Medication intensification in diabetes in rural primary care: a cluster-randomised effectiveness trial

Objective: To determine the effectiveness of a provider-based intervention to improve medication intensification among patients with diabetes. Design: Effectiveness cluster-randomised trial. Baseline and follow-up cross-sections of diabetes physicians' patients. Setting: Eleven U.S. Southeastern states, 2006-2008. Participants: 205 Rural primary care physicians, 95 completed the study. Intervention: Multicomponent interactive intervention including web-based continuing medical education (CME), performance feedback and quality improvement tools. Primary outcome measures: Medication intensification, a dose increase of an existing medication or the addition of a new class of medication for glucose, blood pressure and lipids control on any of the three most recent office visits. Results: Of 364 physicians attempting to register, 102 were randomised to the intervention and 103 to the control arms; 95 physicians (intervention, n=48; control, n=47) provided data on their 1182 of their patients at baseline (intervention, n=715; control, n=467) and 945 patients at follow-up (intervention, n=479; control, n=466). For A1c control, medication intensification increased in both groups (intervention, pre 26.4% vs post 32.6%, p=0.022; control, pre 24.8% vs post 31.1%, p=0.033) (intervention, adjusted OR (AOR) 1.37; 95% CI 1.06 to 1.76; control, AOR 1.41 (95% CI 1.06 to 1.89)); however, we observed no incremental benefit solely due to the intervention (group-by-time interaction, p=0.948). Among patients with the worst glucose control (A1c >9%), intensification increased in both groups (intervention, pre 34.8% vs post 62.5%, p=0.002; control, pre 35.7% vs post 61.4%, p=0.008). Conclusions: A wide-reach, low-intensity, web-based interactive multicomponent intervention had no significant incremental effect on medication intensification for control of glucose, blood pressure or lipids for patients with diabetes of physicians practising in the rural Southeastern USA. Trial registration: NCT00403091.