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Diabetes: Quality Improvement . This review examines strategies for improving the quality of care for adult type 2 diabetic patients, through changes in provider behavior and modifications to the organization of care. Search Strategy and Inclusion Criteria: The researchers searched the MEDLINE.
The investigators included randomized or quasi- randomized controlled trials, controlled before- after studies, and interrupted time series in which at least one reported outcome involved changes in serum hemoglobin A1c or a measure of provider adherence to a recommended process of care. Data Collection and Analysis: Two reviewers independently abstracted relevant data, including classifying the components of each QI intervention as provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self- management, patient reminders, audit and feedback, organizational change, or financial incentives.
Certain categories were further subdivided into major subtypes (e. The investigators also assessed the impact of clinical information systems as a mediator for interventions of all types. They compared different QI strategies in terms of the median effects achieved for glycemic control and for a generalized measure of clinician adherence. In addition, linear regression analyses were performed using methodologic features and QI types as predictors, taking into account baseline groups differences and study size. Main Results: Fifty- eight articles reporting a total of 6. The most common interventions employed were organizational change in 4.
Fifty- two trials involved interventions employing more than one QI strategy, with a median of 2 strategies per trial and a maximum of 5. The included trials reported a median absolute reduction in Hb.
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A1c of 0. 4. 8% (interquartile range: 0. Trials in the lower 2 quartiles of sample size reported substantially larger effect sizes, as did non- randomized trials, strongly suggesting the presence of publication bias, with publication of smaller non- randomized trials occurring more often when reported improvements are large. Multifaceted trials reported a median reduction in Hb.
A1c of 0. 6. 0% (interquartile range: 0. The benefit of employing more than one QI strategy appeared to persist among larger, randomized trials, but the small numbers of studies limits the reliability of this impression. The investigators did not find any specific type of QI strategy to confer unambiguous benefit. Provider education and disease management were the only strategies to approach statistical significance, compared with interventions absent these strategies.
Conclusion: The authors' analysis of quality improvement strategies for diabetes care showed no particular type of QI to have an advantage over others, but suggested that employing at least two strategies provides a greater chance of success than single- faceted interventions, in terms of improving glycemic control or provider adherence. These conclusions are limited by probable publication bias favoring smaller trials and non- randomized trials, and the confounding presence of multiple QI strategies in a given intervention, as well as important patient and provider factors, and organizational characteristics. Download Report. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 2—Diabetes Care.
Evidence- based Practice Center: Stanford- University of California, San Francisco. Topic Nominator: Agency for Healthcare Research and Quality.