The goal of this research was to determine if providing specialist input to primary care providers (PCPs) by means of informal consultation could improve the process and outcomes of care for diabetes. Several studies support the role for specialists and their specific knowledge and expertise in a variety of disorders including diabetes. A variety of methods have been designed to optimize the use of specialty expertise including practice guidelines and disease management approaches as well as the consultation/referral process. The referral-consultation process is an important mechanism for obtaining clinically useful information. At one end of the spectrum of this process, informal consultation involves discussion about a patient with a colleague without the consultant seeing the patient; at the other end of the spectrum, care of the patient is transferred to another physician and the process is formalized. Because much specialist expertise resides in the specialists themselves, the expansion of primary care sites to include community-based outpatient clinics has implications for access to the specialists located elsewhere. This study was designed to evaluate a computer-assisted voice mail system which is relatively inexpensive and more convenient than video-telemedicine systems, making it more practical and more easily exportable. Diabetes care delivery was chosen as the model in which to assess informal consultation based on its frequency among veterans, management challenges, and the emphasis on improvement in diabetes care in VA. A secondary goal of the project was to better characterize the consultation process.
Patients with diabetes mellitus are complex and may benefit from the input of multiple specialists and PCPs must determine the need for and coordinate the input from those multiple specialists. With that in mind, the three objectives of the study are: 1) To assess the impact of computer-assisted access to specialist expertise (CASE) on process of care for patients with diabetes mellitus; 2) To assess the impact of CASE on outcomes of care at the patient level (clinical outcomes and satisfaction), provider level (satisfaction) and the system level (health services utilization and costs); and 3) To characterize the consultation-referral process in community-based outpatient clinics (CBOCs).
Randomized controlled trial with access to the CASE system constituting the intervention and a descriptive study of the consultation process. The major outcome variables will be the consultation type, adherence to diabetes practice guidelines, clinical outcome of diabetes care (glycemic control), patient and provider satisfaction.
Acceptance and operation of the CASE system indicated high initial enthusiasm. All PCPs registered, but use of the system was limited to 35% of the PCPs, all of whom were in CBOCs linked to the Cleveland VAMC. The number of calls range from 0 to 5 per week and totaled 71. Endocrinology has received the most number of questions. At the end of the intervention, diabetes in CBOCs with access to CASE had similar HbA1c levels (mean 7.34+/-1.4 vs 7.37 +/-1.4, p=0.29). All CBOCs grew during the period of study and consult referral rates rose from 1% to 1.7% (p=0.004). There were no differences between control and intervention groups. Transcripts of calls made into the CASE system showed that most of the questions for the endocrinologist related to advice about treatment (56%), followed by assistance in interpretation of data already gathered (33%), and advice on diagnosis (11%). Analysis of the transcripts revealed that the questions were extremely patient-specific and patient-identifying data was often given. Most of these questions could not be readily addressed by reference to standard medical textbooks, and most of the questions could be readily addressed without the consultant actually seeing the patient, although many involved very complex patients. Only a single question was related to diabetes management and it did not involve issues of optimization of glycemic control, but rather an issue of an adverse drug event.
Our study has provided important insights. For example, the presence of a specialist at a facility where a patient-specific question was asked allows discussion of referrals and further communication. Factors like this provide insight into the process of informal consultation and consultation-referral as well as intervention implementation.
None at this time.
Epidemiology, Prevention, Technology Development and Assessment
Access, Decision support, Diabetes