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J Diabetes Sci Technol. 2009 Jul; 3(4): 944–950.
Published online 2009 Jul.
PMCID: PMC2769983

Computerized Prompting and Feedback of Diabetes Care: A Review of the Literature

Suzanne Austin Boren, Ph.D., M.H.A.,1,2,3 Aaron M. Puchbauer, M.H.A.,2,3 and Faustine Williams, M.S.2

Abstract

Background

The objective of this study was to assess published literature on computerized prompting and feedback of diabetes care as well as to identify opportunities to strengthen diabetes care processes.

Methods

Medline (1970–2008), Cumulative Index to Nursing and Allied Health Literature (1982–2008), and Cochrane Central Register of Controlled Trials (4th quarter 2008) were searched, and reference lists from included articles were reviewed to identify additional studies. Patient sample, clinician sample, setting, duration of the trial, intervention description, control description, and results were abstracted from each study.

Results

Fifteen trials were included in this review. The following elements were observed in the interventions: general prompt for a particular patient to be seen for diabetes-related follow-up (5 studies), specific prompt reminding clinicians of particular tests or procedures related to diabetes (13 studies), feedback to clinicians in addition to prompting (5 studies), and patient reminders in addition to clinician prompts (5 studies). Twelve of the 15 studies (80%) measured a significant process or outcome from the intervention.

Conclusions

The majority of trials identified at least one process or outcome that was significantly better in the intervention group than in the control group; however, the success of the information interventions varied greatly. Providing and receiving appropriate care is the first step toward better outcomes in chronic disease management.

Keywords: diabetes mellitus, feedback, outcomes of care, process of care, randomized controlled trials, reminder systems

Introduction

The discrepancy between what is known and what is done in diabetes care suggests the need for better knowledge management to improve processes and outcomes through sharing and leveraging information. For example, the first trial on the benefit of early treatment of diabetic retinopathy was published in 1976.1 The American Diabetes Association started recommending annual eye examinations in 1988 and has restated the recommendation annually.2 According to the Centers for Disease Control and Prevention, the age-adjusted rate of annual dilated eye exams among adults with diabetes is 69.1%.3 The landmark trial for diabetes foot care was published in 1989,4 and the Centers for Disease Control and Prevention reports the age-adjusted rate for self-exam of feet is 64.6%.3

Information interventions are ways of delivering knowledge and can provide clinicians with decision support at appropriate times in order to improve health care processes and patient health outcomes.5 Researchers in diabetes health informatics face challenging opportunities to design clinical information systems to change clinical processes and patient outcomes.6 A variety of trials have focused on information intervention techniques (e.g., reminders and feedback) for modifying clinical processes and patient outcomes. Some reviews have found these interventions to be very effective in improving the quality of health care processes and outcomes,79 while other reviews have found that the interventions do not always produce the expected change.1011

The objective of this study was to identify computerized information interventions targeted at clinicians that can effectively accelerate the translation of evidence into practice, thereby improving clinician processes and patient outcomes in diabetes. This review assessed the published literature on computerized prompting and feedback of diabetes care and identifies opportunities to strengthen diabetes care processes.

Methods

Data Sources

Medline (1970–2008), Cumulative Index to Nursing and Allied Health Literature (1982–2008), and Cochrane Central Register of Controlled Trials (4th quarter 2008) were searched for eligible articles using combinations of the following search terms: (1) diabetes mellitus, type 1 diabetes mellitus, or type 2 diabetes mellitus and (2) reminder systems, practice guidelines as topic, computer-assisted decision making, clinical decision support systems, computer-assisted therapy, prompt, and remind. The reference lists of included studies were also searched.

Study Selection

The authors screened the titles and abstracts of the identified citations and articles based on the following criteria. The inclusion criteria were any randomized controlled trial evaluating computerized prompting or feedback of diabetes care. We excluded studies that were not randomized, without a control group, not reporting results, or not written in English.

Data Extraction

From each eligible article, the authors collected the following information: patient sample (number, clinical situation condition, age, percent male), clinician sample (number, specialty), setting, duration of the trial, intervention description, and results (measure, process or outcome, significance level). Coding disagreements were resolved by discussion among the authors.

Results

The literature searches identified 90 articles. The titles and abstracts of these articles were read, and 31 articles were determined to be potentially relevant. After reading the full articles, 15 articles met the eligibility criteria (Table 1).1226 Articles were excluded if they did not include a computerized clinician prompting intervention for diabetes (65 articles), were not randomized (3 articles), were without a control group (2 articles), did not report results (4 articles), or were not written in English (1 article).

Table 1.
Study Characteristicsa

Site and Sample

Based on preexisting databases and electronic patient records, automated prompts or summaries were generated for more than 2030 clinicians caring for 63,987 persons with diabetes. One study did not provide information on the number of participating clinicians.13 The clinician specialties included endocrinology,18 family practice,1517 general practice,13,14 internal medicine,12,1826 nurse practitioner,17,18 and physician assistant.17Eight of the studies included medical residents.12,1720,22,25,26

The mean age of participating patients ranged from 5821 to 68.19Two studies provided information on age as a proportion of patients above a certain age.14,16 Four studies did not provide any information on the mean age of patients.17,18,20,25 The percentage of male patients in the studies ranges from 33%22,26 to 98%.12 Five studies did not provide information about patient gender. One study intervened for diabetes prevention.16 Eleven studies intervened for persons with type 1 or type 2 diabetes.1215,17,18,20,21,2325 Three studies intervened for persons with type 2 diabetes only.19,22,26 Finally, three studies intervened for cardiovascular disease in addition to diabetes.12,14,23

The studies took place in five countries: Canada,15 Italy,14 New Zealand,16 the United Kingdom,13 and the United States.12,1726 Nine of the studies occurred in academic settings.1722,2426 Most of the studies took place in community-based outpatient clinics1417,21,23,24,26 or hospital-based outpatient clinics.12,13,19,20,22,23,25 Only one study occurred in an inpatient setting.18

Interventions

The primary intervention in this group of 15 studies was aimed at physicians and consisted of clinically relevant and diabetes guideline-based computerized reminders and feedback (Table 2). A general prompt reminding clinicians of the need for a particular patient to be seen for diabetes-related follow-up was observed in five studies.13,16,17,20,26 A specific prompt reminding clinicians of particular tests or procedures related to diabetes that are needed was observed in 13 studies.12,14,15,1726 Feedback to clinicians, in addition to prompting, was provided in five studies.17,22,2426 Patient prompts, in addition to clinician prompts, were provided in five studies.13,15,16,21,25 Specific prompts and feedback were provided to clinicians about hemoglobin A1c (HbA1c),12,15,17,19,22,24–26 glycemic control,20,24,26 blood pressure,15,22,2426 cholesterol,15,17,19,2325 microalbuminuria,12,15,17,19 weight,15,22,24,26 eye exam,12,15,17,19,20,24 foot care,12,15,17,19,20,24 nutritional counseling,12 lab tests,18,22 macrovascular care,20 neurologic care,20 renal care,20 physical exam,17 influenza vaccinations,17 pneumococcal vaccinations,17 medications,22,23,26 aspirin,21,23 and anti-platelet drugs.14 One study provided only a general reminder of a needed diabetes appointment,13 while another study provided a general reminder of a need for diabetes screening and a diabetes self-risk assessment.16 The length of the intervention and follow-up ranged from 216 to 36 months26 with an average of 13 months.

Table 2.
Reminders and Process / Outcome Measuresa

Process and Outcome Measures

Fifty processes and 57 outcomes were measured in the 15 studies (Table 2). Fourteen studies evaluated the effect the interventions had on the processes of care.1521,2326 Thirty-five of 50 process measures (70%) were significantly improved. Three13,15,17 of the five13,15,17,20,24 studies that measured adherence with general diabetes guidelines for routine clinic visits were significantly improved. Process measures assessed in more than one study (e.g., blood pressure, cholesterol, eye exam, foot exam, and HbA1c) are summarized later. Blood pressure measurement was significantly improved in two13,15 of three13,15,19 studies. Cholesterol testing and monitoring was significantly improved in four15,19,23,25 studies in which it was measured. Eye exam performance was significantly improved in three12,13,15 of five12,13,15,19,23 studies. Foot exams were significantly improved in four12,13,15,19 studies in which they were measured. Hemoglobin A1c measurement and monitoring was significantly improved in five12,13,15,19,25 of the six12,13,15,19,23,25 studies in which it was measured. Five of the studies evaluated the effect the interventions had on the outcomes of care.13,15,19,22,24 Nine of the 57 outcome measures (16%) were significantly improved. The significantly improved outcome measures include HbA1c,15,22 blood pressure,15,19 cholesterol,24 regular aspirin use,24 quit smoking,24 belief in medical control,13 and support from others.13 Three studies20,21,26 did not have any significant process or outcome measures.

Discussion

This review assessed published literature on computerized prompting and feedback of diabetes care. The 15 studies included in this review contributed information on the study characteristics as well as the associated processes and outcomes. Results of this review indicate that diabetes care processes can be improved by providing reminders and feedback to clinicians. Providing and receiving appropriate care is the first step toward better outcomes in chronic disease management.

Prompting and feedback can be used across the complete spectrum of diabetes care from prevention, diagnosis, and treatment, through monitoring. Each encounter with the healthcare system is an opportunity for a person with diabetes to keep current with the recommendations for diabetes care. However, prompting fatigue and the fragmentation of health care information can pose challenges for clinicians. Too many prompts can interfere with a busy clinician's schedule, especially when the patient's current reason for a visit takes precedence. In addition, verifying a patent's eligibility for a prompted service can be time-consuming when health care information is fragmented. It is also important to keep the guidelines, embedded in the medical record or other decision support system, current as well as maintain consensus with the rules that govern the reminders.

The results of this review should be interpreted with limitations in mind. We attempted to search the literature comprehensively; however, we may have unknowingly left out some studies that were eligible for inclusion. We did not include gestational diabetes among our search terms. Publication bias may exist, because studies that show a statistically significant outcome are more likely to be written by the investigator and published. We also limited our searches to randomized controlled trials. It is possible that including only randomized controlled trials excluded some studies that used historical controls instead of a current control group. The shortcomings of the available studies represent opportunities for future research. The follow-up period in most studies was not long enough to assess the long-term differences made by computerized reminders and feedback on the behavioral and clinical outcomes of diabetes. We did not explore the degree to which the outcomes were due to the clinical decision-making approach used in these studies. It should not be assumed that more information per se leads to better outcomes. Future studies should also consider the inclusion of an economic evaluation of the computerized interventions.

Abbreviations

HbA1c
hemoglobin A1c

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