Strategies to improve the quality of diabetes care work better when aimed at patients and the healthcare system rather than at individual doctors, results of a large meta-analysis suggested.
Overall, the use of quality improvement (QI) strategies resulted in a 0.37% mean reduction of hemoglobin A1c (HbA1c) after an average follow-up of 1 year, which is consistent with a previous smaller meta-analysis, according to Andrea C. Tricco, PhD, from St Michael’s Hospital in Toronto, and colleagues.
However, this larger review also found that team-based QI strategies had a positive impact on cardiovascular risk factors such as LDL cholesterol and blood pressure after a median follow-up of 1 year, they reported here at the annual meeting of the American Diabetes Association.
”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,” the researchers wrote in the study, which was simultaneously published online in The Lancet. ”Interventions solely targeting healthcare professionals seem to be beneficial only if baseline HbA1c control is poor.”
”The inclusion of cardiovascular outcomes and smoking cessation is important because of the growing recognition that blood glucose control alone is not adequate to prevent both the microvascular and macrovascular complications of diabetes,” Martha M. Funnell, MS, RN, and Gretchen A. Piatt, MPH, PhD, of the University of Michigan in Ann Arbor, wrote in an accompanying editorial.
The editorialists echoed the sentiments of Tricco and colleagues that too few studies in this analysis included QI strategies to boost statin use, lower hypertension, or increase smoking cessation, which is possibly why there was no statistical improvement in those markers.
The analysis included 48 cluster-randomized controlled trials, which randomize groups of people such as from various primary care practices, and 94 patient-randomized controlled trials, which randomize individual patients.
The cluster trials included 84,865 patients (mean age 62), while the patient trials included 38,664 patients (mean age 56). Men and women were equally represented.
Both types of trials utilized most QI strategies, but to varying degrees. For example, a higher percentage of patient-randomized studies looked at QI strategies targeting healthcare systems, such as case management and team changes. The cluster trials, on the other hand, more often examined strategies targeting individual providers, such as audit and feedback systems, clinician reminders, and clinician education.
Both types of trials looked equally at strategies targeting patient behavior, such as patient education and reminder systems.
Baseline glycemic control appeared to have an effect on the success of QI strategies, Tricco and colleagues reported. When HbA1c levels were greater than 8%, the most effective strategies were team changes, case management, patient education, and promotion of self-management. These approaches led to decreases in HbA1c by a mean of 0.5% or more.
When researchers analyzed the data by sequentially omitting each QI strategy, the most effective strategies were team changes (further lowering HbA1c by a mean of 0.33%), case management (0.21% reduction), and promotion of self-management (0.21% reduction).
When HbA1c levels at enrollment were 8% or less, the best strategies were facilitated relay of information, team changes, patient reminders, and electronic register of patients.
Overall, QI strategies played an important role in increasing the use of aspirin and antihypertensive medication over a median follow-up of 13 months. They also were associated with an increase in retinopathy screening, screening for renal disease, and foot screening over a median follow-up of 12 months.
”Our findings suggest that QI strategies that intervened upon the entire system of chronic disease management were associated with the largest effects irrespective of baseline HbA1c,” they concluded.
The study was limited by the complexity of the QI strategies, which did not allow the researchers to control for all potential confounding factors, they said.
Also, there was substantial heterogeneity among the studies, as well as inconsistent definitions of usual care. The strategies aimed at patient behavior ”should be interpreted as implemented in combination with QI strategies targeting healthcare professionals,” they said.
Funding for this study came from the Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates — Health Solutions).
The authors reported they had no conflicts of interest.
The editorialists reported they had no conflicts of interest.
Tricco AR, et al ”Effectiveness of quality improvement strategies on the management of diabetes: A systematic review and meta-analysis” Lancet 2012;
Funnell MM, et al ”Diabetes quality improvement: Beyond glucose control” Lancet 2012; DOI: 10.1016/S0140-6736(12)60637-0.
From ADA
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