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Surawit A, Pongkunakorn T, Manosan T, Mongkolsucharitkul P, Chamnan P, Suvarnabhumi K, Puangpet T, Suta S, Pumeiam S, Pinsawas B, Ophakas S, Pisitpornsuk S, Utchin C, Mayurasakorn K. Factors influencing optimal diabetes care and clinical outcomes in Thai patients with type 2 diabetes mellitus: a multilevel modelling analysis. BMJ Open 2024; 14:e079415. [PMID: 38702083 PMCID: PMC11086275 DOI: 10.1136/bmjopen-2023-079415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Increasing levels of poor glycaemic control among Thai patients with type 2 diabetes mellitus (T2DM) motivated us to compare T2DM care between urban and suburban primary care units (PCUs), to identify gaps in care, and to identify significant factors that may influence strategies to enhance the quality of care and clinical outcomes in this population. METHODS We conducted a cross-sectional study involving 2160 patients with T2DM treated at four Thai PCUs from 2019 to 2021, comprising one urban and three suburban facilities. Using mixed effects logistic regression, we compared care factors between urban and suburban PCUs. RESULTS Patients attending suburban PCUs were significantly more likely to undergo eye (adjusted OR (AOR): 1.83, 95% CI 1.35 to 1.72), foot (AOR: 1.61, 95% CI 0.65 to 4.59) and HbA1c (AOR: 1.66, 95% CI 1.09 to 2.30) exams and achieved all ABC (HbA1c, blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C)) goals (AOR: 2.23, 95% CI 1.30 to 3.83). Conversely, those at an urban PCU were more likely to undergo albuminuria exams. Variables significantly associated with good glycaemic control included age (AOR: 1.51, 95% CI 1.31 to 1.79), T2DM duration (AOR: 0.59, 95% CI 0.41 to 0.88), FAACE (foot, HbA1c, albuminuria, LDL-C and eye) goals (AOR: 1.23, 95% CI 1.12 to 1.36) and All8Q (AOR: 1.20, 95% CI 1.05 to 1.41). Chronic kidney disease (CKD) was significantly linked with high triglyceride and HbA1c levels (AOR: 5.23, 95% CI 1.21 to 7.61). Elevated HbA1c levels, longer T2DM duration, insulin use, high systolic BP and high lipid profile levels correlated strongly with diabetic retinopathy (DR) and CKD progression. CONCLUSION This highlights the necessity for targeted interventions to bridge urban-suburban care gaps, optimise drug prescriptions and implement comprehensive care strategies for improved glycaemic control, DR prevention and CKD progression mitigation among in Thai patients with T2DM. The value of the clinical target aggregate (ABC) and the process of care aggregate (FAACE) was also conclusively demonstrated.
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Affiliation(s)
- Apinya Surawit
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tanyaporn Pongkunakorn
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thamonwan Manosan
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pichanun Mongkolsucharitkul
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Parinya Chamnan
- Department of Social Medicine, Sunpasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Krishna Suvarnabhumi
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thanapat Puangpet
- Department of Social Medicine, Samutsakhon Hospital, Samut Sakhon, Thailand
| | - Sophida Suta
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sureeporn Pumeiam
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bonggochpass Pinsawas
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suphawan Ophakas
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sananon Pisitpornsuk
- Division of Nursing, Siriraj Primary Care Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chalita Utchin
- Division of Nursing, Siriraj Primary Care Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Korapat Mayurasakorn
- Population Health and Nutrition Research Group, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Kunstler BE, Furler J, Holmes-Truscott E, McLachlan H, Boyle D, Lo S, Speight J, O'Neal D, Audehm R, Kilov G, Manski-Nankervis JA. Guiding Glucose Management Discussions Among Adults With Type 2 Diabetes in General Practice: Development and Pretesting of a Clinical Decision Support Tool Prototype Embedded in an Electronic Medical Record. JMIR Form Res 2020; 4:e17785. [PMID: 32876576 PMCID: PMC7495264 DOI: 10.2196/17785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/20/2020] [Accepted: 07/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Managing type 2 diabetes (T2D) requires progressive lifestyle changes and, sometimes, pharmacological treatment intensification. General practitioners (GPs) are integral to this process but can find pharmacological treatment intensification challenging because of the complexity of continually emerging treatment options. OBJECTIVE This study aimed to use a co-design method to develop and pretest a clinical decision support (CDS) tool prototype (GlycASSIST) embedded within an electronic medical record, which uses evidence-based guidelines to provide GPs and people with T2D with recommendations for setting glycated hemoglobin (HbA1c) targets and intensifying treatment together in real time in consultations. METHODS The literature on T2D-related CDS tools informed the initial GlycASSIST design. A two-part co-design method was then used. Initial feedback was sought via interviews and focus groups with clinicians (4 GPs, 5 endocrinologists, and 3 diabetes educators) and 6 people with T2D. Following refinements, 8 GPs participated in mock consultations in which they had access to GlycASSIST. Six people with T2D viewed a similar mock consultation. Participants provided feedback on the functionality of GlycASSIST and its role in supporting shared decision making (SDM) and treatment intensification. RESULTS Clinicians and people with T2D believed that GlycASSIST could support SDM (although this was not always observed in the mock consultations) and individualized treatment intensification. They recommended that GlycASSIST includes less information while maintaining relevance and credibility and using graphs and colors to enhance visual appeal. Maintaining clinical autonomy was important to GPs, as they wanted the capacity to override GlycASSIST's recommendations when appropriate. Clinicians requested easier screen navigation and greater prescribing guidance and capabilities. CONCLUSIONS GlycASSIST was perceived to achieve its purpose of facilitating treatment intensification and was acceptable to people with T2D and GPs. The GlycASSIST prototype is being refined based on these findings to prepare for quantitative evaluation.
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Affiliation(s)
- Breanne E Kunstler
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - John Furler
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - Hamish McLachlan
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Douglas Boyle
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Sean Lo
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - David O'Neal
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Ralph Audehm
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Kilov
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
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Giguère A, Zomahoun HTV, Carmichael PH, Uwizeye CB, Légaré F, Grimshaw JM, Gagnon MP, Auguste DU, Massougbodji J. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2020; 8:CD004398. [PMID: 32748975 PMCID: PMC8475791 DOI: 10.1002/14651858.cd004398.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review. OBJECTIVES To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes. SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews. SELECTION CRITERIA We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. DATA COLLECTION AND ANALYSIS Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies. MAIN RESULTS We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend. AUTHORS' CONCLUSIONS The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.
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Affiliation(s)
- Anik Giguère
- Department of Family Medicine and Emergency Medicine, Laval University, Québec, Canada
- VITAM Research center on Sustainable Health, Quebec, Canada
| | - Hervé Tchala Vignon Zomahoun
- Health and Social Services Systems, Knowledge Translation and Implementation Component of the SPOR-SUPPORT Unit of Québec, Centre de recherche sur les soins et les services de première ligne - Université Laval, Quebec, Canada
| | | | - Claude Bernard Uwizeye
- Laval University Research Center on Primary Health Care and Services (CERSSPL-UL), Québec, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marie-Pierre Gagnon
- Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Québec City, Canada
| | - David U Auguste
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - José Massougbodji
- Health and Social Services Systems, Knowledge Translation and Implementation Component of the SPOR-SUPPORT Unit of Québec, Quebec SPOR-SUPPORT Unit, Québec, Canada
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Steyl T. Satisfaction with quality of healthcare at primary healthcare settings: Perspectives of patients with type 2 diabetes mellitus. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2020; 76:1321. [PMID: 32285017 PMCID: PMC7136797 DOI: 10.4102/sajp.v76i1.1321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 10/02/2019] [Indexed: 11/01/2022] Open
Abstract
Background Measuring client satisfaction is part of the quality assurance process and has become an integral part of healthcare management strategies globally. It is essential for improvement of amenities in healthcare facilities. Objectives The aim of this study was to assess patients with type 2 diabetes' satisfaction with healthcare services at primary healthcare settings in the Cape Metropolitan district, Western Cape, South Africa. Methods This cross-sectional study used proportionate stratified random sampling. The Patient Survey for Quality of Care scale was used to assess patients with type 2 diabetes' satisfaction with quality of care received. Descriptive and inferential statistics were employed in the analysis of the quantitative data. The open-ended question was analysed qualitatively. Results The majority of patients were satisfied with the overall quality of care. Dissatisfaction was reported for waiting time to get appointments at the clinic, to see a healthcare professional on the same day and clarity of instructions for managing their diabetes. Conclusion Employing more staff in the multidisciplinary team and improving health information by developing staff through continuous education could foster more positive experiences and provide care that contributes to the well-being of patients. Clinical implications Addressing patients' views regarding quality of healthcare services could assist in overall improvement of healthcare provision through the rectification of the system weaknesses. Satisfaction with quality of care could positively affect adherence to treatment protocols that could lead to better quality of life of patients with type 2 diabetes.
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Affiliation(s)
- Tania Steyl
- Department of Physiotherapy, University of the Western Cape, Cape Town, South Africa
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Perceptions, behaviours, barriers and needs of evidence-based medicine in primary care in Beijing: a qualitative study. BMC FAMILY PRACTICE 2019; 20:171. [PMID: 31810450 PMCID: PMC6896763 DOI: 10.1186/s12875-019-1062-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022]
Abstract
Background Evidence-based medicine (EBM) is gradually being recognized worldwide as an important clinical skill and plays an important role in health care. Although the concept has successfully spread in the health care field, EBM still has not been widely incorporated into clinical decisions in primary care due to potential barriers. This study aimed to explore the views, experiences and obstacles of general practitioners (GPs) regarding the use EBM in their daily clinical practices in Beijing. Methods We performed a qualitative study with GP focus groups. Thirty-two GPs working in 26 community health service centres in 7 districts in Beijing were recruited. Four focus group sessions with 32 GPs were conducted in a meeting room at the Capital Medical University from January to February in 2018 in Beijing. All sessions were audio-recorded, transcribed and analysed for themes using an inductive content analysis approach. Results GPs believed that EBM could help them enhance the quality of their clinical practice. The most common EBM behaviour of GPs was making clinical decisions according to guidelines. The barriers that limited the implementation of EBM were patients’ poor compliance, lack of time, lack of resources, inadequate skills or knowledge, and guideline production problems. The first need for GPs was to participate in training to enhance their skills in practising EBM. Conclusions To practise EBM in general practice, integrated interventions of different levels need to be developed, including enhancing GPs’ communication skill and professional competency, training GPs on the implementation of EBM, employing more staff to reduce GPs’ workloads, providing adequate resource support, and developing evidence-based clinical guidelines for GPs.
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Hashmi NR, Khan SA. Interventional study to improve diabetic guidelines adherence using mobile health (m-Health) technology in Lahore, Pakistan. BMJ Open 2018; 8:e020094. [PMID: 29858411 PMCID: PMC5988082 DOI: 10.1136/bmjopen-2017-020094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To check if mobile health (m-Health) short message service (SMS) can improve the knowledge and practice of the American Diabetic Association preventive care guidelines (ADA guidelines) recommendations among physicians. METHODOLOGY Quasi-experimental pre-post study design with a control group. PARTICIPANTS The participants of the study were 62 medical officers/medical postgraduate trainees from two hospitals in Lahore, Pakistan. Pretested questionnaire was used to collect baseline information about physicians' knowledge and adherence according to the ADA guidelines. All the respondents attended 1-day workshop about the guidelines. The intervention group received regular reminders by SMS about the ADA guidelines for the next 5 months. Postintervention knowledge and practice scores of 13 variables were checked again using the same questionnaire. Statistical analysis included χ2 and McNemar's tests for categorical variables and t-test for continuous variables. Pearson's correlation analysis was done to check correlation between knowledge and practice scores in the intervention group. P values of <0.05 were considered statistically significant. RESULTS The total number of participating physicians was 62. Fifty-three (85.5%) respondents completed the study. Composite scores within the intervention group showed statistically significant improvement in knowledge (p<0.001) and practice (p<0.001) postintervention. The overall composite scores preintervention and postintervention also showed statistically significant difference of improvement in knowledge (p=0.002) and practice (p=0.001) between non-intervention and intervention groups. Adherence to individual 13 ADA preventive care guidelines level was noted to be suboptimal at baseline. Statistically significant improvement in the intervention group was seen in the following individual variables: review of symptoms of hypoglycaemia and hyperglycaemia, eye examination, neurological examination, lipid examination, referral to ophthalmologist, and counselling about non-smoking. CONCLUSION m-Health technology can be a useful educational tool to help with improving knowledge and practice of diabetic guidelines. Future multicentre trials will help to scale this intervention for wider use in resource-limited countries.
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Affiliation(s)
- Noreen Rahat Hashmi
- Health Services Academy, Islamabad, Pakistan
- Department of Community Medicine, Rahbar Medical and Dental College, Lahore, Pakistan
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Clement M, Filteau P, Harvey B, Jin S, Laubscher T, Mukerji G, Sherifali D. Organization of Diabetes Care. Can J Diabetes 2018; 42 Suppl 1:S27-S35. [DOI: 10.1016/j.jcjd.2017.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 02/06/2023]
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Coombs LJ, Burston B, Liu D. Importance of an alternative approach to measuring quality in a volume-to-value world: a case study of diabetes care. BMJ Open Qual 2018; 6:e000216. [PMID: 29435512 PMCID: PMC5736086 DOI: 10.1136/bmjoq-2017-000216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 11/04/2022] Open
Abstract
Background To develop a statistical tool that allows practitioners and/or their practice managers to easily select the relevant range in which volume and value are maximised. Methods Data for the study were based on 55 primary care practices that participated in the Colorado Improving Performance in Practice programme in 2014. We used two composite variables including the volume of processes of care variables listed in Diabetes Practice Guidelines and value (quality) as measured by changes in the intermediate outcomes. We assessed volume/value trade-offs using a multilevel model with a time-varying covariate partitioned into a between-practice and within-practice effect. Results The study revealed a strong linear relationship between volume and value (P<0.0001). Specifically, practices with an above-average volume of care as measured by their process of care scores also had above-average quality outcomes (expected value 57; average volume 49.48) as quantified by their intermediate outcome scores. Additionally, in those months when practices provided a volume of care that exceeded their average process of care score, further improvements occurred in quality as measured by intermediate outcome scores (P<0.0001). Conclusion Such findings suggest an inherent linkage between volume of care and quality. This statistical approach, if provided as an app containing an easy-to-use statistical calculator, will allow practice managers and clinicians to systematically identify volume/quality trade-offs, thereby reducing undertreatment and/or overtreatment among patients with chronicities.
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Affiliation(s)
- Letoynia Jenee Coombs
- Department of Family Medicine, The University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Betty Burston
- Department of Health Care Administration and Policy, School of Community Health Sciences, University of Nevada, Las Vegas, Nevada, USA
| | - Darren Liu
- Department of Public Health, Des Moines University, Des Moines, Iowa, USA
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Etxeberria A, Alcorta I, Pérez I, Emparanza JI, Ruiz de Velasco E, Iglesias MT, Rotaeche R. Results from the CLUES study: a cluster randomized trial for the evaluation of cardiovascular guideline implementation in primary care in Spain. BMC Health Serv Res 2018; 18:93. [PMID: 29422049 PMCID: PMC5806349 DOI: 10.1186/s12913-018-2863-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background The implementation of evidence-based clinical practice guidelines (CPG) can improve patients care. To date, the impact of implementation strategies has not been evaluated in our context. This study is aimed to evaluate the effectiveness of a multifaceted tailored intervention targeting clinician education for the implementation of three cardiovascular risk-related CPGs (type 2 diabetes, hypertension and dyslipidemia) in primary care at the Basque Health Service compared with usual implementation. Methods We conducted a cluster randomized controlled trial in two urban districts with 43 primary care units (PCU). Data from all patients diagnosed with diabetes, hypertension and all those eligible for coronary risk (CR) assessment were included. In the control group, guidelines were introduced in the usual way (by email, intranet and clinical meetings). In the intervention group, the implementation also included a specific website and workshops. Primary endpoints were annual HbA1c testing (diabetes), annual general laboratory testing (hypertension) and annual CR assessment (dyslipidemia). Secondary endpoints were process, prescription and clinical endpoints related with guideline recommendations. Analysis was performed at a PCU level weighted by cluster size. Results Significant differences between groups were observed in primary outcomes in the dyslipidemia CPG: increased CR assessment for both women and men (weighted mean difference, WMD, 13.58 and 12.91%). No significant differences were observed in diabetes and hypertension CPGs primary outcomes. Regarding secondary endpoints, annual CR assessment was significantly higher in both diabetic and hypertensive patients in the intervention group (WMD 28.16 and 27.55%). Rates of CR assessment before starting new statin treatments also increased (WMD 23.09%), resulting in a lower rate of statin prescribing in low risk women. Diuretic prescribing was higher in the intervention group (WMD 20.59%). Clinical outcomes (HbA1c and blood pressure control) did not differ between groups. Conclusions The multifaceted implementation proved to be effective to increase the CR assessment and to improve prescription, but ineffective to improve diabetes and hypertension related outcomes. In order to obtain real improvements when cardiovascular issues are tackled, perhaps other or additional interventions need to be implemented besides education of professionals. Trial registration Current Controlled Trials, ISRCTN 88876909 (retrospectively registered on January 13, 2009) Electronic supplementary material The online version of this article (10.1186/s12913-018-2863-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arritxu Etxeberria
- Donostialdea Integrated Healthcare Organization, Osakidetza-Basque Health Service, Biodonostia Health Research Institute, Hernani, Spain. .,Hernani Health Centre, Aristizabal 1, 20120, Hernani, Spain.
| | - Idoia Alcorta
- Bidasoa Integrated Healthcare Organization, Osakidetza-Basque Health Service, Irún, Spain
| | - Itziar Pérez
- Bidasoa Integrated Healthcare Organization, Osakidetza-Basque Health Service, Irún, Spain
| | - Jose Ignacio Emparanza
- Clinical Epidemiology Unit, Donostia University Hospital, Osakidetza-Basque Health Service, Biodonostia Health Research Institute, CIBERESP, Critical Appraisal Skills Programme, San Sebastian, Spain
| | - Elena Ruiz de Velasco
- Bilbao-Basurto Integrated Healthcare Organization, Osakidetza-Basque Health Service, Bilbao, Spain
| | - Maria Teresa Iglesias
- Clinical Epidemiology Unit, CIBERESP, Donostia University Hospital, Osakidetza-Basque Health Service, San Sebastian, Spain
| | - Rafael Rotaeche
- Alza Health Centre, Osakidetza-Basque Health Service, Biodonostia Health Research Institute, San Sebastian, Spain
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Panisch S, Johansson T, Flamm M, Winkler H, Weitgasser R, Sönnichsen AC. The impact of a disease management programme for type 2 diabetes on health-related quality of life: multilevel analysis of a cluster-randomised controlled trial. Diabetol Metab Syndr 2018; 10:28. [PMID: 29643940 PMCID: PMC5892002 DOI: 10.1186/s13098-018-0330-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/28/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Type 2 diabetes is a chronic disease associated with poorer health outcomes and decreased health related quality of life (HRQoL). The aim of this analysis was to explore the impact of a disease management programme (DMP) in type 2 diabetes on HRQoL. A multilevel model was used to explain the variation in EQ-VAS. METHODS A cluster-randomized controlled trial-analysis of the secondary endpoint HRQoL. Our study population were general practitioners and patients in the province of Salzburg. The DMP "Therapie-Aktiv" was implemented in the intervention group, and controls received usual care. Outcome measure was a change in EQ-VAS after 12 months. For comparison of rates, we used Fisher's Exact test; for continuous variables the independent T test or Welch test were used. In the multilevel modeling, we examined various models, continuously adding variables to explain the variation in the dependent variable, starting with an empty model, including only the random intercept. We analysed random effects parameters in order to disentangle variation of the final EQ-VAS. RESULTS The EQ-VAS significantly increased within the intervention group (mean difference 2.19, p = 0.005). There was no significant difference in EQ-VAS between groups (mean difference 1.00, p = 0.339). In the intervention group the improvement was more distinct in women (2.46, p = 0.036) compared to men (1.92, p = 0.063). In multilevel modeling, sex, age, family and work circumstances, any macrovascular diabetic complication, duration of diabetes, baseline body mass index and baseline EQ-VAS significantly influence final EQ-VAS, while DMP does not. The final model explains 28.9% (EQ-VAS) of the total variance. Most of the unexplained variance was found on patient-level (95%) and less on GP-level (5%). CONCLUSION DMP "Therapie-Aktiv" has no significant impact on final EQ-VAS. The impact of DMPs in type 2 diabetes on HRQoL is still unclear and future programmes should focus on patient specific needs and predictors in order to improve HRQoL.Trial registration Current Controlled trials Ltd., ISRCTN27414162.
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Affiliation(s)
- Sigrid Panisch
- Department of Mathematics, University of Salzburg, Hellbrunner Str. 34, 5020 Salzburg, Austria
| | - Tim Johansson
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Strubergasse 21, 5020 Salzburg, Austria
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Strubergasse 21, 5020 Salzburg, Austria
| | - Henrike Winkler
- Paris Lodron University, Kapitelgasse 4-6, 5020 Salzburg, Austria
| | - Raimund Weitgasser
- Department of Internal Medicine, Wehrle-Diakonissen Hospital, Haydnstrasse 18, 5020 Salzburg, Austria
- Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Andreas C. Sönnichsen
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL UK
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Sieng S, Hurst C. A combination of process of care and clinical target among type 2 diabetes mellitus patients in general medical clinics and specialist diabetes clinics at hospital levels. BMC Health Serv Res 2017; 17:533. [PMID: 28784176 PMCID: PMC5545871 DOI: 10.1186/s12913-017-2486-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study compares a combination of processes of care and clinical targets among patients with type 2 diabetes mellitus (T2DM) between specialist diabetes clinics (SDCs) and general medical clinics (GMCs), and how differences between these two types of clinics differ with hospital type (community, provincial and regional). METHODS Type 2 diabetes mellitus patient medical records were collected from 595 hospitals (499 community, 70 provincial, 26 regional) in Thailand between April 1 to June 30, 2012 resulting in a cross-sectional sample of 26,860 patients. Generalized linear mixed modeling was conducted to examine associations between clinic type and quality of care. The outcome variables of interest were split into clinical targets and process of care. A subsequent subgroup analysis was conducted to examine if the nature of clinical target and process of care differences between GMCs and SDCs varied with hospital type (regional, provincial, community). RESULTS Regardless of the types of hospitals (regional, provincial, or community) patients attending SDCs were considerably more likely to have eye and foot exam. In terms of larger hospitals (regional and provincial) patients attending SDCs were more likely to achieve HbA1c exam, All FACE exam, BP target, and the Num7Q. Interestingly, SDCs performed better than GMCs at only provincial hospitals for LDL-C target and the All7Q. Finally, patients with T2DM who attended community hospital-GMCs had a better chance of achieving the blood pressure target than patients who attended community hospital-SDCs. CONCLUSIONS Specialized diabetes clinics outperform general medical clinics for both regional and provincial hospitals for all quality of care indicators and the number of quality of care indicators achieved was never lower. However, this better performance of SDC was not observed in community hospital. Indeed, GMCs outperformed SDCs for some quality of care indicators in the community level setting.
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Affiliation(s)
- Sokha Sieng
- Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand. .,School Health Department, Ministry of Education, Youth and Sport, Phnom Penh, Cambodia. .,Office of Dean for Undergraduate Studies Division, University of Cambodia, Phnom Penh, Cambodia.
| | - Cameron Hurst
- Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand. .,Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
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12
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Chauhan BF, Jeyaraman MM, Mann AS, Lys J, Skidmore B, Sibley KM, Abou-Setta AM, Zarychanski R. Behavior change interventions and policies influencing primary healthcare professionals' practice-an overview of reviews. Implement Sci 2017; 12:3. [PMID: 28057024 PMCID: PMC5216570 DOI: 10.1186/s13012-016-0538-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/13/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers. METHODS Study design: overview of reviews. DATA SOURCE MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015). STUDY SELECTION two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language. DATA EXTRACTION AND SYNTHESIS two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.). RESULTS Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change. CONCLUSIONS Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.
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Affiliation(s)
- Bhupendrasinh F Chauhan
- College of Pharmacy, University of Manitoba, Winnipeg, Canada.
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada.
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada.
| | - Maya M Jeyaraman
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | | | - Justin Lys
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | | | - Kathryn M Sibley
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ahmed M Abou-Setta
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ryan Zarychanski
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Haematology and Medical Oncology, CancerCare Manitoba, Winnipeg, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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13
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Kortekaas MF, Bartelink MLEL, van der Heijden GJMG, Hoes AW, de Wit NJ. Development and validation of a new instrument measuring guideline adherence in clinical practice. Fam Pract 2016; 33:562-8. [PMID: 27461491 DOI: 10.1093/fampra/cmw063] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Education in evidence-based medicine (EBM) is an important part of the postgraduate training of GPs. Evaluation of its effect on EBM behaviour in daily clinical practice is difficult and instruments are scarce. Working in accordance with guidelines is considered as one of the key indicators of EBM behaviour. OBJECTIVE To develop and validate an instrument assessing guideline adherence of GP trainees in clinical practice. METHODS We developed an instrument that assesses guideline adherence, taking conscious deviation into account. The instrument assesses guideline adherence on 59 different management decisions (diagnosis N = 17, therapy N = 20, referral N = 22) for 23 conditions as described in 27 different clinical practice guidelines. We validated this instrument using performance data as collected by third-year GP trainees on three important properties: validity, reliability and feasibility. RESULTS Performance data were collected by 76 GP trainees on 12106 patient consultations with 12587 different reasons for encounter. Overall, guideline adherence was 82% (95% confidence interval 77-88%). The significant correlation with the national GP knowledge test (r 0.33, P 0.004) showed the instrument to be a valid instrument. Interrater reliabilities (intraclass correlation coefficient) varied between moderate and excellent (0.64-1.00, P < 0.001). The instrument proved feasible with coverage of 24% (N = 3082) of reasons for encounter presented to GP trainees and a mean and median time of 1 minute to score a patient consultation. CONCLUSION This instrument proved valid, reliable and feasible to assess guideline adherence among trainees in the clinical primary care setting.
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Affiliation(s)
- Marlous F Kortekaas
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
| | - Marie-Louise E L Bartelink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
| | - Geert J M G van der Heijden
- Department Social Dentistry, Academic Center for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
| | - Niek J de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
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Valinejadi A, Sadoughi F, Salehi M. Diabetes Knowledge Translation Status in Developing Countries: A Mixed Method Study Among Diabetes Researchers in Case of Iran. Int J Prev Med 2016; 7:33. [PMID: 26955462 PMCID: PMC4763462 DOI: 10.4103/2008-7802.175992] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/07/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Despite considerable investment in research, the existing research evidence is frequently not implemented and/or leads to useless or detrimental care in healthcare. The knowledge-practice gap proposed as one of the main causes of not achieving the treatment goals in diabetes. Iran also is facing a difference between the production and utilization of the knowledge of diabetes. The aim of this study was to assess the status of diabetes knowledge translation (KT) in Iran. METHODS This was a survey that executed in 2015 by concurrent mixed methods approach in a descriptive, cross-sectional method. The research population was 65 diabetes researchers from 14 diabetes research centers throughout Iran. The research was carried out via the self-assessment tool for research institutes (SATORI), a valid and reliable tool. Focus group discussions were used to complete this tool. The data were analyzed using quantitative (descriptive method by Excel software) and qualitative approaches (thematic analysis) based on SATORI-extracted seven themes. RESULTS The mean of scores "the question of research," "knowledge production," "knowledge transfer," "promoting the use of evidence," and all aspects altogether were 2.48, 2.80, 2.18, 2.06, and 2.39, respectively. The themes "research quality and timeliness" and "promoting and evaluating the use of evidence" received the lowest (1.91) and highest mean scores (2.94), respectively. Except for the theme "interaction with research users" with a relatively mediocre scores (2.63), the other areas had scores below the mean. CONCLUSIONS The overall status of diabetes KT in Iran was lower than the ideal situation. There are many challenges that require great interventions at the organizational or macro level. To reinforce diabetes KT in Iran, it should hold a more leading and centralized function in the strategies of the country's diabetes research system.
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Affiliation(s)
- Ali Valinejadi
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farahnaz Sadoughi
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Salehi
- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
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15
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Young CE, Boyle FM, Brooker KS, Mutch AJ. Incorporating patient preferences in the management of multiple long-term conditions: is this a role for clinical practice guidelines? JOURNAL OF COMORBIDITY 2015; 5:122-131. [PMID: 29090160 PMCID: PMC5636037 DOI: 10.15256/joc.2015.5.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/15/2015] [Indexed: 12/05/2022]
Abstract
BACKGROUND Clinical practice guidelines provide an evidence-based approach to managing single chronic conditions, but their applicability to multiple conditions has been actively debated. Incorporating patient-preference recommendations and involving consumers in guideline development may enhance their applicability, but further understanding is needed. OBJECTIVES To assess guidelines that include recommendations for comorbid conditions to determine the extent to which they incorporate patient-preference recommendations; use consumer-engagement processes during development, and, if so, whether these processes produce more patient-preference recommendations; and meet standard quality criteria, particularly in relation to stakeholder involvement. DESIGN A review of Australian guidelines published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Document analysis of guidelines examined the presence of patient-preference recommendations and the consumer-engagement processes used. The Appraisal of Guidelines for Research and Evaluation instrument was used to assess guideline quality. RESULTS Thirteen guidelines were reviewed. Twelve included at least one core patient-preference recommendation. Ten used consumer-engagement processes, including participation in development groups (seven guidelines) and reviewing drafts (ten guidelines). More extensive consumer engagement was generally linked to greater incorporation of patient-preference recommendations. Overall quality of guidelines was mixed, particularly in relation to stakeholder involvement. CONCLUSIONS Guidelines do incorporate some patient-preference recommendations, but more explicit acknowledgement is required. Consumer-engagement processes used during guideline development have the potential to assist in identifying patient preferences, but further research is needed. Clarification of the consumer role and investment in consumer training may strengthen these processes.
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Affiliation(s)
- Charlotte E Young
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Frances M Boyle
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Katie S Brooker
- Queensland Centre for Intellectual and Developmental Disability (QCIDD), School of Medicine, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Allyson J Mutch
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
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16
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Practice-level quality improvement interventions in primary care: a review of systematic reviews. Prim Health Care Res Dev 2015; 16:556-77. [PMID: 26004929 DOI: 10.1017/s1463423615000274] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AIM To present an overview of effective interventions for quality improvement in primary care at the practice level utilising existing systematic reviews. BACKGROUND Quality improvement in primary care involves a range of approaches from the system-level to patient-level improvement. One key setting in which quality improvement needs to occur is at the level of the basic unit of primary care--the individual general practice. Therefore, there is a need for practitioners to have access to an overview of the effectiveness of quality improvement interventions available in this setting. METHODS DESIGN A tertiary evidence synthesis was conducted (a review of systematic reviews). A systematic approach was used to identify and summarise published literature relevant to understanding primary-care quality improvement at the practice level. Quality assessment was via the Critical Appraisal Skills Programme tool for systematic reviews, with data extraction identifying evidence of effect for the examined interventions. SCOPE Included reviews had to be relevant to quality improvement at the practice level and relevant to the UK primary-care context. Reviews were excluded if describing system-level interventions. OUTCOME MEASURES A range of measures across care structure, process and outcomes were defined and interpreted across the quality improvement interventions. FINDINGS Audit and feedback, computerised advice, point-of-care reminders, practice facilitation, educational outreach and processes for patient review and follow-up all demonstrated evidence of a quality improvement effect. Evidence of an improvement effect was higher where baseline performance was low and was particularly demonstrated across process measures and measures related to prescribing. Evidence was not sufficient to suggest that multifaceted approaches were more effective than single interventions. CONCLUSION Evidence exists for a range of quality improvement interventions at the primary-care practice level. More research is required to determine the use and impact of quality improvement interventions using theoretical frameworks and cost-effectiveness analysis.
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Trans-anethole, a terpenoid ameliorates hyperglycemia by regulating key enzymes of carbohydrate metabolism in streptozotocin induced diabetic rats. Biochimie 2015; 112:57-65. [DOI: 10.1016/j.biochi.2015.02.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/12/2015] [Indexed: 11/21/2022]
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Anderson JE, Rhinehart AS, Reid TS, Cuddihy RM, Vlajnic A, Dalal MR, Gemmen E, Johnstone B, Abbaszadeh B, Reed J, Sheller J, Stewart J, Mozaffari E. A Practice-Based Research Network Focused on Comparative Effectiveness Research in Type 2 Diabetes Management. Postgrad Med 2015; 125:172-80. [DOI: 10.3810/pgm.2013.05.2658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Steyl T, Phillips J. Management of type 2 diabetes mellitus: adherence challenges in environments of low socio-economic status. Afr J Prim Health Care Fam Med 2014; 6:E1-7. [PMID: 26245413 PMCID: PMC4502898 DOI: 10.4102/phcfm.v6i1.713] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 09/17/2014] [Accepted: 08/07/2014] [Indexed: 02/01/2023] Open
Abstract
Background The efficacy of treatment for clients with diabetes is highly dependent on the individual's ability to manage the disease. Several constraints, such as poverty, illiteracy and insufficient resources (finances and specialised healthcare professionals), especially communities of low socio-economic status, could influence clients’ ability to manage their disease. Aim The main aim of this study was to outline the obstacles encountered by individuals with type 2 diabetes mellitus from an urban community with regard to management of their disease. Setting The study was conducted at a primary health care facility in the Western Cape, South Africa. Methods Ethical clearance was obtained from all relevant authorities. Eight (8) conveniently selected clients with type 2 diabetes mellitus per participating community healthcare centre (six approved centres in total) were invited to take part in focus group discussions. Twenty six clients, 15 females and 11 males, with a mean age of 58.92 years (SD = 7.33), agreed to participate. Audiotaped data were transcribed verbatim followed by content analysis and identification of themes. Results Themes that emerged were challenges with: a healthy eating plan, physical activity, financial constraints, other people's understanding of the disease, and service received at the community healthcare centre. Verbatim quotes were used to exemplify the themes. Conclusion Clients with type 2 diabetes mellitus experienced several challenges in the management of their disease. These challenges should be addressed to assist with better glycaemic control and to curb the emergence of diabetic complications and their attendant cost implications.
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Affiliation(s)
- Tania Steyl
- Department of Physiotherapy, University of the Western Cape.
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van der Heijden AAWA, de Bruijne MC, Feenstra TL, Dekker JM, Baan CA, Bosmans JE, Bot SDM, Donker GA, Nijpels G. Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial. BMC Health Serv Res 2014; 14:280. [PMID: 24966055 PMCID: PMC4099139 DOI: 10.1186/1472-6963-14-280] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 06/09/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. METHODS In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. RESULTS Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). CONCLUSIONS Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant. TRIAL REGISTRATION Current Controlled trials: ISRCTN66124817.
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Affiliation(s)
- Amber AWA van der Heijden
- Department of General Practice, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Martine C de Bruijne
- Department of General Practice, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands
- Department of Public and Occupational Health, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands
| | - Talitha L Feenstra
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacqueline M Dekker
- Department of General Practice, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands
| | - Caroline A Baan
- Department of General Practice, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Judith E Bosmans
- Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Sandra DM Bot
- Department of General Practice, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands
| | - Gé A Donker
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Giel Nijpels
- Department of General Practice, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2014:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Clement M, Harvey B, Rabi DM, Roscoe RS, Sherifali D. Organisation des soins du diabète. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Beaulieu MD, Haggerty J, Tousignant P, Barnsley J, Hogg W, Geneau R, Hudon É, Duplain R, Denis JL, Bonin L, Del Grande C, Dragieva N. Characteristics of primary care practices associated with high quality of care. CMAJ 2013; 185:E590-6. [PMID: 23877669 DOI: 10.1503/cmaj.121802] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. METHODS We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. RESULTS The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care. INTERPRETATION We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.
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Kamble HV, Bodhankar SL. Antihyperglycemic activity of trigonelline and sitagliptin in nicotinamide-streptozotocin induced diabetes in Wistar rats. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.biomag.2013.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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[Relationship between process indicators measured using electronic records and intermediate health outcomes in patients with diabetes]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2013; 28:207-16. [PMID: 23684049 DOI: 10.1016/j.cali.2013.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 03/19/2013] [Accepted: 03/21/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To study relationship between institutional process indicators (measured using electronic records) and intermediate outcomes of patients with diabetes. METHOD Cross-sectional epidemiological study. Setting Primary care health district 1. Madrid. 2010. PATIENTS all patients with diabetes; n = 16.652. Main measures variables. Independent. Institutional process indicators. Dependent. Intermediate outcomes: GHb, BP, LDL, tobacco and weight within target limits and detected complications. Confounding. Age, gender, type and years for DM, co-morbidity, drugs and professional variables. RESULTS GHb of 55.9% (SE 0,4) of patients was within target limits. Bivariate analysis and multivariate logistic regression showed that the recording of some process indicators was associated with an increase in the probability to achieve targets in intermediate outcomes: reviewing personal and family history, lifestyle and drug therapy, creatinine, GHb, BP and weight measurement, smoking advice, EKG, ankle-arm index, and eye examination. OR were from 1,15 (CI 95%: 1.01-1.32) to 2.05 (CI 95%: 1.76-2.39). Relationship among other indicators and higher probability to achieve targets was not found: classification, reviewing care plan, glucose, BMI, LDL and microalbuminury measurement. CONCLUSIONS In diabetes, a lot of institutional process indicators measured on electronic records was associated with increase of probability to achieve targets in intermediate outcomes. It suggests to maintain process and outcome measurement, to include other outcomes, to include other interventions, to prioritize improvements in process indicators that show low performance and high impact and to keep out or to change process indicators that relationship was not found.
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Umar-Kamara M, Tufts KA. Impact of a quality improvement intervention on provider adherence to recommended standards of care for adults with type 2 diabetes mellitus. J Am Assoc Nurse Pract 2013; 25:527-534. [PMID: 24170484 DOI: 10.1111/1745-7599.12018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To report provider adherence to standards of care for adults with type 2 diabetes before and after a quality improvement (QI) intervention. DATA SOURCES Pre- and post intervention data were abstracted from 50 medical records of patients with type 2 diabetes in a small primary care practice. CONCLUSION There was a significant increase in the rates of foot and urine microalbumin screenings, documentation for dilated eye exams were not statistically significant. These findings demonstrated the effectiveness of using simple practice aids to reinforce adherence to the standards of care in diabetes. The failure to see a corresponding improvement in glycemic and blood pressure control is consistent with prior research and the need for more research in this area remain critical. IMPLICATIONS FOR PRACTICE Ethnic minorities are more likely to have worse control of their diabetes and more likely to receive all their care in the primary care setting, QI interventions targeting primary care providers have the potential to reduce disparities in diabetes care. Future research to determine whether cultural tailoring of diabetes QI interventions will produce additional benefits above those of generic diabetes QI interventions are needed.
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Affiliation(s)
- Marie Umar-Kamara
- (Assistant Professor), South University, Richmond, Virginia, (Assistant Professor), Minuteclinic, Richmond, Virginia, (Associate Professor), School of Nursing College of Health Sciences, Old Dominion University, Norfolk, Virginia
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Giorda CB. The role of the care model in modifying prognosis in diabetes. Nutr Metab Cardiovasc Dis 2013; 23:11-16. [PMID: 22906566 DOI: 10.1016/j.numecd.2012.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 06/05/2012] [Accepted: 07/04/2012] [Indexed: 11/22/2022]
Abstract
Organizational factors in diabetes care can influence long- and medium-term outcomes, affecting the prognosis to the same extent as new therapies. A growing body of evidence supports the hypothesis that diabetes team consultation can favorably impact on hospital utilization, the costliest item in diabetes management, as well as on hospitalization rates, inpatient hospital length of stay, and re-admission rates. Moreover, the model of diabetes care has been reported to influence guidelines adherence, an additional factor linked to the variability in the quality of diabetes care. The strongest predictor and effect modifier of the quality of diabetes care is specialist referral. Compared to patients seen in primary care or other settings, those visiting a diabetes center are more likely to be monitored according to guidelines, regardless of the severity-of-disease effect, and to receive structured education, as well as more aggressive treatment when needed. Finally, at least eight published studies suggest that when continuity of care is shared with diabetes clinics, all-cause mortality and major cardiovascular events are both reduced. The sharing of care pathways between primary care providers and diabetes teams is likely to be the best and most affordable solution in the complex management of this chronic condition.
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Affiliation(s)
- C B Giorda
- Metabolism and Diabetes Unit, ASL TORINO 5, Chieri (TO), Italy.
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Giguère A, Légaré F, Grimshaw J, Turcotte S, Fiander M, Grudniewicz A, Makosso-Kallyth S, Wolf FM, Farmer AP, Gagnon MP. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; 10:CD004398. [PMID: 23076904 PMCID: PMC7197046 DOI: 10.1002/14651858.cd004398.pub3] [Citation(s) in RCA: 209] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. OBJECTIVES To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes. SEARCH METHODS For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. DATA COLLECTION AND ANALYSIS Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. MAIN RESULTS The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness. AUTHORS' CONCLUSIONS The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.
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Affiliation(s)
- Anik Giguère
- Health Information Research Unit (HIRU), Department of Clinical Epidemiology, McMaster University, Hamilton, Canada.
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Zipkin DA, Greenblatt L, Kushinka JT. Evidence-Based Medicine and Primary Care: Keeping Up Is Hard to Do. ACTA ACUST UNITED AC 2012; 79:545-54. [DOI: 10.1002/msj.21337] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Giorda C, Picariello R, Nada E, Tartaglino B, Marafetti L, Costa G, Gnavi R. The impact of adherence to screening guidelines and of diabetes clinics referral on morbidity and mortality in diabetes. PLoS One 2012; 7:e33839. [PMID: 22509263 PMCID: PMC3317933 DOI: 10.1371/journal.pone.0033839] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 02/17/2012] [Indexed: 11/19/2022] Open
Abstract
Despite the heightened awareness of diabetes as a major health problem, evidence on the impact of assistance and organizational factors, as well as of adherence to recommended care guidelines, on morbidity and mortality in diabetes is scanty. We identified diabetic residents in Torino, Italy, as of 1st January 2002, using multiple independent data sources. We collected data on several laboratory tests and specialist medical examinations to compare primary versus specialty care management of diabetes and the fulfillment of a quality-of-care indicator based on existing screening guidelines (GCI). Then, we performed regression analyses to identify associations of these factors with mortality and cardiovascular morbidity over a 4 year-follow-up. Patients with the lowest degree of quality of care (i.e. only cared for by primary care and with no fulfillment of GCI) had worse RRs for all-cause (1.72 [95% CI 1.57-1.89]), cardiovascular (1.74 [95% CI 1.50-2.01]) and cancer (1.35 [95% CI 1.14-1.61]) mortality, compared with those with the highest quality of care. They also showed increased RRs for incidence of major cardiovascular events up to 2.03 (95% CI 1.26-3.28) for lower extremity amputations. Receiving specialist care itself increased survival, but was far more effective when combined with the fulfillment of GCI. Throughout the whole set of analysis, implementation of guidelines emerged as a strong modifier of prognosis. We conclude that management of diabetic patients with a pathway based on both primary and specialist care is associated with a favorable impact on all-cause mortality and CV incidence, provided that guidelines are implemented.
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Affiliation(s)
- Carlo Giorda
- Metabolism and Diabetes Unit, ASL TO5, Regione Piemonte, Chieri, Italy.
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Alencar AMPG, Zanetti ML, Araújo MFMD, Freitas RWJFD, Marinho NBP, Damasceno MMC. Avaliação de resultados em um serviço de atenção secundária para pacientes com Diabetes mellitus. ACTA PAUL ENFERM 2012. [DOI: 10.1590/s0103-21002012000400021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar o componente resultado em um serviço de atenção secundária a usuários com Diabetes mellitus tipo 2, tomando como indicadores os controles de pressão arterial, hemoglobina glicada e lipoproteína de baixa densidade. MÉTODOS: Estudo do tipo documental e retrospectivo envolvendo a análise desses indicadores, obtidos nos anos entre 2007 e 2009, com base na consulta de 108 prontuários de usuários de um serviço de atenção secundária, realizada na avaliação de cuidados em saúde. RESULTADOS: Os resultados evidenciaram que 30,3% dos usuários alcançaram a meta para a hemoglobina glicada, 48,1%, para a pressão arterial e 42,3%, para a lipoproteína de baixa densidade. CONCLUSÃO: Os dados avaliados foram semelhantes aos encontrados em outras investigações internacionais e nacionais, com grande proporção de usuários com DM2 estudados, apresentando controle dos níveis hemoglobina A1c, PA e LDL-C, aquém do preconizado nos consensos.
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Pilon R, Bailey PH, Montgomery P, Bakker D. The future is the present: diabetes complication stories. ACTA ACUST UNITED AC 2011. [DOI: 10.1111/j.1752-9824.2011.01095.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Boaz A, Baeza J, Fraser A. Effective implementation of research into practice: an overview of systematic reviews of the health literature. BMC Res Notes 2011; 4:212. [PMID: 21696585 PMCID: PMC3148986 DOI: 10.1186/1756-0500-4-212] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 06/22/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The gap between research findings and clinical practice is well documented and a range of interventions has been developed to increase the implementation of research into clinical practice. FINDINGS A review of systematic reviews of the effectiveness of interventions designed to increase the use of research in clinical practice. A search for relevant systematic reviews was conducted of Medline and the Cochrane Database of Reviews 1998-2009. 13 systematic reviews containing 313 primary studies were included. Four strategy types are identified: audit and feedback; computerised decision support; opinion leaders; and multifaceted interventions. Nine of the reviews reported on multifaceted interventions. This review highlights the small effects of single interventions such as audit and feedback, computerised decision support and opinion leaders. Systematic reviews of multifaceted interventions claim an improvement in effectiveness over single interventions, with effect sizes ranging from small to moderate. This review found that a number of published systematic reviews fail to state whether the recommended practice change is based on the best available research evidence. CONCLUSIONS This overview of systematic reviews updates the body of knowledge relating to the effectiveness of key mechanisms for improving clinical practice and service development. Multifaceted interventions are more likely to improve practice than single interventions such as audit and feedback. This review identified a small literature focusing explicitly on getting research evidence into clinical practice. It emphasizes the importance of ensuring that primary studies and systematic reviews are precise about the extent to which the reported interventions focus on changing practice based on research evidence (as opposed to other information codified in guidelines and education materials).
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Affiliation(s)
- Annette Boaz
- Department of Primary Care and Public Health Sciences, King's College London, 7th Floor, Capital House, 42 Weston Street, London SE1 3QD, UK
| | - Juan Baeza
- Department of Management, School of Social Science and Public Policy, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, UK
| | - Alec Fraser
- Department of Management, School of Social Science and Public Policy, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, UK
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Shuval K, Linn S, Brezis M, Shadmi E, Green ML, Reis S. Association between primary care physicians' evidence-based medicine knowledge and quality of care. Int J Qual Health Care 2009; 22:16-23. [PMID: 19951965 DOI: 10.1093/intqhc/mzp054] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care. DESIGN A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire. SETTING One region of the largest Health Maintenance Organization in Israel. PARTICIPANTS Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients. MAIN OUTCOME MEASURES Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval. RESULTS Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores. CONCLUSIONS Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.
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Affiliation(s)
- Kerem Shuval
- School of Public Health, University of Haifa, Haifa, Israel.
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