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Shi X, He J, Lin M, Liu C, Yan B, Song H, Wang C, Xiao F, Huang P, Wang L, Li Z, Huang Y, Zhang M, Chen CS, Obst K, Shi L, Li W, Yang S, Yao G, Li X. Comparative Effectiveness of Team-Based Care With and Without a Clinical Decision Support System for Diabetes Management : A Cluster Randomized Trial. Ann Intern Med 2023; 176:49-58. [PMID: 36469915 DOI: 10.7326/m22-1950] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Uncontrolled hyperglycemia, hypercholesterolemia, and hypertension are common in persons with diabetes. OBJECTIVE To compare the effectiveness of team-based care with and without a clinical decision support system (CDSS) in controlling glycemia, lipids, and blood pressure (BP) among patients with type 2 diabetes. DESIGN Cluster randomized trial. (ClinicalTrials.gov: NCT02835287). SETTING 38 community health centers in Xiamen, China. PATIENTS 11 132 persons aged 50 years or older with uncontrolled diabetes and comorbid conditions, 5475 receiving team-based care with a CDSS and 5657 receiving team-based care alone. INTERVENTION Team-based care was delivered by primary care physicians, health coaches, and diabetes specialists in all centers. In addition, a computerized CDSS, which generated individualized treatment recommendations based on clinical guidelines, was implemented in 19 centers delivering team-based care with a CDSS. MEASUREMENTS Coprimary outcomes were mean reductions in hemoglobin A1c (HbA1c) level, low-density lipoprotein cholesterol (LDL-C) level, and systolic BP over 18 months and the proportion of participants with all 3 risk factors controlled at 18 months. RESULTS During the 18-month intervention, HbA1c levels, LDL-C levels, and systolic BP significantly decreased by -0.9 percentage point (95% CI, -0.9 to -0.8 percentage point), -0.49 mmol/L (CI, -0.53 to -0.45 mmol/L) (-19.0 mg/dL [CI, -20.4 to -17.5 mg/dL]), and -9.1 mm Hg (CI, -9.9 to -8.3 mm Hg), respectively, in team-based care with a CDSS and by -0.6 percentage point (CI, -0.7 to -0.5 percentage point), -0.32 mmol/L (CI, -0.35 to -0.29 mmol/L) (-12.5 mg/dL [CI, -13.6 to -11.3 mg/dL]), and -7.5 mm Hg (CI, -8.4 to -6.6 mm Hg), respectively, in team-based care alone. Net differences were -0.2 percentage point (CI, -0.3 to -0.1 percentage point) for HbA1c level, -0.17 mmol/L (CI, -0.21 to -0.12 mmol/L) (-6.5 mg/dL [CI, -8.3 to -4.6 mg/dL]) for LDL-C level, and -1.5 mm Hg (CI, -2.8 to -0.3 mm Hg) for systolic BP. The proportion of patients with controlled HbA1c, LDL-C, and systolic BP was 16.9% (CI, 15.7% to 18.2%) in team-based care with a CDSS and 13.0% (CI, 11.7% to 14.3%) in team-based care alone. LIMITATION There was no usual care control, and clinical outcome assessors were unblinded; the analysis did not account for multiple comparisons. CONCLUSION Compared with team-based care alone, team-based care with a CDSS significantly reduced cardiovascular risk factors in patients with diabetes, but the effect was modest. PRIMARY FUNDING SOURCE Xiamen Municipal Health Commission.
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Affiliation(s)
- Xiulin Shi
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China, Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China, and Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana (X.S.)
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, and Tulane University Translational Science Institute, New Orleans, Louisiana (J.H., C.S.C., K.O.)
| | - Mingzhu Lin
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Changqin Liu
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Bing Yan
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Haiqu Song
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Caihong Wang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Fangsen Xiao
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Peiying Huang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Liying Wang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Zhibin Li
- Epidemiology Research Unit, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China (Z.L.)
| | - Yinxiang Huang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Mulin Zhang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Chung-Shiuan Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, and Tulane University Translational Science Institute, New Orleans, Louisiana (J.H., C.S.C., K.O.)
| | - Katherine Obst
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, and Tulane University Translational Science Institute, New Orleans, Louisiana (J.H., C.S.C., K.O.)
| | - Lizheng Shi
- Department of Health Policy and Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana (L.S.)
| | - Weihua Li
- Department of Cardiology, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China (W.L.)
| | - Shuyu Yang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
| | - Guanhua Yao
- Xiamen Municipal Health Commission, Xiamen, China (G.Y.)
| | - Xuejun Li
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, and Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, and Fujian Province Key Laboratory of Diabetes Translational Medicine, Xiamen, China (M.L., C.L., B.Y., H.S., C.W., F.X., P.H., L.W., Y.H., M.Z., S.Y., X.L.)
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