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The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System

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Abstract

BACKGROUND

Optimal care for patients with diabetes is difficult to achieve in clinical practice.

OBJECTIVE

To evaluate the impact of a registry and decision support system on processes of care, and physiologic control.

PARTICIPANTS

Randomized trial with clustering at the practice level, involving 7,412 adults with diabetes in 64 primary care practices in the Northeast.

INTERVENTIONS

Provider decision support (reminders for overdue diabetes tests, alerts regarding abnormal results, and quarterly population reports with peer comparisons) and patient decision support (reminders and alerts).

MEASUREMENTS AND MAIN RESULTS

Process and physiologic outcomes were evaluated in all subjects. Functional status was evaluated in a random patient sample via questionnaire. We used multiple logistic regression to quantify the effect, adjusting for clustering and potential confounders. Intervention subjects were significantly more likely to receive guideline-appropriate testing for cholesterol (OR = 1.39; [95%CI 1.07, 1.80] P = 0.012), creatinine (OR = 1.40; [95%CI 1.06, 1.84] P = 0.018), and proteinuria (OR = 1.74; [95%CI 1.13, 1.69] P = 0.012), but not A1C (OR = 1.17; [95% CI 0.80, 1.72] P = 0.43). Rates of control of A1C and LDL cholesterol were similar in the two groups. There were no differences in blood pressure, body mass index, or functional status.

CONCLUSIONS

A chronic disease registry and decision support system based on easily obtainable laboratory data was feasible and acceptable to patients and providers. This system improved the process of laboratory monitoring in primary care, but not physiologic control.

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References

  1. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348(5):383–93.

    Article  PubMed  Google Scholar 

  2. Saaddine JB, Cadwell B, Gregg EW, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med. 2006;144(7):465–74.

    PubMed  Google Scholar 

  3. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. Jama. 2004;291(3):335–42.

    Article  CAS  PubMed  Google Scholar 

  4. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. Jama. 2002;288(15):1909–14.

    Article  PubMed  Google Scholar 

  5. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. Jama. 2002;288(14):1775–9.

    Article  PubMed  Google Scholar 

  6. Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. 2001;27(2):63–80.

    CAS  PubMed  Google Scholar 

  7. Pearson ML, Wu S, Schaefer J, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res. 2005;40(4):978–96.

    Article  PubMed  Google Scholar 

  8. Grant RW, Cagliero E, Sullivan CM, et al. A controlled trial of population management: diabetes mellitus: putting evidence into practice (DM-PEP). Diabetes Care. 2004;27(10):2299–305.

    Article  PubMed  Google Scholar 

  9. Maddigan SL, Majumdar SR, Guirguis LM, et al. Improvements in patient-reported outcomes associated with an intervention to enhance quality of care for rural patients with type 2 diabetes: results of a controlled trial. Diabetes Care. 2004;27(6):1306–12.

    Article  PubMed  Google Scholar 

  10. Glasgow RE, Nutting PA, King DK, et al. Randomized effectiveness trial of a computer-assisted intervention to improve diabetes care. Diabetes Care. 2005;28(1):33–9.

    Article  PubMed  Google Scholar 

  11. Montori VM, Dinneen SF, Gorman CA, et al. The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Diabetes Care. 2002;25(11):1952–7.

    Article  PubMed  Google Scholar 

  12. O'Connor PJ, Desai J, Solberg LI, et al. Randomized trial of quality improvement intervention to improve diabetes care in primary care settings. Diabetes Care. 2005;28(8):1890–7.

    Article  PubMed  Google Scholar 

  13. Sequist TD, Gandhi TK, Karson AS, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005;12(4):431–7.

    Article  PubMed  Google Scholar 

  14. Piatt GA, Orchard TJ, Emerson S, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811–7.

    Article  PubMed  Google Scholar 

  15. Peterson KA, Radosevich DM, O'Connor PJ, et al. Improving diabetes care in practice: findings from the TRANSLATE trial. Diabetes Care. 2008;31(12):2238–43.

    Article  PubMed  Google Scholar 

  16. Cleveringa FG, Gorter KJ, van den Donk M, Rutten GE. Combined task delegation, computerized decision support, and feedback improve cardiovascular risk for type 2 diabetic patients: a cluster randomized trial in primary care. Diabetes Care. 2008;31(12):2273–5.

    Article  PubMed  Google Scholar 

  17. Cherry DK, Hing E, Woodwell DA, Rechtsteiner EA. National ambulatory medical care survey: 2006 summary. Natl Health Stat Report. 2008;(3):1–39.

  18. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care-a national survey of physicians. N Engl J Med. 2008;359(1):50–60.

    Article  CAS  PubMed  Google Scholar 

  19. MacLean CD, Littenberg B, Gagnon M. Diabetes decision support: initial experience with the Vermont diabetes information system. Am J Public Health. 2006;96(4):593–5.

    Article  PubMed  Google Scholar 

  20. MacLean CD, Littenberg B, Gagnon MS, Reardon M, Turner PD, Jordan C. The Vermont Diabetes Information System (VDIS): study design and subject recruitment for a cluster randomized trial of a decision support system in a regional sample of primary care practices. Clinical Trials. 2004;1:532–44.

    Article  PubMed  Google Scholar 

  21. Littenberg B, Maclean CD. Passive consent for clinical research in the age of HIPAA. J Gen Intern Med. 2006;21(3):207–11.

    Article  PubMed  Google Scholar 

  22. Donner A, Birkett N, Buck C. Randomization by cluster. Sample size requirements and analysis. Am J Epidemiol. 1981;114(6):906–14.

    CAS  PubMed  Google Scholar 

  23. Donner A, Klar N. Pitfalls of and controversies in cluster randomization trials. Am J Public Health. 2004;94(3):416–22.

    Article  PubMed  Google Scholar 

  24. Koepsell TD, Wagner EH, Cheadle AD, et al. Selected methodological issues in evaluating community-based health promotion and disease prevention programs. Annu Rev Publ Health. 1992;13:31–57.

    Article  CAS  Google Scholar 

  25. Littenberg B, Maclean CD. Intra-cluster correlation coefficients in adults with diabetes in primary care practices: the Vermont Diabetes Information System Field Survey. BMC Med Res Methodol. 2006;6(1):20.

    Article  PubMed  Google Scholar 

  26. ADA. Standards of medical care in diabetes-2006. Diabetes Care. 2006;29(Suppl 1):S4–42.

    Google Scholar 

  27. Ware JE, Kosinski M, Turner-Bowker DM, Gandek B. How to Score Version 2 of the SF-12 Health Survey. Lincoln: QualityMetric Inc.; 2003.

    Google Scholar 

  28. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care. 2000;23(7):943–50.

    Article  CAS  PubMed  Google Scholar 

  29. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33–42.

    Article  CAS  PubMed  Google Scholar 

  30. Sangha O, Stucki G, Liang MH, Fossel AH, Katz JN. The self-administered comorbidity questionnaire: a new method to assess comorbidity for clinical and health services research. Arthritis Rheum. 2003;49(2):156–63.

    Article  PubMed  Google Scholar 

  31. Bradley C, Todd C, Gorton T, Symonds E, Martin A, Plowright R. The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL. Qual Life Res. 1999;8(1–2):79–91.

    Article  CAS  PubMed  Google Scholar 

  32. Ritter PL, Stewart AL, Kaymaz H, Sobel DS, Block DA, Lorig KR. Self-reports of health care utilization compared to provider records. J Clin Epidemiol. 2001;54(2):136–41.

    Article  CAS  PubMed  Google Scholar 

  33. Machlin CR, Carper K. Expenses for a hospital emergency room visit, 2003. AHRQ statistical brief #111. http://www.meps.ahrq.gov/mepsweb/datafiles/publications/st111/stat111.pdf. Accessed September 29, 2009.

  34. Machlin CR, Carper K. Expenses for office-based physician visits by specialty, 2004. http://www.meps.ahrq.gov/mepsweb/datafiles/publications/st166/stat166.pdf. Accessed September 29, 2009.

  35. Medical Expenditure Panel Survey. 2005 Hospital Inpatient Stays, 2007. (October 2007). http://www.meps.ahrq.gov/mepsweb/datastats/downloaddatafilesdetail.jsp?cboPufNumber=HC-094D. Accessed September 29, 2009.

  36. Brown H, Prescott R. Applied mixed models in medicine. 2nd ed. Chichester, England; Hoboken, NJ: John Wiley; 2006.

    Google Scholar 

  37. Murray DM. Design and analysis of group-randomized trials. New York: Oxford University Press; 1998.

    Google Scholar 

  38. Piantadosi S. Clinical Trials: A Methodologic Perspective. New York: Wiley-Interscience; 1997.

    Google Scholar 

  39. Royston P. Multiple imputation of missing values: update. Stata Journal. 2005;5(2):188–201.

    Google Scholar 

  40. Ambler G, Omar RZ, Royston P. A comparison of imputation techniques for handling missing predictor values in a risk model with a binary outcome. Stat Methods Med Res. 2007;16(3):277–98.

    Article  PubMed  Google Scholar 

  41. Calle EE, Terrell DD. Utility of the National Death Index for ascertainment of mortality among cancer prevention study II participants. Am J Epidemiol. 1993;137(2):235–41.

    CAS  PubMed  Google Scholar 

  42. Lash TL, Silliman RA. A comparison of the National Death Index and Social Security Administration databases to ascertain vital status. Epidemiology. 2001;12(2):259–61.

    Article  CAS  PubMed  Google Scholar 

  43. US Census. Income, Poverty, and Health Insurance Coverage in the United States:2003. http://www.census.gov/prod/2004pubs/p60-226.pdf. Accessed September 29, 2009.

  44. US Census. Health Insurance Coverage Status and Type of Coverage by State and Age for All People:2004. http://pubdb3.census.gov/macro/032005/health/h05000.htm. Accessed September 29, 2009.

  45. Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev. 2001(1):CD001481.

  46. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. Jama. 2006;296(4):427–40.

    Article  CAS  PubMed  Google Scholar 

  47. O'Conner PJ, Sperl-Hillen J, Johnson PE, Rush WA, Crain AL. Customized feedback to patients and providers failed to improve safety or quality of diabetes care: a randomized trial. Diabetes Care. 2009;32:1158–63.

    Article  Google Scholar 

  48. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. Jama. 2005;294(14):1788–93.

    Article  CAS  PubMed  Google Scholar 

  49. Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135(9):825–34.

    CAS  PubMed  Google Scholar 

  50. Parchman ML, Pugh JA, Romero RL, Bowers KW. Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med. 2007;5(3):196–201.

    Article  PubMed  Google Scholar 

  51. Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ. 2003;29(3):488–501.

    Article  PubMed  Google Scholar 

  52. Krein SL, Klamerus ML, Vijan S, et al. Case management for patients with poorly controlled diabetes: a randomized trial. Am J Med. 2004;116(11):732–9.

    Article  PubMed  Google Scholar 

  53. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953–7.

    Article  PubMed  Google Scholar 

  54. Bodenheimer T. Coordinating care-a perilous journey through the health care system. N Engl J Med. 2008;358(10):1064–71.

    Article  CAS  PubMed  Google Scholar 

  55. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. March 2007. http://www.acponline.org/advocacy/wherewestand/medicalhome/approvejp.pdf. Accessed September 29, 2009.

  56. Batalden PB, Godfrey MM, Nelson EC. Quality by Design: A Clinical Microsystems Approach1st ed. San Francisco: Jossey-Bass; 2007.

    Google Scholar 

  57. MacLean CD, Littenberg B. Patient assignment in a diabetes decision support system: implications for population management and pay for performance. Society of General Internal Medicine. Pittsburgh; 2008.

  58. Littenberg B, MacLean CD, Zygarowski K, Drapola BH, Duncan JA, Frank CR. The Vermedx Diabetes Information System reduces healthcare utilization. Am J Manag Care. 2009;15(3):166–70.

    PubMed  Google Scholar 

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Acknowledgments

The authors are grateful for the generous contributions made by the patients, providers, and staffs of the participating practices and hospitals.

Funded by the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK61167 and K24 DK068380).

Conflict of Interest

Drs. MacLean and Littenberg, and Mr. Gagnon are principals of Vermedx, Inc., which distributes clinical decision support systems based on this work.

Author information

Authors and Affiliations

  1. Division of General Internal Medicine, University of Vermont College of Medicine, 371 Pearl Street, Burlington, VT, 05401, USA

    Charles D. MacLean MDCM & Benjamin Littenberg MD

  2. Department of Information Services, Fletcher Allen Health Care, Burlington, VT, USA

    Michael Gagnon MS

  3. Department of Biometry, University of Vermont, Burlington, VT, USA

    Peter Callas PhD

  4. Department of Nursing, University of Vermont, Burlington, VT, USA

    Benjamin Littenberg MD

Authors
  1. Charles D. MacLean MDCM
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  2. Michael Gagnon MS
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  4. Benjamin Littenberg MD
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Corresponding author

Correspondence to Charles D. MacLean MDCM.

Additional information

Clinical Trials Registration Number: ClinicalTrials.gov—NCT00109369

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MacLean, C.D., Gagnon, M., Callas, P. et al. The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System. J GEN INTERN MED 24, 1303–1310 (2009). https://doi.org/10.1007/s11606-009-1147-x

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  • DOI: https://doi.org/10.1007/s11606-009-1147-x

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