BRIEF REPORT
Laura A. Young, MD, PhD; Jacqueline R. Halladay, MD, MPH; Ping Chen, PhD; Kathleen Mottus, PhD; Karen Goeke-Austin; Jennifer Rees, RN, CPF, CRN; Maihan B. Vu, DrPH, MPH; Erica L. Richman, PhD, MSW; Jordan Sharpe; Aaron Thomas, MS; Katrina E. Donahue, MD, MPH
Corresponding Author: Katrina Donahue, MD, MPH; Cecil G. Sheps Center for Health Services Research, Department of Family Medicine, University of North Carolina at Chapel Hill.
Email: katrina_donahue@med.unc.edu
DOI: 10.3122/jabfm.2025.250280R1
Keywords: Best Practices, Electronic Health Record, Family Medicine, Logistic Regression, Patient Education, Primary Health Care, Randomized Controlled Trial, Referral and Consultation, Self-Management, Type 2 Diabetes Mellitus
Dates: Submitted: 07-23-2025; Revised: 09-27-2025; Accepted: 10-06-2025
Status: Volume 39, Issue 1 (Publishes March 2026)
BACKGROUND: Diabetes self-management education and support (DSMES) services are often underutilized, partly due to low referral rates by clinicians. This examines if using a Best Practice Advisory (BPA) integrated into the electronic health record (EHR) during clinic visits increases DSMES referral rates.
METHODS: We developed a BPA within the Epic EHR for patients with type 2 diabetes (T2D) eligible for DSMES services. This BPA was implemented in four primary care practices within a university-based health system, while two additional practices served as controls. We analyzed data using multilevel logistic regression with patient data nested within clinicians. We employed binary logit functions and maximum likelihood estimation to assess the odds of DSMES referrals post-visit. Both unadjusted and adjusted models were tested, accounting for clinic and patient variables.
RESULTS: From April 1, 2023, to March 31, 2024, 2,526 BPAs were deployed in intervention clinics, resulting in a 12.9% DSMES referral rate. In contrast, control clinics had 1,444 eligible patient visits with a 1.2% referral rate (p<0.001). After adjusting for patient and clinic variables, the odds of referral in BPA-equipped clinics were higher compared to control clinics (OR 10.55, 95% CI: 4.65-23.94, p<0.001).
CONCLUSIONS: Integrating BPA prompts into the EHR significantly enhances DSMES referral rates. This approach effectively identifies eligible patients and simplifies the referral process, addressing some barriers to DSMES utilization.
TRIAL REGISTRATION: NCT05587348