An Endocrinologist-Supported Intervention Aimed at Providers Improves Diabetes Management in a Primary Care Site Improving Primary Care of African Americans with Diabetes (IPCAAD) 7 LAWRENCE S. PHILLIPS, MD 1 DAVID C. ZIEMER, MD 1 JOYCE P. DOYLE, MD 2 CATHERINE S. BARNES, PHD 1 PAUL KOLM, PHD 3 WILLIAM T. BRANCH, MD 2 JANE M. CAUDLE, MLN 1 CURTISS B. COOK, MD 4 VIRGINIA G. DUNBAR, BS 1 IMAD M. EL-KEBBI, MD 1 DANIEL L. GALLINA, MD 1 RISA P. HAYES, PHD 5 CHRISTOPHER D. MILLER, MD 1 MARY K. RHEE, MD 1 DENNIS M. THOMPSON, PHD 6 CLYDE WATKINS, MD 2 OBJECTIVE — Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS — A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient’s visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS — Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA 1c (A1C) with feedback + reminders (A1C 0.6%, final A1C 7.46%) were significantly better than control (A1C 0.2%, final A1C 7.84%, P  0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabe- tes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P  0.001). CONCLUSIONS — Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partner- ing generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings. Diabetes Care 28:2352–2360, 2005 T ype 2 diabetes is a public health pan- demic with devastating impact on morbidity, mortality, and cost. In the U.S., the prevalence of diabetes in- creased from 4.9% of the population in 1990 to 7.9% in 2001 (1– 4), and preva- lence is projected to rise to 30 million Americans in 2030 (5). The lifetime risk of diabetes is currently projected at 33 and 38% for American men and women, respectively, born in 2000 (6), with ac- companying decrease in life expectancy (6 – 8). Diabetes increases the risk of both microvascular (9,10) and macrovascular disease (11), and diabetes is now the sixth leading cause of death in the U.S (12). Diabetes accounted for 11% of total U.S. health care expenditures in 2002 ($92 billion) (13), but better metabolic control can reduce costs (14). Most diabetes management in the U.S. takes place in primary care settings, where measures of both process and out- come indicate that care is often subopti- mal. Surveys in the early 1990s revealed that many Medicare beneficiaries had lim- ited evaluation of levels of HbA 1c (A1C), cholesterol, or urine protein, and both di- lated eye and foot examinations were in- frequent (15). Although more recent studies indicate that performance mea- sures have improved (15,16), A1C levels remain high. In the National Health and Nutrition Examination Surveys, the aver- age A1C in patients with diagnosed dia- betes rose from 7.8% in 1988 –1994 to 8.1% in 1999 –2000 (17). Inadequate glycemic control and re- lated diabetes complications are due both to patient nonadherence (18,19) and to the failure of providers to initiate or inten- sify therapy appropriately. We have des- ignated the latter problem as clinical inertia (20), which may limit control of hypertension (21) and dyslipidemia (22) ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; the 2 Division of General Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; the 3 Division of Cardiology, Department of Medicine, Emory Univer- sity School of Medicine, Atlanta, Georgia; the 4 Department of Medicine, Mayo Clinic, Scottsdale, Arizona; 5 Eli Lilly, Indianapolis, Indiana; and the 6 Department of Educational Psychology and Special Education, Georgia State University, Atlanta, Georgia. Address correspondence and reprint requests to Lawrence S. Phillips, MD, General Clinical Research Center, Emory University Hospital, Room GG-23, 1364 Clifton Rd., Atlanta, GA 30322. E-mail: medlsp@emory.edu. Received for publication 27 April 2005 and accepted in revised form 23 June 2005. Additional information for this article can be found in an online appendix at http://diabetes. diabetesjournals.org. C.D.M. has received honoraria from Aventis and Bristol-Myers Squibb. Abbreviations: ADA, American Diabetes Association; GEE, generalized estimating equation; IPCAAD, Improving Primary Care of African Americans with Diabetes; sBP, systolic blood pressure. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2005 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Clinical Care/Education/Nutrition O R I G I N A L A R T I C L E 2352 DIABETES CARE, VOLUME 28, NUMBER 10, OCTOBER 2005