Diabetes management in primary care, outpatient and community settings can be improved by interventions targeting health professionals, and organisational interventions that increase continuity of care

Renders CM, Valk GD, Griffin SJ, Wagner E, van Eijk JThM, Assendelft WJJ

Published Online:

January 21, 2009

Diabetes is a major and growing health problem. This review examined the effects of interventions targeting health professionals or the way care is organised, with the aim of improving the management of people with diabetes in primary care, outpatient and community settings. The review found that multifaceted professional interventions (for example combinations of postgraduate education, reminders, audit and feedback, local consensus processes, and peer review) could enhance the performance of care providers. Organisational interventions that increased structured recall, such as central computerised tracking systems or nurses who regularly contacted patients, could also lead to improved care for patients with diabetes. The effectiveness of these interventions on patient outcomes (glycaemic control, cardiovascular risk factors, wellbeing) is less clear.

Abstract (click to read)

Background:

Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care.

Objectives:

To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings.

Search strategy:

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles.

Selection criteria:

Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability.

Data collection and analysis:

Two reviewers independently extracted data and assessed study quality.

Main results:

Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes.

Authors' conclusions:

Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.

This record should be cited as:

Renders CM, Valk GD, Griffin SJ, Wagner E, van Eijk JThM, Assendelft WJJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD001481. DOI: 10.1002/14651858.CD001481

Assessed as up to date:

June 29, 2000

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Primary Review Group:

Effective Practice and Organisation of Care Group

Health topics:

Effective practice/health systems > Reviews of interventions to improve specific types of practice > General management of a problem

Endocrine & metabolic > Diabetes > Effective practice/health systems

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Diabetes management in primary care, outpatient and community settings can be improved by interventions targeting health professionals, and organisational interventions that increase continuity of care

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