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      Customized Feedback to Patients and Providers Failed to Improve Safety or Quality of Diabetes Care : A randomized trial

      research-article
      , MD, MPH 1 , , MD 1 , , PHD 2 , , PHD 1 , , PHD 1
      Diabetes Care
      American Diabetes Association

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          Abstract

          OBJECTIVE

          To assess whether providing customized clinical information to patients and physicians improves safety or quality of diabetes care.

          RESEARCH DESIGN AND METHODS

          Study subjects included 123 primary care physicians and 3,703 eligible adult diabetic patients with elevated A1C or LDL cholesterol, who were randomly assigned to receive customized feedback of clinical information as follows: 1) patient only, 2) physician only, 3) both the patient and physician, or 4) neither patient nor physician. In the intervention groups, patients received customized mailed information or physicians received printed, prioritized lists of patients with recommended clinical actions and performance feedback. Hierarchical models were used to accommodate group random assignment.

          RESULTS

          Study interventions did not improve A1C test ordering ( P = 0.35) and negatively affected LDL cholesterol test ordering ( P < 0.001) in the 12 months postintervention. Interventions had no effect on LDL cholesterol values ( P = 0.64), which improved in all groups over time. Interventions had a borderline unfavorable effect on A1C values among those with baseline A1C ≥7% ( P = 0.10) and an unfavorable effect on A1C values among those with baseline A1C ≥8% ( P < 0.01). Interventions did not reduce risky prescribing events or increase treatment intensification. Time to next visit was longer in all intervention groups compared with that for the control group ( P < 0.05).

          CONCLUSIONS

          Providing customized decision support to physicians and/or patients did not improve quality or safety of diabetes care and worsened A1C control in patients with baseline A1C ≥8%. Future researchers should consider providing point-of-care decision support with redesign of office systems and/or incentives to increase appropriate actions in response to decision-support information.

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          Most cited references12

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          Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

          Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting. To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting. Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors. Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable. There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events. Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.
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            Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.

            There have been numerous reports of interventions designed to improve the care of patients with diabetes, but the effectiveness of such interventions is unclear. To assess the impact on glycemic control of 11 distinct strategies for quality improvement (QI) in adults with type 2 diabetes. MEDLINE (1966-April 2006) and the Cochrane Collaboration's Effective Practice and Organisation of Care Group database, which covers multiple bibliographic databases. Eligible studies included randomized or quasi-randomized controlled trials and controlled before-after studies that evaluated a QI intervention targeting some aspect of clinician behavior or organizational change and reported changes in glycosylated hemoglobin (HbA1c) values. Postintervention difference in HbA1c values were estimated using a meta-regression model that included baseline glycemic control and other key intervention and study features as predictors. Fifty randomized controlled trials, 3 quasi-randomized trials, and 13 controlled before-after trials met all inclusion criteria. Across these 66 trials, interventions reduced HbA(1c) values by a mean of 0.42% (95% confidence interval [CI], 0.29%-0.54%) over a median of 13 months of follow-up. Trials with fewer patients than the median for all included trials reported significantly greater effects than did larger trials (0.61% vs 0.27%, P = .004), strongly suggesting publication bias. Trials with mean baseline HbA1c values of 8.0% or greater also reported significantly larger effects (0.54% vs 0.20%, P = .005). Adjusting for these effects, 2 of the 11 categories of QI strategies were associated with reductions in HbA(1c) values of at least 0.50%: team changes (0.67%; 95% CI, 0.43%-0.91%; n = 26 trials) and case management (0.52%; 95% CI, 0.31%-0.73%; n = 26 trials); these also represented the only 2 strategies conferring significant incremental reductions in HbA1c values. Interventions involving team changes reduced values by 0.33% more (95% CI, 0.12%-0.54%; P = .004) than those without this strategy, and those involving case management reduced values by 0.22% more (95% CI, 0.00%-0.44%; P = .04) than those without case management. Interventions in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced values by 0.80% (95% CI, 0.51%-1.10%), vs only 0.32% (95% CI, 0.14%-0.49%) for all other interventions (P = .002). Most QI strategies produced small to modest improvements in glycemic control. Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias.
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              The use of health information technology in seven nations.

              To assess the state of health information technology (HIT) adoption and use in seven industrialized nations. We used a combination of literature review, as well as interviews with experts in individual nations, to determine use of key information technologies. We examined rates of electronic health record (EHR) use in ambulatory care and hospital settings, along with current activities in health information exchange (HIE) in seven countries: the United States (U.S.), Canada, United Kingdom (UK), Germany, Netherlands, Australia, and New Zealand (NZ). Four nations (the UK, Netherlands, Australia, and NZ) had nearly universal use of EHRs among general practitioners (each >90%) and Germany was far along (40-80%). The U.S. and Canada had a minority of ambulatory care physicians who used EHRs consistently (10-30%). While there are no high quality data for the hospital setting from any of the nations we examined, evidence suggests that only a small fraction of hospitals (<10%) in any single country had the key components of an EHR. HIE efforts were a high priority in all seven nations but the early efforts have had varying degrees of active clinical data exchange. We examined HIT adoption in seven industrialized nations and found that many have achieved high levels of ambulatory EHR adoption but lagged with respect to inpatient EHR and HIE. These data suggest that increased efforts will be needed if interoperable EHRs are soon to become ubiquitous in these seven nations.
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                Author and article information

                Journal
                Diabetes Care
                diacare
                dcare
                Diabetes Care
                Diabetes Care
                American Diabetes Association
                0149-5992
                1935-5548
                July 2009
                14 April 2009
                : 32
                : 7
                : 1158-1163
                Affiliations
                [1] 1HealthPartners Research Foundation, Minneapolis, Minnesota;
                [2] 2University of Minnesota Carlson School of Management, Minneapolis, Minnesota.
                Author notes
                Corresponding author: Patrick O'Connor, patrick.j.oconnor@ 123456healthparnters.com .
                Article
                2247
                10.2337/dc08-2247
                2699722
                19366977
                90596632-2e31-42aa-a2f9-7878d61cd189
                © 2009 by the American Diabetes Association.

                Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

                History
                : 16 December 2008
                : 27 March 2009
                Categories
                Original Research
                Clinical Care/Education/Nutrition/Psychosocial Research

                Endocrinology & Diabetes
                Endocrinology & Diabetes

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