Electronic Documentation of Lifestyle Counseling and Glycemic Control in Patients With Diabetes

To establish quantitative characteristics of lifestyle counseling documentation associated with improved glycemic control in patients with diabetes.

We retrospectively studied 10,870 hyperglycemic (HbA1c ≥7.0% [53 mmol/mol]) adults with diabetes followed at primary care practices affiliated with two academic hospitals between 2000 and 2010. Documentation intensity was represented by the mean number of characters per note documenting lifestyle counseling. Heterogeneity was calculated as the normalized Levenshtein distance between lifestyle counseling sentences between consecutive notes. Cox proportional hazards model was constructed to assess association of heterogeneity and intensity of lifestyle counseling documentation to time to HbA1c <7.0% (53 mmol/mol) while adjusting for demographics, initial HbA1c level, insulin therapy, medication intensification, and frequency of lifestyle counseling.

Comparing patients in the highest versus lowest tertile by documentation heterogeneity and documentation intensity, median time to HbA1c <7.0% (53 mmol/mol) was 26 vs. 39 months and 24 vs. 39 months, respectively (P < 0.001 for all). In multivariable analysis, an increase of documentation heterogeneity by 0.15 units and an increase of documentation intensity by 45 characters/note was associated with hazard ratios of 1.08 (95% CI 1.04-1.12; P < 0.001) and 1.27 (95% CI 1.23-1.31; P < 0.001) for time to HbA1c target, respectively.

Higher heterogeneity and intensity of lifestyle counseling documentation in provider notes were associated with better glycemic control. Further studies involving direct observation of patient care are needed to establish the nature of the relationship between documentation characteristics and patient outcomes.