Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings

 

Abstract

Background

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

Objectives

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

Search methods

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

Selection criteria

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

Data collection and analysis

Two reviewers independently extracted data and assessed study quality.

Main results

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

Authors' conclusions

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

 

Plain language summary

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

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

 

摘要

背景

促進初級照護，門診及社區機構糖尿病患者管理的介入措施

糖尿病是一種常見的慢性疾病，在初級照護中已逐漸增加管理。建議採用不同的系統來管理糖尿病照護。

目標

評估針對健康專家或他們提供照護的結構的不同介入措施，對於初級照護，門診及社區機構糖尿病患者管理的效果。

搜尋策略

我們檢索the Cochrane Effective Practice 及 Organisation of Care Group的專科登記資料庫，the Cochrane Controlled Trials Register (1999年，第4期)，MEDLINE (1966 – 1999年)，EMBASE (1980 – 1999年)，Cinahl (1982 – 1999年)，及文章的相關文獻。

選擇標準

針對促進第一型或第二型糖尿病患者照護之專家，財務及組織策略的隨機試驗(Randomised trials (RCTs))，對照臨床試驗(controlled clinical trials (CCTs))，前後對照研究(controlled before and after studies (CBAs))及間斷時間序列(interrupted time series (ITS))分析。研究對象為健康照護專家，包括醫師、護士及藥師。研究結果包括客觀測量的健康專家行為或病人的健康結果，以及已知效度與信度的自我報告。

資料收集與分析

兩名回顧者分別摘錄資料並評估研究品質。

主要結論

納入41篇研究共包含超過200種做法及48,000名病患。27篇研究為RCTs，12篇為CBAs，2篇為ITS。這些研究的介入措施、參與者、環境設施、及結果測量指標是具有異質性的。研究的方法學品質普遍不佳。所有的研究其介入措施的策略都是多面向的。12篇研究的介入措施是針對健康專家，9篇是針對照護組織，而20篇研究針對上述兩者。15篇研究中病患教育被加入於專家及組織介入措施中。結合專家介入措施可以改善過程面的結果。影響患者的治療效果仍不清楚，因為這很少被評估。另外也顯示安排追蹤(組織的介入措施)對於過程面的結果具有利的影響。且也報告加入病患教育的多項介入措施或增強護士角色對於病患的健康結果具有利的影響。

作者結論

多面向的專家介入措施可以增強健康專家在管理糖尿病患者的行為。改善定期提示與病患評估之組織介入措施(中央電腦化追蹤系統或定期聯絡病患的護士)也可以改善糖尿病的管理。加入以病人為導向的介入措施可以改善病人的健康結果。透過對病人的教育或促進病人遵守治療，護士在以病患為導向的介入措施中扮演重要的角色。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

經由針對健康專家及增加照護連續性之組織的介入措施，可以促進初級照護，門診與社區機構之糖尿病管理。糖尿病是一種重要且持續成長的健康問題。這篇回顧評估針對健康專家或安排照護方法的介入措施的效果，其目的為改善初級照護，門診與社區機構的糖尿病患者管理。回顧發現多面向的專家介入措施(如合併畢業後教育，提示，稽核與回饋，地方共識過程，及同儕審核)可以促進照護提供者的行為。增加結構化提示的組織介入措施，如中央電腦化的追蹤系統或定期聯絡病患的護士，也可以改善對糖尿病患者的照護。這些介入措施對患者治療效果的成效(血糖控制，心血管危險因素，福利)不太清楚。