PURPOSE We wanted to assess the impact of an electronic health record-based diabetes clinical decision support system on control of hemoglobin A 1c (glycated hemoglobin), blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes. METHODSWe conducted a clinic-randomized trial conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians' 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)-based clinical decision support system designed to improve care for those patients whose hemoglobin A 1c , blood pressure, or LDL cholesterol levels were higher than goal at any offi ce visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure. RESULTSThe intervention group physicians used the EHR-based decision support system at 62.6% of all offi ce visits made by adults with diabetes. The intervention group diabetes patients had signifi cantly better hemoglobin A 1c (intervention effect -0.26%; 95% confi dence interval, -0.06% to -0.47%; P = .01), and better maintenance of systolic blood pressure control (80.2% vs 75.1%, P = .03) and borderline better maintenance of diastolic blood pressure control (85.6% vs 81.7%, P = .07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfi ed or very satisfi ed with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued.CONCLUSIONS EHR-based diabetes clinical decision support signifi cantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes. INTRODUCTIOND espite recent improvement trends in the United States, in 2008 less than 20% of patients with diabetes concurrently reach evidence-based goals for hemoglobin A 1c (glycated hemoglobin), systolic and diastolic blood pressure, and low-density lipoprotein (LDL) cholesterol levels.1,2 Care is unsatisfactory in both subspecialty and primary care settings, but because more than 80% of diabetes care is delivered by primary care physicians, effective strategies to improve diabetes care in primary care settings are urgently needed.Among the major barriers to better diabetes care is lack of timely intensifi cation of pharmacotherapy in patients who have not achieved recommended clinical goals. Many factors contribute to this problem, including competing demands at the time of the visit 3 and medication In theory, treatment intensifi cation and control of hemoglobin A 1c , blood pressure, and lipid levels in patients with diabetes mellitus could be improved by providing patient-specifi c and drug-specifi c clinical decision support at the time of a clinical encounter. Electronic health recor...

HbA1c provides useful information to providers and patients regarding both health status and future medical care charges. Economic data suggest that clinicians should assign high importance to low HbA1c results and aggressively maintain the HbA1c status of patients who have low HbA1c values. For economic as well as clinical reasons, it may be beneficial to lower HbA1c when it is > 8% and to reduce cardiovascular risk factors. The medical charge data suggest that investment in clinical systems to improve diabetes care may benefit both payers and patients.

OBJECTIVE -The purpose of this study was to assess the impact of baseline A1c, cardiovascular disease, and depression on subsequent health care costs among adults with diabetes. RESEARCH DESIGN AND METHODS-A prospective analysis was performed of data from a patient survey and medical record review merged with 3 years of medical claims. Costs were estimated using detailed data on resource use and Medicare payment methodologies. Generalized linear models were used to analyze costs related to clinical predictors after adjusting for demographic and socioeconomic factors.RESULTS -In multivariate analysis of 1,694 adults with diabetes, 3-year costs in those with coronary heart disease (CHD) and hypertension were over 300% of those with diabetes only ($46,879 vs. $14,233; P Ͻ 0.05). Depression was associated with a 50% increase in costs ($31,967 vs. $21,609; P Ͻ 0.05). Relative to those with a baseline A1c of 6%, those with an A1c of 10% had 3-year costs that were 11% higher ($26,408 vs. $23,873; P Ͻ 0.05). Higher A1c predicted higher costs only for those with baseline A1c Ͼ7.5% (P ϭ 0.015).CONCLUSIONS -In adults with diabetes, CHD, hypertension, and depression spectrum disorders more strongly predicted future costs than the A1c level. Concurrent with aggressive efforts to control glucose, greater efforts to prevent or control CHD, hypertension, and depression are necessary to control health care costs in adults with diabetes. Diabetes Care 28:59 -64, 2005A dults with diabetes experience significantly higher health care costs than sex-and age-matched adults without diabetes (1-5). This increased use of resources is related to a broad range of factors including higher outpatient costs, higher pharmaceutical costs, higher rates of hospitalization, and longer hospital stays during admissions related to many diagnoses (6). Cardiovascular disease accounts for about 70% of deaths in adults with diabetes, and several studies show that cardiovascular disease is a major driver of costs in diabetes patients (7-10).A substantial body of research on diabetes management has focused on glycemic control. Large randomized controlled trials have shown that aggressive management of A1c reduces the risk of microvascular complications in patients with type 1 and type 2 diabetes (11,12). In earlier work, we examined medical charges related to A1c and found that after controlling for demographics and cardiovascular disease, charges rose by ϳ30% as A1c increased from 6 to10%. In the same study subjects, after controlling for A1c, sex, and age, those with heart disease and hypertension had charges over 400% of those with diabetes alone. At the time, we concluded that cardiovascular disease was a stronger predictor of resource use in adults with diabetes than was the level of glycemic control (8).Our previous analysis was conducted using data from 1992 to 1996, in an era when glycemic control was generally worse than it is now. In recent years, A1c levels have improved with the increased availability of more effective pharmacologic agents incl...

Clinical inertia is defined as lack of treatment intensification in a patient not at evidence-based goals for care. Clinical inertia is a major factor that contributes to inadequate chronic disease care in patients with diabetes mellitus, hypertension, dyslipidemias, depression, coronary heart disease, and other conditions. Recent work suggests that clinical inertia related to the management of diabetes, hypertension, and lipid disorders may contribute to up to 80 percent of heart attacks and strokes. Clinical inertia is, therefore, a leading cause of potentially preventable adverse events, disability, death, and excess medical care costs. This paper addresses three specific objectives: (1) to present a conceptual model of clinical inertia that takes into account recent developments in human factors research, cognitive science, and organizational behavior; (2) to operationally define clinical inertia and propose simple clinical protocols that can be used to identify and map its incidence across populations of patients and physicians; and (3) to propose future research to reduce clinical inertia by specifically targeting the root causes of the problem. Ultimately, a better understanding of clinical inertia and the development of specific interventions to reduce it may be a productive strategy to reduce passive errors that contribute to hundreds of thousands of adverse events and tens of thousands of premature deaths annually in the United States.

PURPOSE This study was designed to evaluate the impact of electronic medical record (EMR) implementation on quality of diabetes care. METHODSWe conducted a 5-year longitudinal study of 122 adults with diabetes mellitus at an intervention (EMR) clinic and a comparison (non-EMR) clinic. Clinics had similarly trained primary care physicians, similar patient populations, and used a common diabetes care guideline that emphasized the importance of glucose control. The EMR provided basic decision support, including prompts and reminders for diabetes care. Preintervention and postintervention frequency of testing for glycated hemoglobin (HbA 1c ) and low-density lipoprotein (LDL) levels were compared with and without adjustment for patient age, sex, comorbidity, and baseline HbA 1c level. RESULTSFrequency of HbA 1c tests increased at the EMR clinic compared with the frequency at the non-EMR clinic (P <.001). HbA 1c levels improved in both clinics (P <.05) with no signifi cant differences between clinics 2 years (P = .10) or 4 years (P = .27) after EMR implementation. Similar results were observed for LDL levels.CONCLUSIONS In this controlled study, EMR use led to an increased number of HbA 1c and LDL tests but not to better metabolic control. If EMRs are to fulfi ll their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed. INTRODUCTIONQ uality of outpatient diabetes care lags behind evidence-based care recommendations, 1,2 and various strategies have been suggested to improve care. [3][4][5][6][7] Electronic medical records (EMRs) have been proposed as an effective information management tool with the potential to improve diabetes care, [8][9][10] and an Institute of Medicine report has identifi ed key features of EMRs that may lead to better care. 10 Currently available outpatient EMRs can identify patients with diabetes, assess whether the patient is due for recommended tests or screening procedures, and determine which patients have not achieved evidence-based clinical goals for glycemic, lipid, or blood pressure control. This information is typically presented to the clinician as reminders (patient due for a glycated hemoglobin [HbA 1c ] test) or prompts (patient's HbA 1c level is above recommended level) delivered electronically at the point of care. Current diabetes care is characterized by high rates of clinical inertia, defi ned as failure to intensify treatment in patients who have not achieved evidence-based clinical goals.11,12 Rates of clinical inertia at diabetes visits exceed 50%, and EMR technology seems well-suited to reducing this problem, thus improving care.Currently only about 20% of primary care physicians report use of EMRs. Because of the well-established administrative and fi nancial management advantages of EMRs and the pressure from payers, purchasers, and regulators of health care to use EMRs, investments in such technology are 17 In controlled studies, current EMR systems have had limited positive imp...