Review Article
Can primary care professionals’ adherence to Evidence Based Medicine tools improve quality of care in Type 2 diabetes mellitus? A systematic review

https://doi.org/10.1016/j.diabres.2009.05.007Get rights and content

Abstract

Background

Our aim is to review the effectiveness of EBM tools available to primary care professionals to improve the quality of Type 2 diabetes disease management.

Methods

A systematic review of RCT was performed according to the Cochrane methods.

Results

Starting from an overall number of 1737 references found, a total of 13 studies met all the inclusion criteria.

Conclusions

The adherence to EBM instruments is likely to improve process of care, rather than patient outcomes. In addition, our review outlines that feedback reports and use of ICT devices are likely to be effective in diabetes disease management.

Introduction

Diabetes is a group of chronic diseases characterized by high levels of blood glucose due to alterations in insulin production or insulin action or both. There are two main types of diabetes disease, different for aetiology, pathology, risk factors, therapy and evolution. Type 1 diabetes occurs when the immune system produces self immunoglobulin against pancreatic beta cells; it typically strikes children and young adults, but it can occur at any age. Type 2 diabetes mellitus (T2DM) usually begins as insulin resistance and it is quite always associated with risk factors such as older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity [1]. The excess global mortality attributable to diabetes in the year 2000 was estimated to be 2.9 million deaths, equivalent to 5.2% of all deaths [2]. Excess mortality attributable to diabetes accounted for 2–3% of deaths in poorest countries and over 8% in the U.S., Canada, and the Middle East [2]. In adults, Type 2 diabetes accounts for about 90–95% of all diagnosed cases of diabetes [3]: the worldwide epidemic of Type 2 diabetes is a big challenge, which health care service providers are facing to, although lots of evidence suggest that little strategies are needed to reduce the adverse impact of Type 2 diabetes and deliver substantial health benefits, such as tight blood glucose, blood pressure, and lipid control [4]. Patients with diabetes typically obtain most of their medical care from primary care providers (PCPs) [5]; methods of disease management have been applied to Type 2 diabetes care: although algorithms for diabetes care exist, it may be complex and difficult for physicians to follow them, given patient load, diversity of patients seen, lack of information systems, and time constraints [6], so that the global quality of disease management often fails to achieve predefined standards.

Physician compliance with treatment guidelines is relatively poor. Some studies conducted in Europe have found that in any given year, HbA1c and blood lipids are measured only in about half of patients and are below target in even less, while blood pressure is frequently measured but controlled in less than 50% [7]. Some reasons for this unsatisfactory situation are providers’ lack of adherence with treatment guidelines, patient barriers and the fact that the guidelines are not easy to access and implement.

Strategies for changing general practitioner's (GPs) behavior by dissemination and implementation of guidelines and translating evidence into practice are notoriously difficult areas [8], [9], [10]. Reviews of implementation strategies to achieve disease treatment targets indicate that a multifaceted approach is most successful [11].

On the other hand, patient's non-adherence can be changed by improving education, perception, motivation and self-management [12]. Therefore, the scope of our research is to review the interventions aimed at improving primary care providers’ adherence to EBM tools in order to improve quality of care in the management of T2DM.

Section snippets

Systematic literature search

The systematic review was conducted according to methods provided by the Cochrane Handbook for Systematic Reviews of Interventions [13]. A search strategy was formulated, piloted and focused particularly on randomized controlled trials (RCTs), as these are likely to provide more reliable information than other sources of evidence on the differential effects of alternative forms of healthcare [14]. Studies fulfilling search purposes were identified through an electronic search of Pubmed/Medline

Results

This paper summarizes the results of 13 RCTs [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], to assess primary care providers’ adherence to EBM tools and its impact on quality of care in the management of patient with T2DM. A summary of the studies characteristics is shown in Table 1.

According to the classification of kind of intervention, the selected articles were classified as follows: (1) educational training, including face-to-face training individual or

Discussion

The aim of our review was to summarize the results of effects of RCTs evaluating the adherence to EBM interventions targeted to Primary care professionals (physicians, nurses, other professionals, single handed or in teams) aimed at improving clinical care quality (measured by applying process or outcome indicators) in T2DM patients. As previous studies assessed the effectiveness of interventions for improving adherence to treatment recommendations in people with Type 2 diabetes mellitus [30],

Implications for practice

Despite the increasing number of clinical and organizational guidelines on diabetes care, little is known about how to gain effective quality results, rather than their provision. This includes better and more effective instruments to improve and monitor care providers’ adherence.

As multifaceted interventions, including feedback reports and use of ICT devices, are likely to be effective, the question whether any intervention aimed at improving primary care providers’ adherence to EBM tools has

Implications for research

Despite the burden of diabetes on quality of life and healthcare budgets and the consequent proliferation of clinical and organizational guidelines, most of the reviewed articles showed that the adherence to EBM tools is more likely to improve process of care than patient outcomes.

This issue is more relevant when considering that the research on care providers’ adherence still suffers from both conceptual and operative weaknesses. As for T2DM, more robust evidence based research is needed on

Conflict of interest

The authors state that they have no conflict of interest.

Acknowledgements

The research project was made possible by a grant of the Italian Ministry of Health – SIVEAS Project 2007–2008.

We would thank Dr. Thomas Jefferson of the Cochrane Collaboration in Rome (Italy) for his kind and useful suggestions, Dr. Luigi Pinnarelli and Mrs. Noemi Di Giuseppe for the collaboration in manuscript production.

The methodological framework of this research has been presented at the 16th European Conference on Public Health (EUPHA) held in Lisbon, 6–8 November 2008: de Belvis AG,

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