OBJECTIVE—Population-level strategies to organize and deliver care may improve diabetes management. We conducted a multiclinic controlled trial of population management in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS—We created diabetic patient registries (n = 3,079) for four primary care clinics within a single academic health center. In the intervention clinic (n = 898), a nurse practitioner used novel clinical software (PopMan) to identify patients on a weekly basis with outlying values for visit and testing intervals and last measured levels of HbA1c, LDL cholesterol, and blood pressure. For these patients, the nurse practitioner e-mailed a concise patient-specific summary of evidence-based management suggestions directly to primary care providers (PCPs). Population changes in risk factor testing, medication prescription, and risk factor levels from baseline (1 January 2000 to 31 August 2001) to follow-up (1 December 2001 to 31 July 2003) were compared with the three usual-care control clinics (n = 2,181). RESULTS—Patients had a mean age of 65 years, were mostly white (81%), and the majority were insured by Medicare/Medicaid (62%). From baseline to follow-up, the increase in proportion of patients tested for HbA1c (P = 0.004) and LDL cholesterol (P < 0.001) was greater in the intervention than control sites. Improvements in diabetes-related medication prescription and levels of HbA1c, LDL cholesterol, and blood pressure in the intervention clinic were balanced by similar improvements in the control sites. CONCLUSIONS—Population-level clinical registries combined with summarized recommendations to PCPs had a modest effect on management. The intervention was limited by good overall quality of care at baseline and temporal improvements in all control clinics. It is unknown whether this intervention would have had greater impact in clinical settings with lower overall quality. Further research into more effective methods of translating population registry information into action is required.

Two-dimensional (2-D) polyacrylamide gel electrophoresis combined with mass spectrometry is a powerful combination of technologies that allows high resolution separation of proteins and their rapid identification. Immobilized pH gradient (IPG) first-dimensional gels have several advantages over carrier ampholyte isoelectric focusing, including a high degree of reproducibility, good protein spot resolution, and a selection of pH range. Here we demonstrate the utility and efficacy of combining IPG 2-D gel electrophoresis with mass spectrometry to identify interferon-gamma- (IFN) and tumor necrosis factor (TNF)-regulated proteins in ME-180 cervical carcinoma cells. Three cytokine-regulated proteins have been identified, using imidazole-zinc-stained preparative IPG 2-D gels and in-gel tryptic digestion followed by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry for determination of peptide masses and sequences: 1) triosephosphate isomerase, a glycolytic pathway enzyme, 2) proteasome subunit C3, which is important in protein degradation, and 3) Ran, a GTP-binding protein important in cell cycle regulation, protein import into the nucleus, and RNA export from the nucleus.

OBJECTIVE -Population-level strategies may improve primary care for diabetes. We designed a controlled study to assess the impact of population management versus usual care on metabolic risk factor testing and management in patients with type 2 diabetes. We also identified potential patient-related barriers to effective diabetes management.RESEARCH DESIGN AND METHODS -We used novel clinical software to rank 910 patients in a diabetes registry at a single primary care clinic and thereby identify the 149 patients with the highest HbA 1c and cholesterol levels. After review of the medical records of these 149 patients, evidence-based guideline recommendations regarding metabolic testing and management were sent via e-mail to each intervention patient's primary care provider (PCP). Over a 3-month follow-up period, we assessed changes in the evidence-based management of intervention patients compared with a matched cohort of control patients receiving usual care at a second primary care clinic affiliated with the same academic medical center.RESULTS -In the intervention cohort, PCPs followed testing recommendations more often (78%) than therapeutic change recommendations (36%, P ϭ 0.001). Compared with the usual care control cohort, population management resulted in a greater overall proportion of evidencebased guideline practices being followed (59 vs. 45%, P ϭ 0.02). Most intervention patients (62%) had potential barriers to effective care, including depression (35%), substance abuse (26%), and prior nonadherence to care plans (18%).CONCLUSIONS -Population management with clinical recommendations sent to PCPs had a modest but statistically significant impact on the evidence-based management of diabetes compared with usual care. Depression and substance abuse are prevalent patient-level adherence barriers in patients with poor metabolic control. Diabetes Care 26:2275-2280, 2003M anagement of type 2 diabetes in the U.S. is expensive (representing 25% of the Medicare budget) (1), complex (patients often have hypertension, hyperlipidemia, and other comorbidities) (2-4), and generally falls short of evidence-based goals (most diabetic patients do not reach recommended levels of glycemic, blood pressure, or cholesterol control) (5,6). Patient-related factors such as adherence to medications and healthy lifestyle changes and societal factors such as costs and access to care are important but difficult-to-modify elements of diabetes management (7-10). In contrast, interventions directed toward primary care providers (PCPs) may be more likely to improve quality of diabetes care (11,12).Prior interventions to improve quality of care by changing physician practice patterns have mostly been either physician-centered (e.g., intensive academic detailing, physician report cards) (13-15) or patient-specific and centered on clinic visits (e.g., computerized reminder systems) (12,16 -20). In contrast, population-based diabetes management takes an overview perspective to monitor and deliver patient care (21,22). Population management...

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