Study protocol

A cluster randomized trial to improve adherence to evidence-based guidelines on diabetes and reduce clinical inertia in primary care physicians in Belgium: study protocol [NTR 1369]

Liesbeth Borgermans¹ , Geert Goderis¹ , Carine Van Den Broeke¹ , Chantal Mathieu² , Bert Aertgeerts¹ , Geert Verbeke³ , An Carbonez³ , Anna Ivanova³ , Richard Grol⁴ and Jan Heyrman¹

¹  Catholic University Leuven, Department of General Practice, Kapucijnenvoer 33/J Box 7001, 3000 Leuven, Belgium

²  University Hospitals Leuven, Experimental Medicine, Herestraat 49, 3000 Leuven, Belgium

³  Catholic University Leuven, Leuven Statistics Research Centre (LStat), Celestijnenlaan 200 B, 3001 Heverlee, Belgium

⁴  Radboud University of Nijmegen, Faculty of Medicine, Centre for Quality of Care, PO BOX 9101, KWAZO 114, 6500 HB Nijmegen, The Netherlands

author email corresponding author email

Implementation Science 2008, 3:42doi:10.1186/1748-5908-3-42

Published:	6 October 2008

Abstract

Background

Most quality improvement programs in diabetes care incorporate aspects of clinician education, performance feedback, patient education, care management, and diabetes care teams to support primary care physicians. Few studies have applied all of these dimensions to address clinical inertia.

Aim

To evaluate interventions to improve adherence to evidence-based guidelines for diabetes and reduce clinical inertia in primary care physicians.

Design

Two-arm cluster randomized controlled trial.

Participants

Primary care physicians in Belgium.

Interventions

Primary care physicians will be randomly allocated to 'Usual' (UQIP) or 'Advanced' (AQIP) Quality Improvement Programs. Physicians in the UQIP will receive interventions addressing the main physician, patient, and office system factors that contribute to clinical inertia. Physicians in the AQIP will receive additional interventions that focus on sustainable behavior changes in patients and providers.

Outcomes

Primary endpoints are the proportions of patients within targets for three clinical outcomes: 1) glycosylated hemoglobin < 7%; 2) systolic blood pressure differences ≤130 mmHg; and 3) low density lipoprotein/cholesterol < 100 mg/dl. Secondary endpoints are individual improvements in 12 validated parameters: glycosylated hemoglobin, low and high density lipoprotein/cholesterol, total cholesterol, systolic blood pressure, diastolic blood pressure, weight, physical exercise, healthy diet, smoking status, and statin and anti-platelet therapy.

Primary and secondary analysis

Statistical analyses will be performed using an intent-to-treat approach with a multilevel model. Linear and generalized linear mixed models will be used to account for the clustered nature of the data, i.e., patients clustered withinimary care physicians, and repeated assessments clustered within patients. To compare patient characteristics at baseline and between the intervention arms, the generalized estimating equations (GEE) approach will be used, taking the clustered nature of the data within physicians into account. We will also use the GEE approach to test for differences in evolution of the primary and secondary endpoints for all patients, and for patients in the two interventions arms, accounting for within-patient clustering.

Trial Registration

number: NTR 1369.