A new study has found that programs aimed at helping people prevent or manage diabetes are most successful if directed at the patient or the healthcare system, while programs aimed at healthcare professionals are successful only for patients with poorer diabetes control.
The interventions also work best for diabetics in poorer health than for those who are managing their illness well, the study found.
Andrea Tricco, PhD, of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, led a comprehensive review of 142 clinical trials involving more than 123,000 patients. Tricco said that despite evidence showing improved clinical outcomes for people with diabetes who received various preventive and therapeutic interventions, many patients do not receive them.
"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," she said. "Moreover, it is a challenge to change patient behavior and encourage healthy lifestyles."
Tricco said that with the increasing prevalence of diabetes and the burgeoning cost of managing patients with the disease, improving the efficiency of diabetes care is an important goal. But "although clinicians, managers and policymakers expend significant time and resources attempting to optimize care for patients with diabetes, the optimum approach to improving diabetes care and outcomes remains uncertain."
The review of clinical trials found that for patients with high levels of HbA1c, strategies that target the healthcare system for chronic disease management are effective, especially team changes and case management. Team-change programs add another healthcare worker, such as an endocrinologist or nutritionist, to a patient’s team. Case management programs require someone other than the primary physician, such as a nurse, to coordinate care in a clinic. The review found these strategies had a positive impact on cardiovascular risk factors such as LDL cholesterol and blood pressure after 12 months.
In addition, the researchers found that strategies that target patients are effective regardless of their HbA1c levels. Strategies aimed at healthcare providers are not as effective, especially not for patients who already control their diabetes well
Tricco said the findings of the study could help physicians decide which patients would benefit from which programs. Those who do not control their diabetes well, for example, might benefit from some of the more costly programs, such as team changes and case management. Yet those programs might not be a good use of resources for patients who manage their illness well.
Overall, the researchers found, the use of quality improvement strategies — clinical reminders, clinical education, patient behavior and patient education — resulted in a 0.37% reduction of HbA1c after an average follow-up of a year. The meta-analysis did not find a statistically significant improvement in the use of statins, hypertension reduction or smoking cessation. However, the interventions did help increase the use of aspirin and antihyperintensive medication over a median follow-up of 13 months, and also were associated with an increase in retinopathy screening, screening for renal disease and foot screening over a median follow-up of 12 months.
Tricco said wide implementation of such strategies could have important benefits, with research showing that a 1% reduction in average HbA1c results in 21% fewer deaths, 14% fewer myocardial infarctions and a 37% decrease in microvascular complications.
"Further research is needed to identify which interventions and combinations of [quality improvement] strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," she said.
The study appeared in the June 16 issue of The Lancet. To read the abstract and access the study via subscription or purchase, visit http://bit.ly/KIH2t5.
The interventions also work best for diabetics in poorer health than for those who are managing their illness well, the study found.
Andrea Tricco, PhD, of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, led a comprehensive review of 142 clinical trials involving more than 123,000 patients. Tricco said that despite evidence showing improved clinical outcomes for people with diabetes who received various preventive and therapeutic interventions, many patients do not receive them.
"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," she said. "Moreover, it is a challenge to change patient behavior and encourage healthy lifestyles."
Tricco said that with the increasing prevalence of diabetes and the burgeoning cost of managing patients with the disease, improving the efficiency of diabetes care is an important goal. But "although clinicians, managers and policymakers expend significant time and resources attempting to optimize care for patients with diabetes, the optimum approach to improving diabetes care and outcomes remains uncertain."
The review of clinical trials found that for patients with high levels of HbA1c, strategies that target the healthcare system for chronic disease management are effective, especially team changes and case management. Team-change programs add another healthcare worker, such as an endocrinologist or nutritionist, to a patient’s team. Case management programs require someone other than the primary physician, such as a nurse, to coordinate care in a clinic. The review found these strategies had a positive impact on cardiovascular risk factors such as LDL cholesterol and blood pressure after 12 months.
In addition, the researchers found that strategies that target patients are effective regardless of their HbA1c levels. Strategies aimed at healthcare providers are not as effective, especially not for patients who already control their diabetes well
Tricco said the findings of the study could help physicians decide which patients would benefit from which programs. Those who do not control their diabetes well, for example, might benefit from some of the more costly programs, such as team changes and case management. Yet those programs might not be a good use of resources for patients who manage their illness well.
Overall, the researchers found, the use of quality improvement strategies — clinical reminders, clinical education, patient behavior and patient education — resulted in a 0.37% reduction of HbA1c after an average follow-up of a year. The meta-analysis did not find a statistically significant improvement in the use of statins, hypertension reduction or smoking cessation. However, the interventions did help increase the use of aspirin and antihyperintensive medication over a median follow-up of 13 months, and also were associated with an increase in retinopathy screening, screening for renal disease and foot screening over a median follow-up of 12 months.
Tricco said wide implementation of such strategies could have important benefits, with research showing that a 1% reduction in average HbA1c results in 21% fewer deaths, 14% fewer myocardial infarctions and a 37% decrease in microvascular complications.
"Further research is needed to identify which interventions and combinations of [quality improvement] strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," she said.
The study appeared in the June 16 issue of The Lancet. To read the abstract and access the study via subscription or purchase, visit http://bit.ly/KIH2t5.
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