The association between interpersonal continuity of care (CoC) and progression from the prediabetic state to Type 2 Diabetes (T2D) remains unknown. To evaluate the association between interpersonal CoC and the progression to T2D among persons with prediabetes. A retrospective cohort study using electronic health record (EHR) data from 6620 patients at Geisinger, a large rural health care system in Danville, PA. Cox regression methods were used to estimate the hazard ratio associated with progression to T2D within 3-years of being diagnosed with prediabetes. One additional visit with the primary care provider most frequently seen by the patient is associated with 14% decreased risk (HR = 0.86; 95% CI = 0.85, 0.87; P < .001) of transitioning to type 2 diabetes within 3 years of being diagnosed with prediabetes. This study demonstrates an association between increased interpersonal CoC after a person is diagnosed with prediabetes and a reduced risk of progressing to T2D within 3 years.
The transition from pre-diabetes (pre-DM) to type 2 diabetes (T2D) can be prevented or delayed through lifestyle modifications. Primary care and continuity of care may help patients maintain an HbA1c within the pre-diabetic range.
Objective.
To determine whether continuity of care impedes progression to T2D. Study Design & Analysis. Multivariate logistic regression of a retrospective cohort of primary care patients.
Setting or Dataset.
Data come from the Geisinger healthcare system's EHR between 1997 and 2017.
Population Studied.
Primary care patients with pre-DM were included in the analysis if they had an HbA1c between 5.7-6.4%, were 18-75 years, a BMI >27kg/m2, and at least one primary care visit in the 3 years prior to diagnosis (N=5889). Data were retrospectively collected for 3 years before and 3 years after diagnosis of pre-DM.
Intervention/Instrument.
We measure relational primary care continuity as a count of the number of visits with the primary care provider (PCP) most frequently seen in the 3 years prior to diagnosis.
Outcome Measures.
Our primary outcome of interest is a binary indicator for transition from pre-DM to T2D within 3 years, controlling for the total number of primary care and specialty visits over the 6-year period, sex, race, and ethnicity. We also control for baseline characteristics including age, hypertension, hyperlipidemia, HbA1c, and BMI. Finally, we control for the patient's percent of weight lost at 1-year after baseline and a binary indicator variable for whether the patient lost ≥3% of their baseline weight and then regained ≥2% by year 3 of follow-up.
Results.
The median age at baseline was 55, 56% identified as female, and the majority are non-Hispanic whites. At baseline 29% and 33% of the sample had hypertension and hyperlipidemia, respectively. The median baseline HbA1c was 5.9% and the median baseline BMI was 33.89 kg/m2. Each additional visit with the primary care provider most frequently seen in the 3 years before diagnosis of pre-DM is associated with a 6% decrease in the odds of transitioning to T2D within 3 years after their pre-DM diagnosis (OR=0.95; 95% CI=0.92; 0.97, p<0.000). Finally, the total number of PCP (OR=1.03; p<0.001) and specialty visits (OR=0.99, p<0.05) over the 6-year period were significant.
Conclusion.
Establishing continuity of primary care prior to diagnosis of pre-DM may decrease the likelihood of transitioning to T2D.
Additional file 3: Supplemental Figure 3a. The Cascade Chatbot. The Cascade Chatbot is designed to share information about the proband’s FH result with at-risk relatives, provide the relative information about FH, and connect them with resources for cascade testing. Supplemental Figure 3b. The genetic testing ordering module additionto the Cascade Chatbot. The optimized Cascade Chatbot includes a module for at-risk relatives to order family variant testing through a mail-order genetic testing kit.
Objectives There is a need in clinical genomics for systems that assist in clinical diagnosis, analysis of genomic information and periodic reanalysis of results, and can use information from the electronic health record to do so. Such systems should be built using the concepts of human-centred design, fit within clinical workflows and provide solutions to priority problems. Methods We adapted a commercially available diagnostic decision support system (DDSS) to use extracted findings from a patient record and combine them with genomic variant information in the DDSS interface. Three representative patient cases were created in a simulated clinical environment for user testing. A semistructured interview guide was created to illuminate factors relevant to human factors in CDS design and organisational implementation. Results Six individuals completed the user testing process. Tester responses were positive and noted good fit with real-world clinical genetics workflow. Technical issues related to interface, interaction and design were minor and fixable. Testers suggested solving issues related to terminology and usability through training and infobuttons. Time savings was estimated at 30%–50% and additional uses such as in-house clinical variant analysis were suggested for increase fit with workflow and to further address priority problems. Conclusion This study provides preliminary evidence for usability, workflow fit, acceptability and implementation potential of a modified DDSS that includes machine-assisted chart review. Continued development and testing using principles from human-centred design and implementation science are necessary to improve technical functionality and acceptability for multiple stakeholders and organisational implementation potential to improve the genomic diagnosis process.
Additional file 1: Supplemental Figure 1a. Original Dear Family Letter. The original Dear Family Letter template with lab report for probands to share with at-risk relatives. Supplemental Figure 1b. Optimized Family and Healthcare Professional Packet. The optimized Dear Family Letter template with a flyer on FH, FAQs for relatives, a letter for the relative’s Healthcare Professional, and FAQs for the healthcare professionals.
