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Published on: June 11, 2012
Comparative Effectiveness of Team-Based Care With and Without a Clinical Decision Support System for Diabetes
Xiulin Shi1, Jiang He2, Mingzhu Lin3
1Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China, Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China, and Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana (X.S.).
Background:
Uncontrolled hyperglycemia, hypercholesterolemia, and hypertension are common in persons with diabetes.
Objective:
To compare the effectiveness of team-based care with and without a clinical decision support system (CDSS) in controlling glycemia, lipids, and blood pressure (BP) among patients with type 2 diabetes.
Design:
Cluster randomized trial. (ClinicalTrials.gov: NCT02835287).
Setting:
38 community health centers in Xiamen, China.
Patients:
11 132 persons aged 50 years or older with uncontrolled diabetes and comorbid conditions, 5475 receiving team-based care with a CDSS and 5657 receiving team-based care alone.
Intervention:
Team-based care was delivered by primary care physicians, health coaches, and diabetes specialists in all centers. In addition, a computerized CDSS, which generated individualized treatment recommendations based on clinical guidelines, was implemented in 19 centers delivering team-based care with a CDSS.
Measurements:
Coprimary outcomes were mean reductions in hemoglobin A1c (HbA1c) level, low-density lipoprotein cholesterol (LDL-C) level, and systolic BP over 18 months and the proportion of participants with all 3 risk factors controlled at 18 months.
Results:
During the 18-month intervention, HbA1c levels, LDL-C levels, and systolic BP significantly decreased by -0.9 percentage point (95% CI, -0.9 to -0.8 percentage point), -0.49 mmol/L (CI, -0.53 to -0.45 mmol/L) (-19.0 mg/dL [CI, -20.4 to -17.5 mg/dL]), and -9.1 mm Hg (CI, -9.9 to -8.3 mm Hg), respectively, in team-based care with a CDSS and by -0.6 percentage point (CI, -0.7 to -0.5 percentage point), -0.32 mmol/L (CI, -0.35 to -0.29 mmol/L) (-12.5 mg/dL [CI, -13.6 to -11.3 mg/dL]), and -7.5 mm Hg (CI, -8.4 to -6.6 mm Hg), respectively, in team-based care alone. Net differences were -0.2 percentage point (CI, -0.3 to -0.1 percentage point) for HbA1c level, -0.17 mmol/L (CI, -0.21 to -0.12 mmol/L) (-6.5 mg/dL [CI, -8.3 to -4.6 mg/dL]) for LDL-C level, and -1.5 mm Hg (CI, -2.8 to -0.3 mm Hg) for systolic BP. The proportion of patients with controlled HbA1c, LDL-C, and systolic BP was 16.9% (CI, 15.7% to 18.2%) in team-based care with a CDSS and 13.0% (CI, 11.7% to 14.3%) in team-based care alone.
Limitation:
There was no usual care control, and clinical outcome assessors were unblinded; the analysis did not account for multiple comparisons.
Conclusion:
Compared with team-based care alone, team-based care with a CDSS significantly reduced cardiovascular risk factors in patients with diabetes, but the effect was modest.
Primary Funding Source:
Xiamen Municipal Health Commission.
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