[unreadable] Background.  The prevalence of diabetes in Alabama is 8%, one of the highest among all states.  We propose a 5- year randomized trial of an Internet-based intervention designed to improve guideline adherence by rural Alabama physicians caring for adult patients with type 2 diabetes.  Rural Alabama has many disadvantaged and minority patients with limited health care access, and rural Alabama patients with diabetes receive poorer quality of care and have worse outcomes compared to urban patients.  Objectives. ( 1) Assess barriers to implementation of diabetes guidelines and identify solutions through focus groups and case-based vignette surveys; (2) Develop and implement an interactive Internet intervention, updated regularly; (3) Evaluate the intervention in a randomized controlled trial; (4) Assess changes in performance attributable to feedback; and (5) Examine the sustainability of improved guideline adherence once feedback ceases.  Methods.  In partnership with the University of Alabama rural medicine program, we will randomize 200 rural physicians to an intervention or control arm.  Our 30-month intervention, customized to the individual physician in real-time, consists of Internet learning modules with casebased education, performance feedback, and benchmarks.  Outcomes will be based on previously developed and validated quality measures for diabetes.  The intervention will cover screening, diagnosis, treatment, and prevention.  We will review baseline and follow up medical records of 10 diabetic patients for each physician.  The main analysis, conducted at the physician level, will compare differential improvement in guideline adherence between the study arms.  Ancillary analyses will examine the effects of physician characteristics (e.g., specialty) and patient characteristics (e.g., comorbidities, ethnicity, gender, age, and socioeconomic status).  When appropriate, multivariable techniques will adjust for repeated measures and clustering of patients within physicians.  Significance.  This study offers a technologically advanced, theory-grounded, provider-level intervention for improving care of a high-risk, underserved population.  Our multidisciplinary team has a proven record of collaboration and contains expertise in translating research into practice, rural medicine, behavioral medicine, and clinical diabetes.  This project will produce an evidence-based and replicable cutting-edge intervention that can be sustained in the "real world," readily disseminated, and easily modified for other diseases. [ unreadable] [unreadable]