An EHR prompt raised diabetes education referrals from 1% to 13%, and standing orders held the gain

Design

Cluster-randomised controlled trial, 6 primary care practices (4 intervention, 2 control), 18 months

Population

Adults with type 2 diabetes attending primary care in central North Carolina

Primary outcome

DSMES referral rate

Effect

12.9% vs 1.2% at 12 months (OR 10.55, 95% CI 4.65–23.94); 13.7% vs 1.6% at 18 months (OR 9.44, 4.91–18.17)

PROMPT was a cluster-randomised trial in six primary care practices in central North Carolina. Four practices received a best-practice advisory in the electronic health record that fired when an eligible adult with type 2 diabetes attended; two practices were controls. After 12 months, standing orders were added so the prompt also fired for nurses and medical assistants before the patient saw the clinician.

At 12 months, 12.9% of eligible patients in intervention practices were referred for diabetes self-management education and support (DSMES), against 1.2% in control practices (adjusted OR 10.55, 95% CI 4.65 to 23.94). At 18 months, with standing orders, referral was 13.7% against 1.6% (OR 9.44, 4.91 to 18.17).

The outcome is referral, not attendance or HbA1c, and 13% is still low. But DSMES improves glucose control and is under-used almost everywhere, and the barrier this addresses is simply that nobody remembered to offer it. Letting a nurse or assistant start the referral is the part most clinics could copy without new software.

• Build a standing order so nurses or assistants can refer eligible patients to diabetes education before the doctor sees them.
• If your clinic system supports alerts, a single referral prompt for type 2 diabetes is worth configuring.
• Check referral at diagnosis, at the annual review, and when treatment changes or targets are missed.
• Track attendance, not just referral; a referral nobody attends changes nothing.

Why it matters

The gap in diabetes education is often a referral nobody made, and a system prompt closes much of it at almost no cost.

Don't overread it

The trial measured referrals, not attendance or glucose control.

The statistics, in plain English

An odds ratio of about 10 sounds enormous, but it starts from a very low base: 1 to 2 in 100 patients referred became about 13 in 100. The confidence intervals are wide (roughly 5 to 24) because only six practices were randomised, but even the lower end is a large effect.

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