A multifaceted intervention in support of diabetes treatment guidelines: a cont trial

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Abstract

Objective: in an academic family practice clinic, we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes. Providers received didactic training and computerized compliance feedback to support staged diabetes management, an evidenced-based approach to diabetes care. Research design and methods: one firm of the clinic practice received the intervention, the other served as the control group during a 14-month baseline period and a 14-month study period. HbA1c was the principal outcome measure. Results: there was a significant 0.71% difference in change in HbA1c values between the intervention and control firms (P=0.02). The subgroup with the greatest improvement in HbA1c was those subjects who started the intervention with a HbA1c above 8%. The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy. There were no changes in healthcare utilization or costs between the two firms. Conclusion: in an academic family practice clinic, a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs. The improvement was mostly due to mitigation of the natural deterioration in control usually seen. Further efforts are required to involve all patients in co-managing their diabetes.

Section snippets

A multifaceted intervention in support of diabetes treatment guidelines: a controlled trial

The relationship between hyperglycemia with microvascular and neuropathic complications is now clear. Randomized controlled trials for both type 1 and type 2 diabetes have shown that intensive therapy can decrease the development and progression of these complications [1], [2], [3], [4]. Since the announcement of the Diabetes Control and Complications Trial (DCCT) in 1993 [1], most authoritative bodies have published guidelines stating the target for patients with diabetes should be an HbA1c

Study setting

The study was conducted at The University of Washington's Family Medical Center (FMC), a clinic that provides primary care to 7700 patients in a satellite facility one mile west of the medical school campus. The clinic is geographically divided into two firms, each with its own personnel, exam rooms and waiting area. Both firms include three teams, with each team comprised of two to three faculty members, a family medicine resident from each year of the 3 years of training, and a full-time

HbA1c levels

Overall, the intervention group showed a minimal decline in HbA1c levels while HbA1c levels for the control group increased (Table 3). There was a significant 0.71% difference in change in HbA1c values between the intervention and control firms (P=0.02). To understand more about how this overall difference was achieved, intervention and control groups were stratified by degree of glycemic control at baseline and reanalyzed. Both intervention and control patients with baseline HbA1c levels below

Discussion

We have shown that a multifaceted intervention resulted in a modest improvement in HbA1c of 0.71% over 14 months in an academic family practice clinic. This effect on HbA1c levels was consistent across all three subgroups examined. Yet our effort—which included a team of providers consisting of family physicians, a pharmacist, a nurse educator, and a nutritionist—improved glycemic control over time only in those individuals with an initial HbA1c level above 8%. For those subjects beginning the

Acknowledgements

This work was supported in part by funds from Becton Dickinson. We also greatly appreciate the generous support of Lifescan for providing additional glucose meters and strips for some of our patients.

References (19)

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