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Cited by 65Diabetes Treatment and ManagementDiabetes Management and EducationDiabetes Management and Research

Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control: A Meta-Regression Analysis

Shojania, Kaveh G., Ranji, Sumant R., McDonald, Kathryn M., Grimshaw, Jeremy M., Sundaram, Vandana, Rushakoff, Robert J., Owens, Douglas K.·2006·JAMA
DOI 10.1001/jama.296.4.427
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Abstract

ContextThere have been numerous reports of interventions designed to improve the care of patients with diabetes, but the effectiveness of such interventions is unclear.ObjectiveTo assess the impact on glycemic control of 11 distinct strategies for quality improvement (QI) in adults with type 2 diabetes.Data Sources and Study SelectionMEDLINE (1966-April 2006) and the Cochrane Collaboration's Effective Practice and Organisation of Care Group database, which covers multiple bibliographic databases. Eligible studies included randomized or quasi-randomized controlled trials and controlled before-after studies that evaluated a QI intervention targeting some aspect of clinician behavior or organizational change and reported changes in glycosylated hemoglobin (HbA1c) values.Data ExtractionPostintervention difference in HbA1c values were estimated using a meta-regression model that included baseline glycemic control and other key intervention and study features as predictors.Data SynthesisFifty randomized controlled trials, 3 quasi-randomized trials, and 13 controlled before-after trials met all inclusion criteria. Across these 66 trials, interventions reduced HbA1c values by a mean of 0.42% (95% confidence interval [CI], 0.29%-0.54%) over a median of 13 months of follow-up. Trials with fewer patients than the median for all included trials reported significantly greater effects than did larger trials (0.61% vs 0.27%, P = .004), strongly suggesting publication bias. Trials with mean baseline HbA1c values of 8.0% or greater also reported significantly larger effects (0.54% vs 0.20%, P = .005). Adjusting for these effects, 2 of the 11 categories of QI strategies were associated with reductions in HbA1c values of at least 0.50%: team changes (0.67%; 95% CI, 0.43%-0.91%; n = 26 trials) and case management (0.52%; 95% CI, 0.31%-0.73%; n = 26 trials); these also represented the only 2 strategies conferring significant incremental reductions in HbA1c values. Interventions involving team changes reduced values by 0.33% more (95% CI, 0.12%-0.54%; P = .004) than those without this strategy, and those involving case management reduced values by 0.22% more (95% CI, 0.00%-0.44%; P = .04) than those without case management. Interventions in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced values by 0.80% (95% CI, 0.51%-1.10%), vs only 0.32% (95% CI, 0.14%-0.49%) for all other interventions (P = .002).ConclusionsMost QI strategies produced small to modest improvements in glycemic control. Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias.

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  • A variety of interventions and changes to the organization and functioning of medical practice have proven to help patients meet their needs and improve care and outcomes across chronic diseases.

    “A variety of interventions and changes to the organization and functioning of medical practice have proven to help patients meet their needs and to improve care and outcomes across chronic diseases26-29.”

    From Self-management: Enabling and empowering patients living with cancer as a chronic illness (2011) · cites this paper as [29]

  • Availability of case or care management services, usually by a nurse, is a feature of successful programs.

    “Availability of case or (preferably) care management services, usually by a nurse (372).”

    From Standards of Medical Care in Diabetes—2009 (2009) · cites this paper as [372]

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Authors
Shojania, K. G., Ranji, S. R., McDonald, K. M., Grimshaw, J. M., Sundaram, V., Rushakoff, R. J., & Owens, D. K.
Affiliations
University of Ottawa (CA)
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2006-07-26
Volume
296
Issue
4
Pages
427
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.296.4.427
OpenAlex
W354890834
Cited by
20
References
103
Citations by year
2021: 1 · 2016: 3 · 2015: 3 · 2014: 4 · 2013: 6 · 2012: 3
FWCI
0.00
Type
journal article
Language
en
Open access
closed
Locations
JAMA (publishedVersion)
Funders
U.S. Public Health Service (290-02-0017)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
Keywords
type 2 diabetes, quality improvement intervention, glycemic control, HbA1c, team change, case management, organizational change, clinician behavior, publication bias, sample size, baseline HbA1c, diabetes care quality, meta-regression

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