Project Summary

This implementation project is complete.

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

This PCORI-funded implementation project worked to decrease the use of daily blood sugar testing for patients with type 2 diabetes who don’t need insulin, based on a study showing that daily testing doesn’t help these patients to manage their diabetes or improve their quality of life.

If you have type 2 diabetes, it’s important to keep the amount of glucose, or sugar, in your blood at a healthy level. People with type 2 diabetes should get an HbA1c test every few months. An HbA1c test measures average blood sugar levels over the last three months. Many patients also check their blood sugar at home each day. But most patients with type 2 diabetes who don’t need insulin can avoid the discomfort, time, and expense of testing blood sugar each day.

What was the goal of this implementation project?

Many people with diabetes test their blood sugar daily. Testing involves pricking the finger with a small needle, putting a drop of blood on a test strip, and putting the strip inside a hand-held meter that shows the blood’s sugar level. But a PCORI-funded research study found that people with type 2 diabetes who don’t use insulin didn’t benefit from daily self-testing. Based on this and other research, the project team created a program called Re-Think the Strip. The program aims to increase clinician knowledge about daily blood sugar testing and reduce unnecessary self-testing for patients with type 2 diabetes who don’t use insulin.

This project put Re-Think the Strip in place in North Carolina clinics.

What did this project do?

The project team worked with 20 primary care clinics in North Carolina to adopt Re-Think the Strip. First, the team gathered feedback from three clinics on ways to improve the program. Next the team revised the program and started using it in all 20 clinics.

The Re-Think the Strip program included five components:

  • Practice facilitation. Monthly meetings with a trained nurse practice facilitator took place at each clinic. Clinic staff reviewed case studies and the results of the research on daily blood sugar testing. Facilitators led role-playing activities and answered questions.
  • Audit and feedback reports. Every three months, clinics received a report on how many test strips doctors prescribed.
  • Practice champions. A primary care doctor and practice manager at each clinic led the Re-Think the Strip program.
  • Educational meetings at clinics. A kickoff educational meeting took place when each clinic started the program. Clinics also took part in lunch-and-learns and webinars throughout the program.
  • Educational materials. Clinics received two one-page handouts, one for clinicians and one for patients.

The project team looked at trends in prescriptions for daily blood sugar testing for patients with type 2 diabetes at each clinic. To do so, the team worked with information technology (IT) staff to gather data from electronic health records, or EHRs, and health insurance claims. The team used the EHR data to prepare audit and feedback reports. The team used both data sources to see if the project changed test strip prescribing.

What was the impact of this project?

Each of the 20 clinics took part in Re-Think the Strip for at least 18 months. During the project, the clinics provided care for 3,807 patients with type 2 diabetes who don’t use insulin. 

Clinician adoption and acceptance of Re-Think the Strip
Across the clinics, 132 clinicians took part in the project. Clinicians included 79 doctors, 29 nurse practitioners, 22 physician assistants, and 1 pharmacist. Among the clinicians, 41% attended the kickoff meeting. 

Clinicians found the Re-Think the Strip program to be acceptable. Of 144 surveyed clinicians, 84% agreed or strongly agreed that the program met their expectations and learning needs.

The project team assessed clinicians’ knowledge and attitudes toward reducing unneeded test strip use. For example, the team asked clinicians how much they agreed that research has shown little value in daily test strip use for patients with type 2 diabetes who don’t use insulin. On a scale of 1 (strongly disagree) to 5 (strongly agree), the average response was 4.4. 

Test strip prescribing
Using EHR data, the project team looked at clinics’ rates of test strip prescriptions for eligible patients. The team compared these rates from before the Re-Think the Strip program started to 12 and 18 months after. The team also compared these rates between two groups of clinics. The first group was the 20 clinics that took part in Re-Think the Strip. The second group was 34 primary care clinics in North Carolina that didn’t take part in Re-Think the Strip. 

After 12 months, both groups of clinics reduced test strip prescription rates for eligible patients compared with before the program. Rates changed from 27.5% to 23.3% for Re-Think the Strip clinics and 30.5% to 26.0% for comparison clinics. The two groups did not differ significantly in how much they reduced their prescribing (odds ratio [OR]=1.01; 95% confidence interval [CI]: 1.00, 1.02). After 18 months, test strip prescription rates increased in both groups to about the same level as before Re-Think the Strip. Rates increased to 28.9% for Re-Think the Strip clinics and 32.4% for comparison clinics.

The project team also looked at claims data to see if patients’ use of test strips or lancets differed between Re-Think the Strip clinics and comparison clinics. The groups didn’t differ after 18 months (OR-0.81; 95% CI: 0.61, 1.09); test strip use decreased in both groups. The comparison clinics belong to the same research network as the Re-Think the Strip clinics. As such, clinicians in the comparison clinics may have been aware of the attention to reducing unnecessary test strip prescribing. If this were the case, seeing a difference between Re-Think the Strip clinics and comparison clinics would be more difficult. 

The project team’s analysis showed that Re-Think the Strip may have helped lower test strip prescriptions in new patients. New patients included eligible patients who were newly diagnosed or new to the clinic. After 12 months, Re-Think the Strip clinics had a slightly greater decrease in test strip prescription rates for new patients compared with before the program. Rates changed from 20.9% to 16.6% for Re-Think the Strip clinics and from 19.3% to 16.7% for comparison clinics (OR=0.97; 95% CI: 0.95, 1.00; p<0.05). But this difference didn’t persist at 18 months.

Moving forward, clinicians at the project clinics will continue to discuss Re-Thinking the Strip with eligible patients using the project’s educational materials. Project clinics have no plans to continue the program’s practice facilitation, audit and feedback reports, or educational meetings.

The project team is making Re-Think the Strip resources publicly available for other health systems to use.

Cost of Implementation:

The project team examined the costs associated with providing the five components of Re-Think the Strip for 20 clinics.

The total cost to provide the Re-Think the Strip strategies during the project was approximately $97,000. The largest cost components were programming and coding the EHR data for the audit and feedback reports and conducting the educational meetings for the clinics. 

For more details, view this project’s Cost of Implementation Report and Cost of Implementation publication. This publication was part of a special article collection, “The Cost of Implementation of Evidence-Based Practices” in the October 2023 issue of Medical Care.

PCORI supplemental funding supported project activities to capture and analyze the costs of implementation during this project. PCORI’s goal is to provide decision makers at future sites with information they can use when considering adoption of the intervention that was the focus of this PCORI-funded implementation project.

More about this implementation project:

Stakeholders Involved in This Project

  • UNC Physicians Network
  • Blue Cross Blue Shield of North Carolina
  • North Carolina Division of Public Health, Community and Clinical Connections for Prevention and Health Branch
  • North Carolina Diabetes Advisory Council
  • National Diabetes Education Program
  • Association of Diabetes Care & Education Specialists (ADCES)
  • American Diabetes Association
  • Atrium Health

*Stakeholders were engaged as neutral parties; their views about Re-Think the Strip may be positive or negative.

Publicly Accessible Project Materials

Re-Think the Strip Implementation Toolkit: This toolkit includes educational materials for clinicians and patients, other tools for clinicians (e.g., pocket cards), and resources for health systems (e.g., information about the five Re-Think the Strip strategies).

For more information about these materials, please contact the project team at katrina_donahue@med.unc.edu.

The project team developed these materials, which may be available for free or require a fee to access. Please note that the materials do not necessarily represent the views of PCORI and that PCORI cannot guarantee their accuracy or reliability.

Project Achievements

  • Built audit and feedback reports using EHR and health insurance claims data.
  • Provided clinician education and practice facilitation to 20 clinics.
  • Demonstrated the feasibility of using multicomponent strategies to promote a change in providing unnecessary, low-value care.
  • Cared for 3,807 patients with type 2 diabetes who don’t use insulin. 
  • Created enduring Re-Think the Strip resources for other health systems to use.

Implementation Strategies

  • Packaged a group of evidence-based de-adoption strategies into a multicomponent program.
  • Used data warehousing techniques to generate provider- and site-specific audit and feedback reports.
  • Provided sites with tools to support implementation, including infographic fact sheets, communication scripts, and FAQs.
  • Provided educational materials to patients as handouts.
  • Provided education for clinicians, including webinars, lunch-and-learns, and physician bulletins.
  • Used a phased implementation approach, refining the program with a small number of sites and then expanding it to the remaining sites.
  • Identified and prepared practice champions at sites.
  • Provided clinicians with quarterly audit and feedback report cards.
  • Provided technical assistance to sites, including in-person and virtual practice facilitation to review evidence related to daily self-monitoring of blood glucose, discuss de-adoption strategies, conduct role-playing activities, and answer questions.
  • Offered continuing medical education credits.

Evaluation Measures

To document implementation:

  • Number of clinics that agreed to adopt the program
  • Number of providers and diabetes educators reached
  • Number of patients with non-insulin treated type 2 diabetes receiving care from a project-trained provider
  • Fidelity
  • Feasibility
  • Acceptability based on surveys and focus groups

To assess healthcare and health outcomes:

  • Clinician knowledge about daily blood sugar testing
  • Clinician attitudes about daily blood sugar testing 
  • Trends in test strip prescriptions over time (both for established and newly diagnosed patients)

COVID-19-Related Project Activities

PCORI supplemental funding supported project activities to address evolving or emerging needs in the context of the COVID-19 public health crisis.

Patients with type 2 diabetes go to the clinic regularly to check their A1C levels. They are also at high risk for serious complications from COVID-19. Patients may be unsure how to balance going to the clinic with reducing the risk of getting COVID-19.

With the enhancement, the project team explored the ways that patients and their clinicians could stay on top of their blood glucose control as well as stay healthy and safe during the pandemic. The team interviewed clinicians and then adapted Re-Think the Strip to include clinicians’ suggestions. For example, the team created educational materials for patients on how to manage diabetes at home. The adaptations helped clinicians care for 14,340 patients with type 2 diabetes, including patients who were prescribed insulin.

Project Information

Katrina Donahue, MD, MPH
The University of North Carolina at Chapel Hill
$1,926,578
Rethink the Strip: De-adoption of Glucose Monitoring for Non-Insulin Treated Type 2 Diabetes in Primary Care

Key Dates

November 2018
May 2023
2018
2024

Study Registration Information

Initial PCORI-Funded Research Study

This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Does Daily Self-Monitoring of Blood Sugar Levels Improve Blood Sugar Control and Quality of Life for Patients with Type 2 Diabetes Who Do Not Use Insulin? -- The Monitor Trial

Tags

Project Status
Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Project Details Type
Last updated: April 23, 2024