, and 86 no self -reported diabetes). Medical
records confirmed 84% (95% CI 74%– 94%) of self -reported prevalent
diabetes and 85% (95% CI 74%– 94%) of self- reported incident diabetes.
Among those who never self- reported diabetes there was no medical record
evidence for diabetes in 99% (95% CI 92% to 100%). Results from all four
sites will be presented. Conclusions: Preliminary data suggest a high
positive predictive value of both prevalent (84%) and incident self -report of
diabetes (85%) from WHI and a low false negative rate of about 1%. These
results indicate that self- reports of diabetes may be sufficiently accurate for
use in epidemiologic studies.
PS2-20:
Racial Disparities in A1c Change and Medication Intensification
William A Rush, PhD, HealthPartners Research Foundation; A Lauren
Crain, PhD, HealthPartners Research Foundation; Gerald H Amundson, BS,
HealthPartners Research Foundation; Tessa J Kerby, BA, HealthPartners
Research Foundation; Anne D Murray MPH, HealthPartners Research
Foundation; Karen L Margolis, MD, MPH, HealthPartners Research
Foundation
Introduction: While it is well documented that disparities exist across racial
groups of diabetes patients relative to glucose control, the underlying
causative factors are not well understood. The purpose of this study was to
examine differences in physician orders for adjustments of glucose control
medications in diabetes patients between African Americans and Caucasians.
Methods: A cohort of 434 African American and 1,471 Caucasian diabetes
patients was followed for a period of 18 months from 6/1/2006 through
11/30/2007. All patients were being treated in one of 6 primary care clinics
within a large mid- western medical group. First and last A1c values were
collected during the study period and an A1c change score was calculated.
Patients were also classified as to whether English was their primary