We were able to recruit >50% of eligible PCPs to participate in the study. Physician attrition occurred due to noncompletion of the physician baseline survey (n = 1), withdrawal from the study (n = 1), noncompletion of the intervention (n = 3), and departure from the medical group during the study period (n = 3). Two physicians were excluded from analysis because they had insufficient postintervention diabetic patients available due to changes in job responsibilities. Attrition occurred evenly across randomized groups, and final analysis included 19 physicians in each group. Over 97% of those who completed the learning intervention rated their satisfaction with the interventions as excellent or very good after completing the simulated cases.
characterizes patients and physicians in each of the three study arms. Randomization at the physician level resulted in similar patient samples except that patients of physicians in group B more often had coronary artery disease and higher Charlson scores. Physician attributes did not differ by group.
Description of patients and PCPs
shows changes in A1C testing and A1C levels. There was a significant change in A1C level from before to after intervention, and the time-by-group interaction term was significant (P = 0.04), indicating significant group differences in change in A1C levels over time. A1C values of patients of physicians in group B declined, while the A1C values of patients of physicians in groups A (control) and C increased. An analogous model (data not shown) predicting postintervention A1C levels from each group and controlling for preintervention A1C, patient age, sex, and preintervention Charlson score showed similar results.
Change in A1C and LDL cholesterol testing rates and values
also shows results of the analysis restricted to patients on insulin for ≥120 days in both the pre- and postintervention periods. The overall time-by-condition term indicates no significant postintervention group differences in A1C change in insulin-treated patients. Patients not on insulin had an overall A1C increase of 0.13% from pre- to postintervention, with no differences by group (P = 0.10). Most of the A1C advantage of group B patients was concentrated in the subgroup using insulin.
also shows that LDL cholesterol values improved over time (P < 0.001), with no significant differences in LDL cholesterol test rates (P = 0.30) or LDL cholesterol values (P = 0.67) across study groups. Statin use (P < 0.0001) and fibrate use (P = 0.001) increased over time with no differences across study groups (time-by-group P = 0.22 for statins and P = 0.78 for fibrates).
Among patients above A1C goal during the preintervention time period (n = 907), the rate of postintervention initiation or titration of blood glucose–lowering medications was 31.5% in group A, 32.6% in group B, and 36.8% in group C (P = 0.41). Insulin titration could not be ascertained from data sources. Among patients with their most recent preintervention LDL cholesterol ≥100 mg/dl (n = 701), initiation and titration of lipid medications was 20.8% in group A, 24.2% in group B, and 21.8% in group C (P = 0.66). Among patients with their most recent preintervention blood pressure >130/80 mmHg (n = 949), the rate of postintervention initiation or titration of blood pressure–lowering medications was 27.3% in group A, 24.7% in group B, and 28.2% in group C (P = 0.61). Thus, the intervention did not significantly increase rates of treatment intensification.
provides data on risky prescribing events. While the time-by-condition term was only marginally significant (P = 0.08), a contrast of the control condition (group A) with the combined intervention groups (B plus C) showed a significant effect (P = 0.03) in favor of groups B and C for reduction in metformin use in patients with a renal contraindication to metformin use. No changes by group in metformin use following a CHF diagnosis (P = 0.36) were observed, consistent with the fact that this issue was not highlighted in the clinical cases.
Change in risky metformin-prescribing events