Review ArticleCan primary care professionals’ adherence to Evidence Based Medicine tools improve quality of care in Type 2 diabetes mellitus? A systematic review
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,
References (55)
- et al.
From best evidence to best practice: effective implementation of change in patients’ care
Lancet
(2003) An introduction to evidence-based medicine
Prim Care.
(2006)- et al.
Computerized decision support based on a clinical practice guideline improves compliance with care standards
Am. J. Med.
(1997) - et al.
Educational interventions aiming at improving adherence to treatment recommendations in type 2 diabetes: a sub-analysis of a systematic review of randomised controlled trials
Diabetes Res. Clin. Pract.
(2008) What's in the black box?
Chest
(2006)- National Center for Chronic Disease Prevention and Health Promotion, National Diabetes Fact Sheet, available at...
- et al.
The burden of mortality attributable to diabetes: realistic estimates for the year 2000
Diabetes Care
(2005) - National Institute of Diabetes and Digestive and Kidney Diseases, National Diabetes statistics, available at...
- et al.
Pro-active call center treatment support (PACCTS) to improve glucose control in Type 2 diabetes. A randomized controlled trial
Diabetes Care
(2005) - et al.
Healthcare in urban and rural areas, 1998-2000
MEPS Chartbook 13, AHRQ Pub No. 04-0050
(2004)
Adherence to diabetes control recommendations: impact of nurse telephone calls
J. Adv. Nurs.
Quality of diabetes care: problem of patient or doctor adherence?
Swiss Med. Wkly.
Why don’t physicians follow clinical practice guidelines?
JAMA
Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review
Diabetes Care
Patient adherence to treatment: three decades of research. A comprehensive review
J. Clin. Pharm. Ther.
Cochrane handbook for systematic reviews of interventions 4.2. 6
SIGN 50: A Guideline Developer's Handbook
Review Manager (RevMan) [Computer program], version 5.0
A cluster randomized controlled trial of the effect of a treatment algorithm for hypertension in patients with type 2 diabetes
Br. J. Gen. Pract.
Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in East London
BMJ
Multifaceted support to improve clinical decision making in diabetes care: a randomized controlled trial in general practice
Diabet. Med.
A practical randomized trial to improve diabetes care
J. Gen. Intern. Med.
Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system
Int. J. Technol. Assess Health Care
An educational programme for peer review groups to improve treatment of chronic heart failure and diabetes mellitus type 2 in general practice
J. Eval. Clin. Pract.
Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team
BMJ
Educational outreach in diabetes to encourage practice nurses to use primary care hypertension and hyperlipidaemia guidelines (EDEN): a randomized controlled trial
Diabet. Med.
Cited by (32)
Organization of Diabetes Care
2018, Canadian Journal of DiabetesCitation Excerpt :Decision support or a clinical decision support system (CDSS), which provides health-care practitioners with best-practice information at the point of care to help support decision making, has been shown to improve outcomes. Evidence-based guideline interventions, particularly those that used interactive computer technology to provide recommendations and immediate feedback of personally tailored information, were shown to be the most effective in improving outcomes of people with diabetes (67). A randomized trial using electronic medical record (EMR) decision support in primary care found improvement in A1C (68), and a cluster randomized trial of a Ql program found that the provision of a clear treatment protocol—supported by tailored postgraduate education of the primary care physician and case management support by an endocrinologist—substantially improved the overall quality of diabetes care provided, as well as major diabetes-related outcomes (66).
Trans-anethole, a terpenoid ameliorates hyperglycemia by regulating key enzymes of carbohydrate metabolism in streptozotocin induced diabetic rats
2015, BiochimieCitation Excerpt :Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia with instabilities in carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both [1].
Organisation des soins du diabète
2013, Canadian Journal of DiabetesCitation Excerpt :Renseigner les praticiens sur les pratiques exemplaires et contemporaires, afin de les aider à prendre des décisions, a permis d’obtenir des résultats améliorés. Une revue systématique récente a montré que les interventions conformes aux lignes directrices factuelles, particulièrement celles qui utilisaient des technologies informatiques interactives pour fournir des recommandations et une rétroaction immédiate au cas par cas, étaient les plus efficaces pour améliorer les résultats chez les patients (51). Un essai avec répartition aléatoire dans lequel les dossiers médicaux électroniques étaient utilisés pour aider à prendre des décisions dans le cadre des soins de première ligne (52) a mis en évidence une amélioration du taux d’HbA1c.
Relationship between process indicators measured using electronic records and intermediate health outcomes in patients with diabetes
2013, Revista de Calidad AsistencialAntihyperglycemic activity of trigonelline and sitagliptin in nicotinamide-streptozotocin induced diabetes in Wistar rats
2013, Biomedicine and Aging PathologyCitation Excerpt :Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycemia with disturbances in carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both [1].
Organization of Diabetes Care
2013, Canadian Journal of DiabetesCitation Excerpt :Providing healthcare practitioners with best practice information at the point of care to help support decision making has been shown to improve outcomes. In a systematic review, evidence-based guideline interventions, particularly those that used interactive computer technology to provide recommendations and immediate feedback of personally tailored information, were the most effective in improving patient outcomes (51). A randomized trial using electronic medical record (EMR) decision support in primary care found improvement in A1C (52), and a cluster randomized trial of a QI program found that the provision of a clear treatment protocol—supported by tailored postgraduate education of the primary care physician and case coaching by an endocrinologist—substantially improved the overall quality of diabetes care provided, as well as major diabetes-related outcomes (50).