From Alert to Action: Electronic Practice Advisory Improves DSMES Referrals Over 18 Months

Engagement in diabetes self-management education and support (DSMES) is suboptimal among people with type 2 diabetes (T2D). The PROMPT study examined whether referral rates to DSMES increased through a best practice advisory (BPA) deployed during clinic visits via the electronic health record.

In this cluster-randomized controlled trial in central North Carolina, we created a BPA within the electronic health record that deployed when eligible patients with T2D attended primary care visits. The BPA was active in four primary care practices over 18 months, with two control practices. After 12 months, standing orders were added so the BPA would additionally deploy for nurses or medical assistants before patients saw their clinician. We analyzed data using multilevel logistic regression modeling with patient data nested within clinics, using binary logit functions and maximum likelihood estimation to estimate the odds of DSMES referrals.

At 12 months, the BPA intervention achieved a 12.9% DSMES referral rate compared with 1.2% in control clinics (P < 0.001). At 18 months, the referral rate remained higher in the intervention clinics (13.7%) than in controls (1.6%; P < 0.001). After adjusting for patient and clinic characteristics, the odds of referral in BPA-exposed clinics were significantly greater than in control clinics at both time points: odds ratio (OR) 10.55 (95% CI 4.65-23.94) at 12 months and OR 9.44 (95% CI 4.91-18.17) at 18 months after implementation of standing orders.

Integrating BPA prompts into the electronic health record boosts DSMES referral rates, and adding standing orders helps sustain these gains.