Expansion of Electronic Health Record-Based Screening, Prevention, and Management of Diabetes in New York City

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Jeanine Albu, MD; Nancy Sohler, PhD; Brenda Matti-Orozco, MD; Jordan Sill, MS; Daniel Baxter, MD; Gary Burke, MD; Edwin Young, MD

Suggested citation for this article: Albu J, Sohler N, Matti-Orozco B, Sill J, Baxter D, Burke G, et al. Expansion of Electronic Health Record-Based Screening, Prevention, and Management of Diabetes in New York City. Prev Chronic Dis 2013;10:120148. DOI: http://dx.doi.org/10.5888/pcd10.120148

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Abstract

To address the increasing burden of diabetes in New York City, we designed 2 electronic health records (EHRs)-facilitated diabetes management systems to be implemented in 6 primary care practices on the West Side of Manhattan, a standard system and an enhanced system. The standard system includes screening for diabetes. The enhanced system includes screening and ensures close patient follow-up; it applies principles of the chronic care model, including community–clinic linkages, to the management of patients newly diagnosed with diabetes and prediabetes through screening. We will stagger implementation of the enhanced system across the 6 clinics allowing comparison, through a quasi-experimental design (pre–post difference with a control group), of patients treated in the enhanced system with similar patients treated in the standard system. The findings could inform health system practices at multiple levels and influence the integration of community resources into routine diabetes care.

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Introduction

Significant progress has been made in controlling type 2 diabetes and its complications in primary care settings through the application of the chronic care model (CCM) (1–3). Evidence that CCM modifications to primary care practice can prevent type 2 diabetes is limited (4–6). Screening high-risk patients to detect diabetes and prediabetes was cost-effective (7–9), and prevention of type 2 diabetes in people with prediabetes through adoption of appropriate lifestyle changes and pharmacologic interventions has been successful in experimental settings (10). However, ongoing challenges in translating this evidence into primary care practice include the identification of appropriate target populations and the difficulty of incorporating time- and resource-intensive lifestyle interventions into routine clinical care (6). Although community and peer support systems have proven effective in preventing many chronic diseases (11,12), rigorous evaluations of integrated health care systems and community linkages for preventing type 2 diabetes are lacking (13).
Six clinics in a primary care network in New York City, 3 of which are federally qualified health centers, have established an evidence-based diabetes management system grounded in CCM principles in the context of developing a patient-centered medical home in each clinic (14). As defined by the National Committee for Quality Assurance, a patient-centered medical home is a health care setting that facilitates partnerships between patients and their physicians through the use of registries, information technology, and health information exchange. Our study will examine a standard and an enhanced diabetes management system. The standard system, already implemented, includes an electronic health records (EHR)-based, targeted screening program that is aimed at detecting previously undiagnosed diabetes (hemoglobin A1c [HbA1c] > 6.5%) and prediabetes (HbA1c 5.7%–6.4%). The enhanced diabetes management system is designed to facilitate the management of patients identified through the screening program as having diabetes or prediabetes. The enhanced system, which extends components of the CCM including community–clinic linkages to patient management, will be added to the standard system. The staggered implementation of the enhanced system across the 6 target clinics will allow comparisons of participant outcomes in the enhanced versus standard clinics through a quasi-experimental design (pre–post difference with a control group) by retrospective analyses of the data extracted from the EHR. The primary objective of these analyses is to test 3 hypotheses: first, that patients with newly diagnosed diabetes or prediabetes who will be exposed to the enhanced system will be more likely than patients exposed to the standard system to experience a reduction in HbA1c levels over 12 months; second, that any reductions in HbA1c levels observed in patients in the enhanced system will be sustained over a follow-up period of 30 months; and third, that patients in clinics adopting the enhanced system will be retained longer in appropriate health care than those in the standard system.