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Randomized Controlled Trial
. 2022 Apr;37(5):1081-1087.
doi: 10.1007/s11606-021-07157-x. Epub 2021 Oct 4.

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management

Andrew S Oseran #  1 , Karthik Rao #  2 , Yuchiao Chang  2 , Wei He  2 , Chrisanne E Sikora  3 , Deborah J Wexler #  4 , Daniel M Horn #  5
Affiliations
Randomized Controlled Trial

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management

Andrew S Oseran et al. J Gen Intern Med. 2022 Apr.

Abstract

Background: Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs).

Objective: To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs.

Design: Cluster-randomized matched cohort study with implementation evaluation.

Participants: PCPs affiliated with Massachusetts General Hospital (MGH).

Interventions: Unsolicited endocrinology eConsultation.

Main measures: The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits.

Key results: 161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs -3.1%, p=0.03) and sulfonylureas (1.5% vs -6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications.

Conclusions: The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c.

Trial registration: Clinicaltrials.gov registration: NCT03542084.

Keywords: electronic consultation; electronic health record; healthcare delivery; type 2 diabetes.

PubMed Disclaimer

Conflict of interest statement

DJW reports serving on Data Monitoring Committees for Novo Nordisk.

Figures

Figure 1.
Figure 1.
eConsultation process map and key metrics.
Figure 2.
Figure 2.
Consort diagram.
Figure 3.
Figure 3.
Absolute percent change in number of patients prescribed glucose-lowering medication over 6 months.
See this image and copyright information in PMC

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