OBJECTIVE -Glycemic control remains suboptimal despite the wide range of available medications. More effective medication prescription might result in better control. However, the process by which physicians choose glucose-lowering medicines is poorly understood. We sought to study the means by which physicians choose medications for type 2 diabetic patients.RESEARCH DESIGN AND METHODS -We surveyed 886 physician members of either the Society of General Internal Medicine (academic generalists, response rate 30%) or the American Diabetes Association (specialists, response rate 23%) currently managing patients with type 2 diabetes. Respondents weighed the importance of 15 patient, physician, and nonclinical factors when deciding which medications to prescribe for type 2 diabetic subjects at each of three management stages (initiation, use of second-line oral agents, and insulin).RESULTS -Respondents reported using a median of five major considerations (interquartile range 4 -6) at each stage. Frequently cited major considerations included overall assessment of the patient's health/comorbidity, A1C level, and patient's adherence behavior but not expert guidelines/hospital algorithms or patient age. For insulin initiation, academic generalists placed greater emphasis on patient adherence (76 vs. 60% of specialists, P Ͻ 0.001). These generalists also identified patient fear of injections (68%) and patient desire to prolong noninsulin therapy (68%) as major insulin barriers. Overall, qualitative factors (e.g., adherence, motivation, overall health assessment) were somewhat more highly considered than quantitative factors (e.g., A1C, age, weight) with mean aggregate scores of 7.3 vs. 6.9 on a scale of 0 -10, P Ͻ 0.001.CONCLUSIONS -The physicians in our survey considered a wide range of qualitative and quantitative factors when making medication choices for hyperglycemia management. The apparent complexity of the medication choice process contrasts with current evidence-based treatment guidelines.
OBJECTIVE: Suboptimal treatment of hyperlipidemia in patients with coronary artery disease (CAD) is well documented. We report the impact of a computer-assisted physician-directed intervention to improve secondary prevention of hyperlipidemia. DESIGN AND SETTING: Two hundred thirty-five patients under the care of 14 primary care physicians in an academically affiliated practice with an electronic health record were enrolled in this proof-of-concept physician-blinded randomized, controlled trial. Each patient with CAD or risk equivalent above National Cholesterol Education Program-recommended low-density lipoprotein (LDL) treatment goal for greater than 6 months was randomized, stratified by physician and baseline LDL. Physicians received a single e-mail per intervention patient. Emails were visit independent, provided decision support, and facilitated ''one-click'' order writing. MEASUREMENTS:The primary outcomes were changes in hyperlipidemia prescriptions, time to prescription change, and changes in LDL levels. The time spent using the system was assessed among intervention patients.RESULTS: A greater proportion of intervention patients had prescription changes at 1 month (15.3% vs 2%, P =.001) and 1 year (24.6% vs 17.1%, P =.14). The median interval to first medication adjustment occurred earlier among intervention patients (0 vs 7.1 months, P =.005). Among patients with baseline LDLs 4130 mg/dL, the first postintervention LDLs were substantially lower in the intervention group (119.0 vs 138.0 mg/dL, P =.04). Physician processing time was under 60 seconds per e-mail. CONCLUSION:A visit-independent disease management tool resulted in significant improvement in secondary prevention of hyperlipidemia at 1-month postintervention and showed a trend toward improvement at 1 year.
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