ArticlesEffectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis
Introduction
Despite high-quality evidence showing improved clinical outcomes for patients with diabetes who receive various preventive and therapeutic interventions,1 many patients with diabetes do not receive them.2, 3, 4, 5 The gap between ideal and actual care is not surprising in view of the complex nature of diabetes management, often needing coordinated services of primary-care physicians, allied health practitioners, and subspecialists. Moreover, it is a challenge to change patient behaviour and encourage healthy lifestyles.6
In view of the increasing prevalence of diabetes and the burgeoning cost of managing patients with this disease,7 improving the efficiency of diabetes care is an important goal. Although clinicians, managers, and policy makers expend significant time and resources attempting to optimise care for patients with diabetes, the optimum approach to improving diabetes care (and outcomes) remains uncertain.
A previous systematic review8 assessed the effect of quality improvement (QI) interventions to improve glycaemic control for patients with type 2 diabetes in 66 controlled studies published by April, 2006. Over a median follow-up of 13 months, the QI interventions significantly lowered glycated haemoglobin (HbA1c) by a mean 0·42% (95% CI 0·29–0·54). After adjustment for study size and baseline HbA1c, two of the 11 categories of QI strategies were associated with reductions in HbA1c of at least 0·50%: team changes (26 trials; 0·67%, 95% CI 0·43–0·91) and case management (26 trials; 0·52%, 0·31–0·73). Only these two strategies led to significant incremental reductions in HbA1c (ie, interventions that included either of these two strategies achieved significantly greater improvements than strategies without them).
Since the previous review8 noted a rapid growth of published work on this subject and did not assess the effect of QI strategies on outcomes other than HbA1c, we sought to update and expand the review by considering the effect of QI interventions on glycaemic control, vascular risk-factor management, monitoring of microvascular complications, and smoking cessation in patients with diabetes.
Section snippets
Study selection and search strategy
Our systematic review was based on a protocol with input from experts in diabetes care, methods, and statistics.9 We selected randomised clinical trials that assessed 11 predefined QI strategies or financial incentives targeting health-care professionals8 for the management of adult outpatients with diabetes (panel). The QI strategies targeted health systems (eg, team changes), professionals (eg, professional reminders), or patients (eg, promotion of self management). By use of a framework of
Results
Figure 1 shows the study profile. 48 cluster-randomised trials, including 2538 clusters and 84 865 patients, and 94 patient-randomised trials, including 38 664 patients, fulfilled our inclusion criteria. 20 companion reports provided supplementary information (appendix).
Many characteristics of studies and patients were similar for patient and cluster trials (table 1, appendix). However, the two types differed with respect to sample size, masking, and who gave the intervention. For
Discussion
Our systematic review is an update of a previous review that assessed the effects of QI strategies on glycaemic control,8 includes more than twice as many trials, and reports the effects of QI strategies on other important aspects of diabetes management. By including outcomes that are deemed quality indicators in the management of diabetes, such as diastolic and systolic blood pressure, LDL cholesterol, medication use, and monitoring for diabetes complications, we were able to assess the effect
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