Reducing Clinical Inertia in Diabetes Care
Condition: Diabetes Mellitus; Hypertension; Hyperlipidemia
MeSH terms: Diabetes Mellitus; Hyperlipidemias
Study type: Interventional

Summary: 
      In this randomized trial we evaluate two conceptually distinct but potentially synergistic
      interventions designed to reduce clinical inertia in the outpatient care of adults with type
      2 diabetes. The project addresses the following specific aims;

      Specific Aim 1. Implement and assess two conceptually distinct but potentially synergistic
      interventions to reduce clinical inertia related to control of A1c, SBP, and LDL in adults
      with diabetes.

        -  Hypothesis 1. Patients of physicians who receive the Cognitive Behavioral Intervention
           (CBI) (Group 1) will subsequently have less Clinical Inertia than those who receive no
           intervention (Group 4).

        -  Hypothesis 2. Patients of physicians who receive the Office Systems Redesign
           intervention (CBI) (Group 2) will subsequently have less Clinical Inertia than those who
           receive no intervention (Group 4).

        -  Hypothesis 3. Patients of physicians who receive the combined CBI plus OSR intervention
           (Group 3) will subsequently have less Clinical Inertia than those who receive CBI alone
           (Group 1) or OSR alone (Group 2).

      Specific Aim 2. Assess the impact of interventions to reduce clinical inertia on health care
      charges.

      • Hypothesis 4. After adjustment for baseline measures of health care charges, those who
      receive no intervention (Group 4), will have higher total health care charges over a 24-month
      follow-up, relative to the patients of physicians in intervention Group 1, Group 2, or Group
      3.
    

Detailed description: 
      The objective of this project is to improve the care of adults with diabetes (DM) by
      implementing effective interventions to reduce Clinical Inertia related to control of
      glycated hemoglobin (A1c), systolic blood pressure (SBP) and LDL-Cholesterol (LDL) in primary
      care office settings. Clinical inertia is defined as lack of treatment intensification in a
      patient not at evidence-based goals for A1c, SBP, or LDL. Clinical Inertia (CI) has been
      implicated as a major factor that contributes to inadequate A1c, SBP, and LDL control, and
      has been documented in over 80% of primary care office visits in various settings,despite the
      fact that only 3% to 23% of adults with diabetes have simultaneously achieved A1c < 7%, SBP <
      130 mm Hg, and LDL < 100 mg/dl.

      In this project we test two interventions designed to reduce clinical inertia. The Cognitive
      Behavioral Intervention (CBI) is directed at individual primary care physicians and has three
      components: (a) analyze each physician's clinical moves with diabetes patients to identify
      patterns that indicate clinical inertia, (b) engage each physician in a series of simulated
      clinical cases to assess the underlying causes of clinical inertia, and (c) provide each
      physician with a series of tailored simulated clinical scenarios that are designed to correct
      the failures of thinking and decision making that result in that physician's observed
      patterns of clinical inertia. The CBI intervention is based on recent work in cognitive
      science and learning theory and has been successfully applied in other research and
      educational settings.

      The Office Systems Redesign (OSR) Intervention is also directed to primary care physicians
      and has three major components: (a) identify specific patients in need of intensified
      diabetes care and schedule four consecutive monthly office visits with their primary care
      physician, (b) provide the physician with tailored and specific clinical decision support at
      the time of each visit based on evidence-based treatment algorithms, (c) implement physician
      visit resolution and accountability reporting immediately after each visit, using tools
      adapted from clinical trial protocols.
    

Intervention name(s): Cognitive Behavioral Intervention; Office System Redesign Intervention
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Intervention consists of simulated case based learning for physicians.; Intervention consists of clinical decision support within the electronic medical record.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: physician decision support; diabetes mellitus; electronic medical records; office systems redesign