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

项目摘要 美国有8600万成年人患有糖尿病前期，其中高达75%的人最终会患上糖尿病。 具有里程碑意义的临床试验已经证实，强化生活方式干预(ILI)和二甲双胍是安全和 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 由于包括在专家临床指南中，这些治疗方法很少使用，也很少有研究探索如何 以促进它们在实践中的应用。一种可能的方法，以增加ILI和二甲双胍在小学采用 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 用于循证临床护理。虽然大量证据表明CDS可以改善交付 在其他推荐的预防服务中，这种方法还没有针对ILI和二甲双胍进行明确的研究。 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差距 社区卫生中心糖尿病前期患者的临床决策支持(PreDM CDS)干预 超重/肥胖。这一新型CDS聘请初级保健提供者和临床工作人员提供以下服务 干预部分：1)我们团队开发的关于糖尿病预防的决策辅助；2)EHR转诊 满足推荐计划要求的基于社区的ILI；以及3)提示提供商 考虑开出二甲双胍。临床医生将每月收到有关他们使用PreDM CDS的反馈 通过现有的仪表板。通过实现以下具体目标，这项权威性的R18研究将测试 CDS在初级保健中促进糖尿病预防和减肥努力的潜力。在目标1中，我们将 通过将关于ILI和二甲双胍的叙事指南翻译成CDS，制定拟议的干预措施，同时 纳入了来自用户的广泛反馈。AIM 2是一项实用的整群随机试验，包括6个大 社区卫生中心网站，将检查PreDM CDS在促进减肥方面的有效性 以及改善其他心脏代谢标志物。目标3是对PreDM CDS的混合方法评估，探索 其覆盖范围、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和二甲双胍的采用，产生减肥和其他方面的改善 心脏代谢标志物。由此产生的数据以及研究小组创建的实施工具包将 如果在拟议的研究中被发现是有效的，则支持广泛传播前DM CDS。我们的 提案通过以下方式响应PA-17-261：1)开发纳入循证指南的新CDS 用于当前临床实践中很少使用的糖尿病预防；2)评估 关于患者结局、临床工作流程、医疗保健流程措施、遵守指南的建议CDS， 和成本；以及3)在卫生中心控制的网络中进行这项R18研究，该网络服务于少数人- 人口占主导地位，并有能力在其全国范围内传播拟议的PreDM CDS 为200万名患者提供服务的社区卫生中心网络。

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.