Patients with type 2 diabetes are increasingly living with multiple concurrent conditions and complicated medical regimens. For these patients, diabetes management decisions and treatment goals must be addressed within the larger context of other competing health concerns. In parallel, clinical advances have led to a substantial increase in the number of tasks that primary care providers must perform during each visit. These twin trends of patient and visit complexity present a formidable challenge to effective diabetes primary care. Although there are a variety of non-visit strategies that can and are being instituted to address these issues, the primary care visit remains a vital opportunity fo catalyzing changes in diabetes care. To achieve this change, efficient and scalable tools to support more productive primary care encounters are needed. We hypothesize that among patients with type 2 diabetes and elevated HbA1c, a systematic approach that enables patients to explicitly prioritize their top diabetes and non-diabetes related health concerns before the primary care visit will result in more effective diabetes care over time. To test this hypothesis, our proposal's aims are to:1) Design and implement a web-based tool linked to the electronic medical record that will enable complex patients to indicate, and PCPs to review, patients'top health priorities for their upcoming visit;2) Conduct a randomized clinical trial among patients with type 2 diabetes and elevated HbA1c testing the impact on intermediate care outcomes (medication adherence, medication intensification) compared to usual care and HbA1c (primary clinical outcome), blood pressure, and lipid control (secondary clinical outcomes) compared to usual care;3) Among a sub-set of intervention participants (patients and PCPs), use mixed qualitative and quantitative methods to examine the impact of pre-visit prioritization on the content of subsequent visit discussions and examine the influence of patient and PCP factors on these discussions. The key conceptual innovation of this study is to test a replicable, low-cost approach to improving diabetes primary care that explicitly integrates non-diabetes problems into the process of diabetes management. We will implement an easy-to-use web-based tool linked to our EPIC(R)-based electronic medical record. This patient-centered care model has the potential to significantly improve the design of primary care systems responsible for providing patient-centered care and offers an innovative approach to improving the care of increasingly complex patients with type 2 diabetes. This study addresses the three NIH priorities of translating evidence into practice, improving medication adherence, and understanding health care disparities. If successful, we will work to actively disseminate the tool throughout our system and to other U.S. care organizations.

Public Health Relevance

Type 2 diabetes is increasing in prevalence, cost, and impact on our health system. A growing number of patients with type 2 diabetes live with multiple concurrent conditions that require complicated medical regimens and daily self-management behaviors. We propose to implement and evaluate a novel, patient-centered intervention designed to facilitate communication between patients and their primary care providers with the goal of enabling more effective primary care for complex patients with poorly controlled diabetes.

National Institute of Health (NIH)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Research Project (R01)
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Health Services Organization and Delivery Study Section (HSOD)
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Bremer, Andrew
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Kaiser Foundation Research Institute
United States
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Schmittdiel, Julie A; Grant, Richard W (2018) Crossing the Research to Quality Chasm: A Checklist for Researchers and Clinical Leadership Partners. J Gen Intern Med 33:9-10
Parker, Melissa M; Fernández, Alicia; Moffet, Howard H et al. (2017) Association of Patient-Physician Language Concordance and Glycemic Control for Limited-English Proficiency Latinos With Type 2 Diabetes. JAMA Intern Med 177:380-387
Zamudio, Cindy D; Sanchez, Gabriela; Altschuler, Andrea et al. (2017) Influence of Language and Culture in the Primary Care of Spanish-Speaking Latino Adults with Poorly Controlled Diabetes: A Qualitative Study. Ethn Dis 27:379-386
Grant, Richard William; Altschuler, Andrea; Uratsu, Connie Si et al. (2017) Primary care visit preparation and communication for patients with poorly controlled diabetes: A qualitative study of patients and physicians. Prim Care Diabetes 11:148-153
Adams, Alyce S; Bayliss, Elizabeth A; Schmittdiel, Julie A et al. (2016) The Diabetes Telephone Study: Design and challenges of a pragmatic cluster randomized trial to improve diabetic peripheral neuropathy treatment. Clin Trials 13:286-93
Grant, Richard W; Uratsu, Connie S; Estacio, Karen R et al. (2016) Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system. Contemp Clin Trials 47:196-201
Adams, A S; Bayliss, E; Schmittdiel, J A et al. (2015) The Diabetes Telephone Study: Design and Challenges of a Pragmatic Cluster Randomized Trial to Improve Diabetic Peripheral Neuropathy Treatment. Value Health 18:A723-4
Garcia, Maria E; Grant, Richard W (2015) Community Health Workers: A Missing Piece of the Puzzle for Complex Patients With Diabetes? J Gen Intern Med 30:878-9
Patel, Vishal; Reed, Mary E; Grant, Richard W (2015) Electronic health records and the evolution of diabetes care: a narrative review. J Diabetes Sci Technol 9:676-80
Grant, Richard W; Schmittdiel, Julie A (2015) Building a Career as a Delivery Science Researcher in a Changing Health Care Landscape. J Gen Intern Med 30:880-2

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