- Design
- Cluster-randomised controlled trial, 4 intervention and 2 control primary care practices, 18 months
- Population
- Adults with type 2 diabetes attending primary care in central North Carolina
- Primary outcome
- Referral to diabetes self-management education and support
- Effect
- 12.9% vs 1.2% at 12 months; 13.7% vs 1.6% at 18 months; adjusted OR 9.44 (95% CI 4.91 to 18.17) at 18 months
In a cluster-randomised trial across six primary care practices in North Carolina, an electronic health record advisory fired during visits for eligible adults with type 2 diabetes. Four practices used it for 18 months; two served as controls. At 12 months nurses and medical assistants were also given standing orders.
Referral to diabetes self-management education and support was 12.9% in the intervention practices at 12 months against 1.2% in controls, and 13.7% against 1.6% at 18 months. The adjusted odds ratio was 10.55 (95% CI 4.65 to 23.94) at 12 months and 9.44 (95% CI 4.91 to 18.17) at 18 months.
The relative gain is large, but the absolute referral rate remained low, and the trial measured referral, not attendance or HbA1c.
- Check how many of your patients with type 2 diabetes have ever been referred for education
- Standing orders let nurses and assistants trigger a referral before the doctor enters the room
- Track attendance as well as referral, since the trial did not
- Where there is no electronic record, a visit-checklist item can play the same role
Why it matters
Education is underused mainly because of workflow, not patient refusal, and a small system change shifted it.
Don't overread it
Referral is a process measure; the trial does not show that patients attended or that glycaemic control improved.
The statistics, in plain English
An odds ratio of about 10 describes a large relative increase, but starting from 1% it still leaves most eligible patients unreferred. Cluster trials with only six practices have limited statistical power and results may vary between sites.
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