糖化血红蛋白触发的 2 型糖尿病管理内分泌学电子咨询。
HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management.
机构信息
Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge St. 16th Floor, Boston, MA, 02114, USA.
出版信息
J Gen Intern Med. 2022 Apr;37(5):1081-1087. doi: 10.1007/s11606-021-07157-x. Epub 2021 Oct 4.
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.
背景
电子咨询（eConsultation）为增加获得专科护理的机会、解决知识差距以及克服接受初级保健医生（PCP）管理的 2 型糖尿病（T2DM）患者的治疗惰性提供了一种潜在机制。
目的
开发并实施一种系统，为 HbA1c 为 8.5-10.5%的接受 PCP 管理的 T2DM 患者提供主动内分泌学 eConsult。
设计
整群随机匹配队列研究与实施评估。
参与者
马萨诸塞州综合医院（MGH）附属的 PCP。
干预措施
主动内分泌学 eConsult。
主要观察指标
主要临床结局为 6 个月时 HbA1c 的平均变化。次要过程结局包括转诊完成率、降低血糖药物的处方率、其他管理建议率的差异、所有降血糖药物的变化以及面对面内分泌学就诊次数。
主要结果
161 名 PCP 被随机分配到干预组（n=81）和对照组（n=80）。干预组的 PCP 触发了 130 名患者的 eConsult。与对照组相比，干预组患者的 HbA1c 下降了 0.89（SD 1.45），而对照组下降了 0.69（SD 1.32）（p=0.28）。两组之间在开具降血糖药物方面存在显著差异。与对照组相比，接受 GLP-1 RA 或 SGLT2i 处方的患者增加了 19.3%，而对照组仅增加了 6.9%（p=0.003）。二甲双胍（3.1% vs -3.1%，p=0.03）和磺脲类药物（1.5% vs -6.9%，p=0.03）的处方率也有显著增加。在 6 个月的随访中，干预组有 13 次面对面内分泌学就诊，而对照组有 29 次（p=0.012）。PCP 更有可能接受关于当前药物的依从性或剂量调整的建议，而不是开始新的药物治疗。
结论
为 HbA1c 控制不佳的 T2DM 患者实施主动内分泌学 eConsult 系统是可行的。主动 eConsult 与降低血糖药物的开具增加相关，而 HbA1c 无显著差异。
试验注册
Clinicaltrials.gov 注册：NCT03542084。
Zotero 插件