Systematic QI Strategies Lift all Boats in Diabetes Care

Quality improvement strategies that aim to optimize systems of care have significant favorable effects on diabetes care outcomes, Andrea C. Tricco, Ph.D., of Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, and her colleagues reported online June 9 in the Lancet.

While QI interventions targeting patients might be beneficial irrespective of baseline HbA_1c, those interventions targeting providers only seem beneficial when baseline HbA_1c is greater than 8.0%, according to the findings of their systematic review and meta-analysis, which together involved more than 123,000 patients.

The results were reported simultaneously at the annual meeting of the American Diabetes Association in Philadelphia.

Based on data from a total of 120 relevant trials, QI strategies reduced HbA_1c by a mean difference of 0.37%; and reduced LDL cholesterol by 0.10 mmol/L, systolic blood pressure by 3.13 mm Hg, and diastolic blood pressure by 1.55 mm Hg versus usual care over a median 12-month period, the authors found (Lancet 2012 June 9 [doi: 10.1016/S0140-6736(12)60480-2]).

Specifically, strategies targeting clinicians’ education and audit and feedback led to HbA_1c reductions of 0.33% and 0.44%, respectively, when baseline HbA_1c concentrations were greater than 8.0%, compared with no improvement when baseline HbA_1c was less than 8.0%.

Patient education seemed more effective than reminders when baseline HbA_1c was greater than 8.0%, but less effective when it was less than 8.0%.

Furthermore, QI strategies were associated with increases in aspirin use; use of any antihypertensive drugs; and screening for retinopathy, renal involvement, and foot complications over median follow-up periods ranging from 12 to 18 months. The QI strategies did not, however, have a significant effect on statin use, adequate control of hypertension, or smoking cessation rates over median follow-up periods ranging from 12 to 19 months.

In trials that enrolled patients with an HbA_1c of greater than 8.0%, declines of more than 0.5% were seen with certain QI strategies (specifically, those targeting team changes, case management, patient education, and promotion of self-management). In trials enrolling those with an HbA_1c of 8.0% or less, declines of that magnitude were seen for one QI strategy (facilitated relay).

Nonetheless, "after adjustment for median baseline HbA_1c values and effective sample size, the QI strategies were associated with significantly lower HbA_1c than usual care was," they said.

"We noted greater improvements in HbA_1c control for QI strategies targeting health systems and patients. In fact, all QI strategies were associated with significant changes in HbA_1c except for clinician education," they said.

The trials included in this review and meta-analysis were reported between July 2003 and July 2010, and were selected using 11 predefined QI strategies or financial incentives targeting health care professionals for the management of adult outpatients with diabetes.

"The QI strategies targeted health systems (e.g., team changes), professionals (e.g., professional reminders), or patients (e.g., promotion of self-management)," the investigators explained.

The findings, which represent an update of a previous review that assessed the effects of QI strategies on glycemic control, provide an assessment of the effects of QI strategies on a broader range of diabetic care.

The analysis was limited by the complexity of the QI strategies studied, the inability to control for all potential confounding factors, and the short duration of follow-up in many of the trials, the authors wrote.

Despite these limitations, the findings indicate that diabetes outcomes can be improved by QI interventions. Wide implementation of QI strategies could lead to important population benefits, as data have shown that a 1% reduction in mean HbA_1c results in 21% fewer deaths, 14% fewer myocardial infarctions, and a 37% decrease in microvascular complications at the population level, the investigators noted.

"Further research is needed to identify which interventions and combinations of QI strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," they concluded.

This study was funded by the Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research Interdisciplinary Team Grants program. The authors reported having no conflicts of interest.

Quality improvement strategies that aim to optimize systems of care have significant favorable effects on diabetes care outcomes, Andrea C. Tricco, Ph.D., of Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, and her colleagues reported online June 9 in the Lancet.

While QI interventions targeting patients might be beneficial irrespective of baseline HbA_1c, those interventions targeting providers only seem beneficial when baseline HbA_1c is greater than 8.0%, according to the findings of their systematic review and meta-analysis, which together involved more than 123,000 patients.

The results were reported simultaneously at the annual meeting of the American Diabetes Association in Philadelphia.

Based on data from a total of 120 relevant trials, QI strategies reduced HbA_1c by a mean difference of 0.37%; and reduced LDL cholesterol by 0.10 mmol/L, systolic blood pressure by 3.13 mm Hg, and diastolic blood pressure by 1.55 mm Hg versus usual care over a median 12-month period, the authors found (Lancet 2012 June 9 [doi: 10.1016/S0140-6736(12)60480-2]).

Specifically, strategies targeting clinicians’ education and audit and feedback led to HbA_1c reductions of 0.33% and 0.44%, respectively, when baseline HbA_1c concentrations were greater than 8.0%, compared with no improvement when baseline HbA_1c was less than 8.0%.

Patient education seemed more effective than reminders when baseline HbA_1c was greater than 8.0%, but less effective when it was less than 8.0%.

Furthermore, QI strategies were associated with increases in aspirin use; use of any antihypertensive drugs; and screening for retinopathy, renal involvement, and foot complications over median follow-up periods ranging from 12 to 18 months. The QI strategies did not, however, have a significant effect on statin use, adequate control of hypertension, or smoking cessation rates over median follow-up periods ranging from 12 to 19 months.

In trials that enrolled patients with an HbA_1c of greater than 8.0%, declines of more than 0.5% were seen with certain QI strategies (specifically, those targeting team changes, case management, patient education, and promotion of self-management). In trials enrolling those with an HbA_1c of 8.0% or less, declines of that magnitude were seen for one QI strategy (facilitated relay).

Nonetheless, "after adjustment for median baseline HbA_1c values and effective sample size, the QI strategies were associated with significantly lower HbA_1c than usual care was," they said.

"We noted greater improvements in HbA_1c control for QI strategies targeting health systems and patients. In fact, all QI strategies were associated with significant changes in HbA_1c except for clinician education," they said.

The trials included in this review and meta-analysis were reported between July 2003 and July 2010, and were selected using 11 predefined QI strategies or financial incentives targeting health care professionals for the management of adult outpatients with diabetes.

"The QI strategies targeted health systems (e.g., team changes), professionals (e.g., professional reminders), or patients (e.g., promotion of self-management)," the investigators explained.

The findings, which represent an update of a previous review that assessed the effects of QI strategies on glycemic control, provide an assessment of the effects of QI strategies on a broader range of diabetic care.

The analysis was limited by the complexity of the QI strategies studied, the inability to control for all potential confounding factors, and the short duration of follow-up in many of the trials, the authors wrote.

Despite these limitations, the findings indicate that diabetes outcomes can be improved by QI interventions. Wide implementation of QI strategies could lead to important population benefits, as data have shown that a 1% reduction in mean HbA_1c results in 21% fewer deaths, 14% fewer myocardial infarctions, and a 37% decrease in microvascular complications at the population level, the investigators noted.

"Further research is needed to identify which interventions and combinations of QI strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," they concluded.

This study was funded by the Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research Interdisciplinary Team Grants program. The authors reported having no conflicts of interest.

Quality improvement strategies that aim to optimize systems of care have significant favorable effects on diabetes care outcomes, Andrea C. Tricco, Ph.D., of Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, and her colleagues reported online June 9 in the Lancet.

While QI interventions targeting patients might be beneficial irrespective of baseline HbA_1c, those interventions targeting providers only seem beneficial when baseline HbA_1c is greater than 8.0%, according to the findings of their systematic review and meta-analysis, which together involved more than 123,000 patients.

The results were reported simultaneously at the annual meeting of the American Diabetes Association in Philadelphia.

Based on data from a total of 120 relevant trials, QI strategies reduced HbA_1c by a mean difference of 0.37%; and reduced LDL cholesterol by 0.10 mmol/L, systolic blood pressure by 3.13 mm Hg, and diastolic blood pressure by 1.55 mm Hg versus usual care over a median 12-month period, the authors found (Lancet 2012 June 9 [doi: 10.1016/S0140-6736(12)60480-2]).

Specifically, strategies targeting clinicians’ education and audit and feedback led to HbA_1c reductions of 0.33% and 0.44%, respectively, when baseline HbA_1c concentrations were greater than 8.0%, compared with no improvement when baseline HbA_1c was less than 8.0%.

Patient education seemed more effective than reminders when baseline HbA_1c was greater than 8.0%, but less effective when it was less than 8.0%.

Furthermore, QI strategies were associated with increases in aspirin use; use of any antihypertensive drugs; and screening for retinopathy, renal involvement, and foot complications over median follow-up periods ranging from 12 to 18 months. The QI strategies did not, however, have a significant effect on statin use, adequate control of hypertension, or smoking cessation rates over median follow-up periods ranging from 12 to 19 months.

In trials that enrolled patients with an HbA_1c of greater than 8.0%, declines of more than 0.5% were seen with certain QI strategies (specifically, those targeting team changes, case management, patient education, and promotion of self-management). In trials enrolling those with an HbA_1c of 8.0% or less, declines of that magnitude were seen for one QI strategy (facilitated relay).

Nonetheless, "after adjustment for median baseline HbA_1c values and effective sample size, the QI strategies were associated with significantly lower HbA_1c than usual care was," they said.

"We noted greater improvements in HbA_1c control for QI strategies targeting health systems and patients. In fact, all QI strategies were associated with significant changes in HbA_1c except for clinician education," they said.

The trials included in this review and meta-analysis were reported between July 2003 and July 2010, and were selected using 11 predefined QI strategies or financial incentives targeting health care professionals for the management of adult outpatients with diabetes.

"The QI strategies targeted health systems (e.g., team changes), professionals (e.g., professional reminders), or patients (e.g., promotion of self-management)," the investigators explained.

The findings, which represent an update of a previous review that assessed the effects of QI strategies on glycemic control, provide an assessment of the effects of QI strategies on a broader range of diabetic care.

The analysis was limited by the complexity of the QI strategies studied, the inability to control for all potential confounding factors, and the short duration of follow-up in many of the trials, the authors wrote.

Despite these limitations, the findings indicate that diabetes outcomes can be improved by QI interventions. Wide implementation of QI strategies could lead to important population benefits, as data have shown that a 1% reduction in mean HbA_1c results in 21% fewer deaths, 14% fewer myocardial infarctions, and a 37% decrease in microvascular complications at the population level, the investigators noted.

"Further research is needed to identify which interventions and combinations of QI strategies will optimally improve important outcomes in patients with diabetes at an acceptable cost to aid health-system planning," they concluded.

This study was funded by the Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research Interdisciplinary Team Grants program. The authors reported having no conflicts of interest.