START Diabetes Prevention: A Multilevel Strategy for Primary Care Clinics

OBJECTIVE Prediabetes affects more than one in three adults in the U.S.; however, fewer than 5% receive treatment. Most prior interventions focused on individual-level barriers, neglecting the clinician- and system-level barriers. This study aimed to evaluate the effectiveness of a multilevel intervention in increasing prediabetes treatment uptake in primary care. RESEARCH DESIGN AND METHODS We conducted a pragmatic study of the Screen, Test, Act, Refer, and Treat (START) Diabetes Prevention intervention, which included a structured workflow, shared decision-making resources, and clinical decision support tools within electronic health records. The intervention was implemented over 12 months in a suburban primary care clinic near Baltimore, MD, and compared with a control clinic in the same area. The primary outcome measured was the uptake of prediabetes treatment, defined as referral to the Diabetes Prevention Program and/or metformin prescription within 30 days of a primary care visit. RESULTS Both clinics saw increased use of preventive treatment among patients with prediabetes, with no significant differences between the two. However, the intervention clinic had a higher percentage of patients reporting they had discussions about prediabetes with their primary care clinician (PCP; 60% vs. 48%; P = 0.002), felt informed, and believed that their opinion was valued. PCPs reported increased acceptability and perceived usefulness of the START Diabetes Prevention strategy for engaging patients with prediabetes about treatment by study end. CONCLUSIONS The low-touch multilevel intervention resulted in a modest increase in preventive treatment and improved patient-centered care by increasing the number of discussions and enhancing patients’ understanding of prediabetes.