Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis

doi:10.1016/S0140-6736(12)60480-2

The Lancet

Volume 379, Issue 9833, 16–22 June 2012, Pages 2252-2261

https://doi.org/10.1016/S0140-6736(12)60480-2 Get rights and content

Summary

Background

The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA_1c), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes.

Methods

We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias.

Findings

We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84 865 patients, and 94 patient randomised controlled trials, including 38 664 patients. In random effects meta-analysis, the QI strategies reduced HbA_1c by a mean difference of 0·37% (95% CI 0·28–0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05–0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19–4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95–2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA_1c, 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA_1c control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21–1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01–1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13–1·32), renal function (14 trials; RR 128, 1·13–1·44), and foot abnormalities (22 trials; RR 1·27, 1·16–1·39). However, statin use (ten trials; RR 1·12, 0·99–1·28), hypertension control (18 trials; RR 1·01, 0·96–1·07), and smoking cessation (13 trials; RR 1·13, 0·99–1·29) were not significantly increased.

Interpretation

Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA_1c control is poor.

Funding

Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates—Health Solutions).

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 (HbA_1c) by a mean 0·42% (95% CI 0·29–0·54). After adjustment for study size and baseline HbA_1c, two of the 11 categories of QI strategies were associated with reductions in HbA_1c 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 HbA_1c (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 HbA_1c, 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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L’étude ACCESS (pour Assessing Outcomes of Enhanced Chronic Disease Care Through Patient Education and a Value-based Formulary Study) était un essai à répartition aléatoire avec un plan factoriel 2 x 2 qui a mesuré l’effet d’un programme personnalisé de soutien à la formation sur l’autogestion dans laquelle une réduction de 22 % des événements cliniques défavorables a été observée. Notre objectif était de réaliser une exploration qualitative du point de vue des patients au sujet de l’intervention et des façons dont elle a permis d’améliorer leurs habiletés d’autogestion.
Nous avons utilisé une approche descriptive et qualitative et nous avons mené des entretiens individuels semi-structurés auprès des participants. Des analyses thématiques inductive et déductive ont été réalisées avec NVivo 12 (QSR International, Burlington MA).
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ArticlesEffectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Study selection and search strategy

Results

Discussion

Can J Cardiol

J Clin Epidemiol

Child Youth Serv Rev

J Clin Epidemiol

Control Clin Trials

Standards of medical care in diabetes—2010

Diabetes Care

A diabetes report card for the United States: quality of care in the 1990s

Ann Intern Med

Control of cardiovascular risk factors in patients with diabetes and hypertension at urban academic medical centers

Diabetes Care

Diabetes translation research: where are we and where do we want to be?

Ann Intern Med

Overcoming obstacles to effective care of type 2 diabetes

Am J Manag Care

The cost of major comorbidity in people with diabetes mellitus

CMAJ

Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis

JAMA

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

BMJ

Articles
Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis