Sean F. Dinneen, MD; Máire O’Donnell, PhD
Do quality improvement (QI) strategies improve glycated hemoglobin (HbA1c) levels, low-density lipoprotein (LDL) cholesterol levels, and blood pressure in adults with diabetes?
Included studies assessed ≥ 1 of 12 predefined QI strategies for management of adult outpatients with type 1 or type 2 diabetes. QI strategies could target health systems (e.g., case management, team changes, electronic patient registry, facilitated relay of information to clinicians, and continuous QI), health care providers (e.g., audit and feedback, clinician education, clinician reminders, and financial incentives), or patients (e.g., patient education, promotion of self-management, and reminder systems). Studies that assessed QI strategies directed only at the patient were excluded. Outcomes included change in HbA1c and LDL cholesterol levels and in blood pressure.
MEDLINE and Cochrane Effective Practice and Organisation of Care (EPOC) database (both Jul 2003 to Jul 2010), and reference lists of included trials were searched for randomized controlled trials (RCTs) that were published in English and reported ≥ 1 process of care or intermediate outcome. 142 RCTs, including 48 cluster-randomized trials (n = 84 865, mean age 62 y, 51% women) and 94 patient-randomized trials (n = 38 664, mean age 56 y, 51% men) met the selection criteria and assessed a median of 3 QI strategies. Among cluster-randomized trials, the 3 most common QI strategies were clinician education (42%), patient education (40%), and promotion of self-management (29%); among patient-randomized trials, the 3 most common QI strategies focused on case management (52%), promotion of self-management (52%), and team changes (49%). The median intervention and follow-up durations were both 12 months. 42% of RCTS adequately reported allocation concealment, and 39% adequately reported random sequence generation.
Meta-analysis using a random-effects model showed that QI strategies reduced HbA1c and LDL cholesterol levels and systolic and diastolic blood pressure more than control (Table).
Quality improvement strategies reduce glycated hemoglobin levels, low-density lipoprotein cholesterol levels, and blood pressure in adults with diabetes.
Quality improvement strategies vs control at a median 12 months in adults with diabetes*
*CI defined in Glossary.
†A positive mean difference favors the intervention.
Dinneen SF, O’Donnell M. Review: Quality improvement strategies reduce HbA1c, LDL cholesterol, and BP in diabetes. Ann Intern Med. 2012;157:JC4–11. doi: 10.7326/0003-4819-157-8-201210160-02011
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Published: Ann Intern Med. 2012;157(8):JC4-11.
Cardiology, Coronary Risk Factors, Diabetes, Dyslipidemia, Endocrine and Metabolism.
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