Prevent Diabetes Mellitus (PreDM) Clinical Decision Support Intervention in Community Health Centers

项目摘要 8600万美国成年人患有前驱糖尿病，其中高达75%的人最终会发展为糖尿病。 具有里程碑意义的临床试验已经确定，强化生活方式干预（ILI）和二甲双胍是安全的， 预防或延缓糖尿病前期和超重/肥胖成人糖尿病的有效治疗。尽管 这些治疗方法被列入专家临床指南，但很少使用，也很少有研究探讨如何使用这些方法。 以促进其在实践中的应用。增加ILI和二甲双胍在原发性肝癌患者中的采用的一种可能方法 护理包括临床决策支持（CDS），它使用电子系统来创建定制的建议 进行循证临床护理。虽然大量的证据表明，CDS可以改善交付 在其他推荐的预防服务中，尚未对ILI和二甲双胍的这种方法进行明确研究。 我们计划通过开发和评估预防糖尿病来解决这一关键的知识缺口。 社区卫生中心糖尿病前期患者的临床决策支持干预 超重/肥胖。这种新型CDS让初级保健提供者和临床工作人员参与提供以下内容 干预组件：1）由我们的团队开发的关于糖尿病预防的决策辅助; 2）EHR转诊 以社区为基础的ILI，满足建议的计划要求;和3）提示提供者， 考虑开二甲双胍。临床医生将每月收到关于PreDM CDS使用情况的反馈 通过现有的dashboard。通过实现以下具体目标，这项最终的R18研究将测试 CDS在初级保健中促进糖尿病预防和减肥工作的潜力。在目标1中，我们 通过将关于ILI和二甲双胍的叙述性指南翻译成CDS来制定拟议的干预措施，同时 结合用户的广泛反馈。目的2是一个实用的集群随机试验，包括6个大型 社区卫生中心站点，将检查PreDM CDS诱导体重减轻的有效性 并改善其他心脏代谢指标。目的3是对PreDM CDS进行混合方法评价，探索 其范围、采用、实施、维护和成本。我们假设拟议的PreDM CDS将 增加患者对ILI和二甲双胍采用，产生体重减轻和其他方面的改善 心脏代谢标志物由此产生的数据和研究小组创建的实施工具包将 如果在拟议的研究中发现PreDM CDS有效，则支持广泛传播。我们 提案通过以下方式响应PA-17-261：1）开发包含循证指南的新CDS 目前临床实践中不常使用的糖尿病预防; 2）评估 关于患者结局、临床工作流程、医疗保健过程措施、对指南的依从性的拟议CDS， 和成本;以及3）在为少数人服务的健康中心控制的网络中进行这项R18研究- 主要人群，并有能力在全国范围内传播拟议的PreDM CDS 社区健康中心网络为200万患者提供服务。

Project Summary Eighty six million U.S. adults have prediabetes, and up to 75% of them will eventually develop diabetes. Landmark clinical trials have established that intensive lifestyle interventions (ILI) and metformin are safe and effective treatments to prevent or delay diabetes in adults with prediabetes and overweight/obesity. Despite being included in expert clinical guidelines, these treatments are rarely used and few studies have explored how to promote their uptake in practice. One possible approach for increasing adoption of ILI and metformin in primary care includes clinical decision support (CDS), which uses electronic systems to create tailored recommendations for evidence-based clinical care. While a large body of evidence demonstrates that CDS can improve the delivery of other recommended preventive services, this approach has not been definitively studied for ILI and metformin. We plan to address this critical knowledge gap by developing and evaluating the Prevent Diabetes Mellitus Clinical Decision Support (PreDM CDS) intervention for community health center patients with prediabetes and overweight/obesity. This novel CDS engages primary care providers and clinical staff to deliver the following intervention components: 1) a decision aid about diabetes prevention developed by our team; 2) an EHR referral to community-based ILI that meet recommended program requirements; and 3) a prompt for providers to consider prescribing metformin. Clinicians will receive monthly feedback about their use of the PreDM CDS through an existing dashboard. By accomplishing the following specific aims, this definitive R18 study will test the potential for CDS to promote diabetes prevention and weight loss efforts in primary care. In Aim 1, we will develop the proposed intervention by translating narrative guidelines about ILI and metformin into CDS, while incorporating extensive feedback from users. Aim 2 is a pragmatic cluster randomized trial, including 6 large community health center sites, which will examine the effectiveness of the PreDM CDS at inducing weight loss and improving other cardiometabolic markers. Aim 3 is a mixed-methods evaluation of the PreDM CDS, exploring its reach, adoption, implementation, maintenance, and cost. We hypothesize that the proposed PreDM CDS will increase patient's adoption of ILI and metformin, producing weight loss and improvements in other cardiometabolic markers. The resulting data, and an implementation toolkit created by the study team, will support the widespread dissemination of the PreDM CDS if found to be effective in the proposed study. Our proposal is responsive to PA-17-261 by: 1) developing new CDS that incorporates evidence-based guidelines for diabetes prevention that are infrequently used in current clinical practice; 2) evaluating the impact of the proposed CDS on patient outcomes, clinical workflows, healthcare process measures, adherence to guidelines, and costs; and 3) conducting this R18 study in a Health Center-Controlled Network that serves a minority- predominant population and has the capacity to disseminate the proposed PreDM CDS throughout its national network of community health centers serving 2 million patients.