Supplemental Table S1.

Outcome measures

Domain	Outcome measure	Process measure	Population prevalence	Intervention cohort incidence
Microvascular complications	Kidney disease – classification •Microalbuminuria •Macroalbuminuria •CKD 3, 4, and 5	Kidney disease – process/quality care •Monitoring •Guideline medication use	X	X
	Dialysis		X	X
	Peripheral neuropathy	Process/quality care •Foot exam	X	X
	Retinopathy – classification •NPDR vs. PDR	Retinopathy – process/quality care •Yearly eye exam	X	X
	Wound/skin ulcer treatment – classification •Location •Type	Wound/skin ulcer treatment – process •Foot exam •Ankle brachial indices	X	X
Macrovascular complications	Amputation procedures – classification •Location (i.e., R BKA)	Amputation procedures – process/quality care •Foot exam •Ankle – brachial indices	X	X
	Acute MI events	Guideline medication use	X	X
	Stroke events	Guideline medication use	X	X
	Coronary revascularization procedures	Guideline medication use	X	X
	Heart failure	Guideline medication use	X	X
Diabetes control	Hemoglobin A1c: •Degree of control	Hemoglobin A1c – process/quality care •A1c monitoring •Guideline medications	X	X
	Glucose	•Blood glucose monitoring	X	X
	Hypoglycemia events		X	X
	Hyperglycemia events		X	X
	Hyperosmolar		X	X
	Ketoacidosis		X	X
Risk factors	Obesity	Weight, diet, activity monitoring	X	X
	Hypertension •Degree in control •Guideline medications	Hypertension •Process of BP monitoring	X	X
	Hyperlipidemia •Degree in control •Guideline medication use	Hyperlipidemia •Process of monitoring	X	X
	Smoking status (Fagerstrom test for Nicotine Dependence)	Smoking cessation program attendance		X
	Exercise status (Stanford scale)	Activity monitoring		X
Patient-reported outcomes	Global health scale score (PROMIS-9)	Survey completion rate		X
	Patient depression score (PHQ-2)	Survey completion rate		X
	mDiabetes care profile score (patient perception of self-management skills)	Survey completion rate		X
	Medication adherence score (Morisky)	Survey completion rate		X
Health services utilization	Emergency department encounters (DM-related and non-DM related		X	X
	Inpatient encounters (DM-related, cardiovascular-related, and other)		X	X
	Outpatient encounters •Primary care •Endocrinology •CDE •RD		X	X
	Length of stay for inpatient admissions		X	X
	Billing charges for health services		X
Prediction of adverse outcomes	SEDI risk algorithm scoring		X	X
Death	Mortality status		X	X

BP, blood pressure; CDE, Certified Diabetes Educator; CKD, chronic kidney disease; DM, diabetes mellitus; MI, myocardial infarction; NPDR, nonproliferative diabetic retinopathy; PDR, proliferative diabetic retinopathy; RD, Registered Dietitian; SEDI, Southeast Diabetes Initiative.