The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System
Optimal care for patients with diabetes is difficult to achieve in clinical practice.
To evaluate the impact of a registry and decision support system on processes of care, and physiologic control.
Randomized trial with clustering at the practice level, involving 7,412 adults with diabetes in 64 primary care practices in the Northeast.
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.
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.
- 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. CrossRef
- 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.
- 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. CrossRef
- 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. CrossRef
- Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. Jama. 2002;288(14):1775–9. CrossRef
- 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.
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- Cherry DK, Hing E, Woodwell DA, Rechtsteiner EA. National ambulatory medical care survey: 2006 summary. Natl Health Stat Report. 2008;(3):1–39.
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- Littenberg B, Maclean CD. Passive consent for clinical research in the age of HIPAA. J Gen Intern Med. 2006;21(3):207–11. CrossRef
- Donner A, Birkett N, Buck C. Randomization by cluster. Sample size requirements and analysis. Am J Epidemiol. 1981;114(6):906–14.
- Donner A, Klar N. Pitfalls of and controversies in cluster randomization trials. Am J Public Health. 2004;94(3):416–22. CrossRef
- 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. CrossRef
- 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. CrossRef
- ADA. Standards of medical care in diabetes-2006. Diabetes Care. 2006;29(Suppl 1):S4–42.
- Ware JE, Kosinski M, Turner-Bowker DM, Gandek B. How to Score Version 2 of the SF-12 Health Survey. Lincoln: QualityMetric Inc.; 2003.
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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.
- 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.
- 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.
- Brown H, Prescott R. Applied mixed models in medicine. 2nd ed. Chichester, England; Hoboken, NJ: John Wiley; 2006.
- Murray DM. Design and analysis of group-randomized trials. New York: Oxford University Press; 1998.
- Piantadosi S. Clinical Trials: A Methodologic Perspective. New York: Wiley-Interscience; 1997.
- Royston P. Multiple imputation of missing values: update. Stata Journal. 2005;5(2):188–201.
- 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. CrossRef
- 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.
- 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. CrossRef
- 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.
- 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.
- 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.
- 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. CrossRef
- 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. CrossRef
- Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. Jama. 2005;294(14):1788–93. CrossRef
- Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135(9):825–34.
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20(10):953–7. CrossRef
- Bodenheimer T. Coordinating care-a perilous journey through the health care system. N Engl J Med. 2008;358(10):1064–71. CrossRef
- 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.
- Batalden PB, Godfrey MM, Nelson EC. Quality by Design: A Clinical Microsystems Approach1st ed. San Francisco: Jossey-Bass; 2007.
- 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.
- 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.
- The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System
Journal of General Internal Medicine
Volume 24, Issue 12 , pp 1303-1310
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- diabetes mellitus
- decision support systems, clinical
- patient care management
- chronic disease
- health services research
- primary health care
- randomized controlled trial
- Industry Sectors
- Author Affiliations
- 1. Division of General Internal Medicine, University of Vermont College of Medicine, 371 Pearl Street, Burlington, VT, 05401, USA
- 2. Department of Information Services, Fletcher Allen Health Care, Burlington, VT, USA
- 3. Department of Biometry, University of Vermont, Burlington, VT, USA
- 4. Department of Nursing, University of Vermont, Burlington, VT, USA