Best Practice Advisories Raise Diabetes Education Referrals

ORLANDO, Florida — The use of electronic Best Practice Advisories (BPAs) doubled the rate of patient referrals for diabetes self-management education and support (DSMES) services, new research found.

Despite the proven benefits of DSMES, particularly at the time of a diabetes diagnosis, utilization is “surprisingly low,” at just 6.8% of newly diagnosed people with private insurance and less than 5% of Medicare enrollees, Laura Young, MD, PhD, said in her presentation of the data at the annual American Diabetes Association (ADA) 84th Scientific Sessions.

Similarly low rates of DSMES participation have been reported for people who have had diabetes for more than a year but who met other criteria for DSMES referral, said Young, associate professor of medicine and director of the Fellowship in Endocrinology at the University of North Carolina (UNC), Chapel Hill, North Carolina.

Embedded into electronic health records (EHRs), BPAs are pop-up reminders about the need for a specific intervention for a given patient, such as vaccinations, eye exams, or A1c tests.

“Diabetes education is a best practice. We thought if we made it easy and the provider could just click ‘order’, that it would increase because part of the problem with getting people into diabetes education is providers aren’t ordering it. They’re so busy…So we thought if we made it easier, they might be more willing to do it,” Young told Medscape Medical News.

Even before receiving the funding to conduct the study, Young’s institution worked with Epic to build the DSMES BPA into the electronic healthcare software so it would “fire” when a patient with type 2 diabetes (T2D) who qualified for DSMES attended a routine visit with their primary care provider. “And now that we had some very positive results, hopefully that will expand, and because it is on the Epic platform, it may be able to be more easily disseminated to other healthcare systems,” she said.

Asked to comment, session moderator Curtis L. Triplitt, PharmD, CDE, associate professor in the Department of Medicine, Division of Diabetes, at the University of Texas Health San Antonio, told Medscape Medical News, “I think this was a very good start because one of the problems is that it doesn’t come to the clinician’s mind. They’re so focused on medications and minimizing complications. This is wonderful that a simple BPA could increase referral rates so nicely.”

However, he noted, it’s just a first step. “One of the disconnects is not just the referral rate but also how many people come in. With diabetes education, we’re still having a chronic problem of people who are referred to diabetes education but don’t arrive for that education. There are several steps, including getting patients to understand they need it and getting them to actually obtain that education.”

PROMPT Trial: BPA Doubled the Rate of DSMES Referral

The PROMPT trial took place in six UNC Physicians Network primary care practices between April and October 2023. The BPA was embedded in the EHR in four of the practices, while the other two continued their usual care with current DSMES referral practices. All six practices have access to diabetes educators and support specialists, Young noted.

The BPA would “fire” when a patient met these criteria: At least 18 years of age, speaks English, has an active T2D diagnosis, has not attended a previous UNC DSMES class in the past year, and has one of the following: A new T2D diagnosis with no DSMES, an A1c > 8.5% (regardless of when diagnosed), a new complication, or a recent care transition (such as hospitalization or change in insurance).

The BPA fires when the provider opens the patient’s chart, goes to the BPA section from the Plan activity tab, or enters a diagnosis. The provider then clicks either “order” or “do not order.” If they select the latter, the system asks them to acknowledge the reason.

There were 2526 eligible patients in the intervention practices and 1444 in the control practices. Of those, orders for DSMES were placed for 14.9% (376) of the patients in the intervention practices compared with 6.6% (95) in the control practices (P = .00).

Patients referred for DSMES were less likely than the controls to be Medicare beneficiaries (46.5% vs 62.1%) and more likely to have commercial insurance (46.8% vs 25.3%). And, despite having fewer DSMES orders, the control group actually had more appointments during the study period (6.25 vs 3.93).

After adjustment for differences in baseline characteristics, the odds ratio for a DSMES order being placed was 2.08 in the intervention vs control clinics, a significant difference. Other significant predictors included Black race (1.61), higher comorbidity count (1.16), and a new T2D diagnosis (1.36). Factors reducing the likelihood of a DSMES referral included hospitalization (0.34) and a new diabetes-related diagnosis (0.36).

This spring, Young and her team secured standing orders for DSMES, allowing nurses to order the BPAs. Those referral data are currently being collected. In addition, the team is also using peer support phone calls to encourage patients to attend the DSMES sessions once they’ve been prescribed. “We will hopefully next year come back and tell you about those results,” Young said.

Young received research support from Novo Nordisk, Eli Lilly, and vTv Therapeutics. Triplett is a speaker for Novo Nordisk.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape Medical News, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker.