Randomized trials have clearly shown that angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) substantially reduce morbidity and mortality in patients with diabetes, particularly in those with albuminuria. Even so, these medications are currently under-prescribed across the United States. For example, in the northeastern VA (Veterans Affairs) hospital system, only 67% of the 52,174 patients with diabetes currently receive at least one of these medications. Innovation: Interactive Spaced Education (ISE) is a novel educational methodology based on the "spacing effect", the psychological finding that repeated presentations of educational material over spaced intervals increase learning efficiency and improve knowledge retention. ISE is delivered using periodic emails that contain clinical case scenarios and multiple-choice questions. We recently completed a randomized trial involving 95 primary care providers which demonstrated that an ISE intervention on prostate cancer screening can generate a 40% relative reduction in inappropriate screening for over a year after the intervention.
Specific Aims : We propose to conduct a randomized controlled trial to determine whether ISE directed to VA primary care providers can increase the proportion of patients with diabetes who are (1) treated with an ACEI or ARB and (2) screened for albuminuria (an absolute indication for ACEI or ARB use). Approach: One-hundred six of the 260 primary care practitioners (physicians, nurse practitioners, and physician assistants) in the northeastern VA hospital system will be recruited via email to participate in the study. Participants will be randomized to one of two cohorts: (1) the intervention cohort will receive the ISE intervention over approximately 1 year [7-12 months], and (2) the control cohort will receive the identical educational content as an email link and as a PDF file that can be accessed via an icon on their computer desktop during months 1-12. The ISE intervention will consist of a weekly email containing 1-2 multiple-choice questions based on a curriculum that supports ACEI/ARB use. Providers will submit answers to the questions online and immediately receive the correct answer and an explanation of the pertinent clinical issues. Using a new adaptive methodology, the spacing and content of the ISE intervention will be individualized for each clinician based on their performance. Both cohorts will complete a test at baseline and at 12 months to assess gains in knowledge. ACEI/ARB use among patients followed by participating clinicians will be assessed over 2 years: initial changes attributable to the ISE intervention will be identified in year 1, while the retention of these changes will be monitored in year 2.

Public Health Relevance

Anticipated Impacts on Healthcare: This study aims to demonstrate that online interactive spaced education (ISE) can improve primary care providers'care of their patients with diabetes. With content tailored to meet specific needs, ISE is the type of intervention that can be deployed across US healthcare systems to improve healthcare quality and clinical outcomes.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Project (R01)
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Health Care Quality and Effectiveness Research (HQER)
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Basu, Joy
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Boston VA Research Institute, Inc.
United States
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