Task-sharing interventions for improving control of diabetes in low-income and middle-income countries: a systematic review and meta-analysis.
Task-sharing interventions for improving control of diabetes in low-income and middle-income countries: a systematic review and meta-analysis.
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DOI：
10.1016/s2214-109x(20)30449-6
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发表时间：
2021-03
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影响因子：
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通讯作者：
Jeemon P
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作者：
Maria JL;Anand TN;Dona B;Prinu J;Prabhakaran D;Jeemon P
在受到医生短缺限制的卫生系统中，例如在低收入和中等收入国家（LMIC），使用非医生卫生保健工作者的任务分担干预措施可能是一种潜在的糖尿病管理策略。我们做了一个系统的回顾和荟萃分析任务分担干预策略管理2型糖尿病在中低收入国家。我们检索了PubMed，Embase和CINAHL从数据库开始到2019年9月25日的研究，这些研究是随机对照试验或集群随机试验，由非医生卫生工作者向成人（≥18岁）提供任务转移或任务共享干预措施与常规护理，在LMIC中进行，以糖化血红蛋白（HbA 1c）或空腹血糖（FBS）作为结局指标。使用科克伦偏倚风险工具评估纳入研究的方法学质量。使用随机效应模型荟萃分析估计HbA 1c和FBS的群体平均汇总平均差异及其95% CI。我们的研究方案已在PROSPERO数据库（CRD 42018081015）中注册。我们从文献检索中发现了4213项研究，其中46项（1.1%）符合叙述性综合的条件，共包括16973例受试者。 其中16项研究因偏倚风险高而被排除在荟萃分析之外。HbA 1c荟萃分析纳入了24项研究（共5345例受试者），FBS荟萃分析纳入了18项研究（共3287例受试者）。当任务由护士完成时，干预措施导致HbA 1c平均降低（平均合并平均差异为−0·54% [95% CI为−0·89至−0·18]; I2=80%）和药剂师（-0.91%[-1统计15至-0.68]; I2=58%），但当它们由营养师提供时则不是（-0.50%[-1统计10至0.09]; I2=54%）或社区卫生工作者（0.05%[0.03至0.07]; I2=0%）。当药剂师（平均汇总平均差异为-36.26 mg/dL [-52 statist 60至-19.92]; I2=78%）而不是护士（-7.46 mg/dL [-18 statist 44至3.52]; I2=79%）或社区卫生工作者（-5.41 [-12 statist 74至1.92]; I2=71%）提供干预时，也观察到平均FBS降低。只有一项研究报告了由营养师完成任务时的FBS，平均差异为−35·00 mg/dL（−65·96至−4·04）。在LMIC环境中，与非医生医疗保健工作者的任务分担干预在糖尿病管理中显示出中等有效性。虽然相对较高的异质性限制了对总体结果的解释，但在医生密度相对较高的LMIC中，由药剂师和护士领导的干预措施是糖尿病管理的有效策略。Wellcome Trust-印度生物技术部联盟。
Task-sharing interventions using non-physician health-care workers might be a potential diabetes management strategy in health systems that are constrained by physician shortages, such as those in low-income and middle-income countries (LMICs). We did a systematic review and meta-analysis of task-sharing intervention strategies for managing type 2 diabetes in LMICs. We searched PubMed, Embase, and CINAHL from database inception to Sept 25, 2019, for studies that were randomised control trials or cluster randomised trials with task-shifted or task-shared interventions delivered to adults (≥18 years) by non-physician health workers versus usual care, done in LMICs with glycated haemoglobin (HbA1c) or fasting blood sugar (FBS) as outcome measures. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Random-effects model meta-analysis was used to estimate the population average pooled mean difference for HbA1c and FBS with 95% CIs. Our study protocol was registered in the PROSPERO database (CRD42018081015). We found 4213 studies from the literature search, of which 46 (1·1%) were eligible for the narrative synthesis, including a total of 16 973 participants. 16 of these studies were excluded from the meta-analysis due to high risk of bias. 24 studies with a total of 5345 participants were included in the meta-analysis of HbA1c and 18 studies with a total of 3287 participants for FBS. Interventions led to an average reduction in HbA1c when tasks were delivered by nurses (averaged pooled mean difference −0·54% [95% CI −0·89 to −0·18]; I2=80%) and pharmacists (−0·91% [–1·15 to −0·68]; I2=58%), but not when they were delivered by dietitians (−0·50% [–1·10 to 0·09]; I2=54%) or community health workers (0·05% [0·03 to 0·07]; I2=0%). A reduction in average FBS was also observed when interventions were delivered by pharmacists (average pooled mean difference −36·26 mg/dL [–52·60 to −19·92]; I2=78%) but not nurses (−7·46 mg/dL [–18·44 to 3·52]; I2=79%) or community health workers (−5·41 [–12·74 to 1·92]; I2=71%). Only one study reported on FBS when tasks were delivered by dietitians, with a mean difference of −35·00 mg/dL (−65·96 to −4·04). Task sharing interventions with non-physician healthcare workers show moderate effectiveness in diabetes management in LMIC settings. Although relatively high heterogeneity limits the interpretation of the overall findings, interventions led by pharmacists and nurses in LMICs with relatively high physician density are effective strategies in the management of diabetes. Wellcome Trust–Department of Biotechnology India Alliance.