ORLANDO, Fla. — Use of electronic Best Practice Advisories (BPAs) doubled patient referral rates to Diabetes Self-Management Education and Support (DSMES) services, a new study finds.
Despite the proven benefits of DSMES, particularly at the time of diabetes diagnosis, their uptake is “shockingly low,” accounting for just 6.8 percent of newly diagnosed individuals with private insurance and less than 5 percent of those with Medicare, Laura Young, MD, said in a data presentation at the American Diabetes Association's (ADA) 84th Scientific Session.
Young, an associate professor of medicine and director of the endocrinology fellowship at the University of North Carolina (UNC) Chapel Hill, said similarly low rates of DSMES participation have been reported among people who have had diabetes for more than a year but meet other criteria for DSMES referral.
BPA is embedded in electronic health records (EHRs) and provides pop-up notifications of the need for specific interventions for specific patients, such as vaccinations, eye exams, and A1c testing.
“Diabetes education is a best practice, and we thought if we could make it easy and providers could just click 'order,' we'd get more people to get diabetes education, because part of the problem with getting more people to get diabetes education is providers don't order it. They're so busy… so we thought if we made it easy, they might be more willing to do it,” Young said. Medscape Medical News.
Even before receiving the research funding, Young's institution had been working with Epic to incorporate the DSMES BPA into its electronic medical software so that it would be “activated” when DSMES-eligible patients with type 2 diabetes (T2D) visited their primary care physician for a routine appointment. “We've seen very positive results, so we hope to expand on this, and because it's on the Epic platform, it could easily be rolled out to other health systems,” he said.
When asked for comment, session moderator Curtis L. Triplitt, PharmD, CDE, Associate Professor, Department of Diabetes, University of Texas, College of Medicine at San Antonio, said: Medscape Medical News“I think this is a very good start, because one of the problems is that it's not top of mind for clinicians. They're too focused on medications and minimizing complications. It's great to see such an increase in referral rates with a simple BPA.”
But he points out that this is just the first step: “One of the issues is not just the referral rate, but the number of people coming in. When it comes to diabetes education, we have a chronic lack of people who are referred for diabetes education but don't show up to get it. There are several steps to take, such as getting patients to understand the need for education and actually getting them to get it.”
PROMPT Study: BPA doubles DSMES referral rates
The PROMPT trial took place at six UNC Physicians Network primary care clinics from April to October 2023. Four of the clinics incorporated BPA into their EHRs, while the other two continued care as usual at their current DSMES referral clinics. Young noted that all six clinics have access to diabetes educators and support specialists.
The BPA is “triggered” if a patient meets the following criteria: age 18 years or older, speaks English, is currently diagnosed with T2D, has not attended a UNC DSMES class in the past year, and has any of the following: new T2D diagnosis without DSMES, A1c > 8.5% (regardless of when diagnosed), new comorbidities, or recent treatment transition (e.g., hospitalization or change in insurance).
BPA is triggered when a provider opens a patient's chart, navigates to the BPA section from the plan activity tab, and enters a diagnosis. The provider then clicks “Order” or “Don't Order.” If they choose the latter, the system prompts them to confirm their reason.
There were 2526 eligible patients in the intervention clinic and 1444 in the control clinic. Of these, DSMES orders were placed for 14.9% (376) of patients in the intervention clinic compared with 6.6% (95) in the control clinic (P < .001).
DSMES-referred patients were less likely to be Medicare beneficiaries (46.5% vs. 62.1%) and more likely to have private insurance (46.8% vs. 25.3%) than the control group, and despite having fewer DSMES indications, the control group actually had more appointments during the study period (6.25 vs. 3.93).
After adjusting for differences in baseline characteristics, the odds ratio for DSMES ordering in intervention and control clinics was 2.08, a significant difference. Other significant predictors included black race (1.61), a higher number of comorbidities (1.16), and a new T2D diagnosis (1.36). Factors decreasing the likelihood of DSMES referral included hospitalization (0.34) and a new diabetes-related diagnosis (0.36).
Young and her team secured a standing order for DSMES this spring, allowing nurses to order BPA. These referral data are now being collected. Additionally, the team is also using peer support calls to encourage patients to attend DSMES sessions once a prescription has been filled. “We hope to come back next year and share the results with you all,” Young said.
Dr. Young has received research support from Novo Nordisk, Eli Lilly and Co., and vTv Therapeutics, Inc. Dr. Triplett is a speaker for Novo Nordisk.
Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to Medscape Medical News and has also written for The Washington Post, NPR's Shots blog, and Diatribe. You can find her at X @MiriamETucker.