Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis
Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis
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DOI：
10.1016/s0140-6736(12)60480-2
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发表时间：
2012-06-16
期刊：
影响因子：
168.9
通讯作者：
Shojania, Kaveh
中科院分区：
文献类型：
--
作者：
Tricco, Andrea C.;Ivers, Noah M.;Shojania, Kaveh
背景：质量改进（QI）策略对糖尿病护理的有效性尚不清楚。我们的目的是评估QI策略对糖化血红蛋白（HbA（1c）），血管风险管理，微血管并发症监测和戒烟的影响，通过Medline，科克伦有效的实践和组织的护理数据库（从成立到2010年7月），我们确定了研究，并参考随机临床试验。我们纳入了评估11项预定义QI策略或针对卫生系统、医疗保健专业人员或患者的财务激励措施的试验，以改善成人糖尿病门诊患者的管理。两个审查独立抽象的数据和评估的风险bias.Findings我们回顾了48个集群随机对照试验，包括2538集群和84 865例患者，和94例患者随机对照试验，包括38 664例患者。在随机效应荟萃分析中，QI策略降低HbA（1c）的平均差异为0.37%（95% CI 0.28-0.45; 120项试验），LDL胆固醇降低0.10 mmol/L（0.05-0.14; 47次试验），收缩压降低3.13 mm Hg（2.19-4.06，65次试验），舒张压降低1.55 mm Hg（0.95-2.15，61次试验）。我们注意到当基线浓度大于8.0%时，HbA（1c）、LDL胆固醇2.59 mmol/L、舒张压80 mm Hg和收缩压140 mm Hg的影响较大。QI策略的有效性取决于基线HbA（1c）控制。QI策略增加了患者接受阿司匹林的可能性（11项试验;相对风险[RR] 1.33，95% CI 1.21-1.45），抗高血压药物（10项试验; RR 1.17，1.01-1.37）和视网膜病变筛查（23项试验; RR 1.22，1.13-1.32）、肾功能（14项试验; RR 128，1.13-1.44）和足部异常（22项试验; RR 1.27，1.16-1.39）。然而，他汀类药物的使用（10项试验; RR 1.12，0.99-1.28），高血压控制（18项试验; RR 1.01，0.96-1.07）和戒烟（13项试验; RR 1.13，0.99-1.29）没有显着增加。针对慢性病管理系统的干预措施沿着患者介导的QI策略，应该是旨在改善糖尿病管理的干预措施的重要组成部分。仅针对医疗保健专业人员的干预似乎只有在基线HbA（1c）控制不佳时才有益。
Background The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA(1c)), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes.Methods We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias.Findings We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84 865 patients, and 94 patient randomised controlled trials, including 38 664 patients. In random effects meta-analysis, the QI strategies reduced HbA(1c) by a mean difference of 0.37% (95% CI 0.28-0.45; 120 trials), LDL cholesterol by 0.10 mmol/L (0.05-0.14; 47 trials), systolic blood pressure by 3.13 mm Hg (2.19-4.06, 65 trials), and diastolic blood pressure by 1.55 mm Hg (0.95-2.15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8.0% for HbA(1c), 2.59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA(1c) control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1.33, 95% CI 1.21-1.45), antihypertensive drugs (ten trials; RR 1.17, 1.01-1.37), and screening for retinopathy (23 trials; RR 1.22, 1.13-1.32), renal function (14 trials; RR 128, 1.13-1.44), and foot abnormalities (22 trials; RR 1.27, 1.16-1.39). However, statin use (ten trials; RR 1.12, 0.99-1.28), hypertension control (18 trials; RR 1.01, 0.96-1.07), and smoking cessation (13 trials; RR 1.13, 0.99-1.29) were not significantly increased.Interpretation Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA(1c) control is poor.