• Andrew S Oseran, Karthik Rao, Yuchiao Chang, Wei He, Chrisanne E Sikora, Deborah J Wexler, and Daniel M Horn.
• Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
• J Gen Intern Med. 2022 Apr 1; 37 (5): 108110871081-1087.

BackgroundElectronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs).ObjectiveTo develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs.DesignCluster-randomized matched cohort study with implementation evaluation.ParticipantsPCPs affiliated with Massachusetts General Hospital (MGH).InterventionsUnsolicited endocrinology eConsultation.Main MeasuresThe primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits.Key Results161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs -3.1%, p=0.03) and sulfonylureas (1.5% vs -6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications.ConclusionsThe implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c.Trial RegistrationClinicaltrials.gov registration: NCT03542084.© 2021. Society of General Internal Medicine.

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