Results of a meta-analysis that looked at the effectiveness of quality improvement (QI) strategies beyond controlling hemoglobin (Hb)A1c levels indicate that many trials of such strategies show improvements in patient care for diabetes.
“QI strategies significantly improved intermediate disease outcomes, including HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, and diastolic blood pressure,” said the study’s principal investigator, Andrea C. Tricco, PhD, MSc, Instructor, Systematic Reviews and Meta-Analysis, King Saud University Medical Research at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Ontario, Canada.
“These effects are important on a population level, and the effects were larger with poor baseline control,” said Dr Tricco, who presented the results of this meta-analysis at the 2012 ADA annual meeting; the study was simultaneously published in the Lancet (Tricco AC, et al. Lancet. 2012;379:2252-2261).
Through a systematic review of published trial data, the investigators assessed the effects of QI strategies on HbA1c levels, vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes.
A total of 142 clinical trials were reviewed, which included 38,664 patients from patient-randomized trials and 84,865 patients from cluster-randomized trials. In addition, predefined QI strategies or financial incentives targeting health systems, providers, and patients were also assessed.
The QI strategies targeting health systems were case management, team changes, electronic patient registries, facilitated relay of information to clinicians, and continuous QI.
Strategies assessing providers were audit and feedback, clinician education, clinician reminders, and financial incentives. For patients, the strategies were education, promotion of self-management, and reminder systems.
Overall, compared with usual care, implementing QI strategies was associated with reductions in:
- HbA1c levels (mean reduction, 0.37%)
- Low-density lipoprotein cholesterol (LDL-C; 0.10 mmol/L)
- Systolic blood pressure (BP; 3.13 mm Hg)
- Diastolic BP (1.55 mm Hg).
Implementing QI strategies increased the likelihood that patients received aspirin by 33%, antihypertensive drugs by 17%, screenings for retinopathy by 22%, screenings for renal function by 28%, and screenings for foot abnormalities by 27%.
The results for some cardiovascular outcomes were not as robust, because statin use, hypertension control, and smoking cessation were not increased significantly with QI strategies versus usual care. Few studies reported harmful outcomes, said Dr Tricco.
Larger effects on outcomes were noted when baseline concentrations were >8% for HbA1c, 2.59 mmol/L for LDL-C, and 80 mm Hg and 140 mm Hg for diastolic BP and systolic BP, respectively. For lowering HbA1c levels, the most effective QI strategies were promotion of self-management, team changes, case management, and patient education, which accounted for a reduction of approximately 0.60%.
The effectiveness of QI intervention strategies targeting providers and patients varied, depending on baseline HbA1c control. According to the researchers, the results show that the strategies involving interventions targeting the entire system of chronic disease management were associated with the best results, regardless of baseline HbA1c levels.
Interventions aimed only at patients may be beneficial regardless of baseline HbA1c, whereas interventions solely targeting providers are beneficial only if baseline HbA1c control was poor (>8%). Therefore, optimization of all of the systems of care should be included in programs to improve diabetes management, said Dr Tricco.
If these quality indicators are widely adopted, the population benefits would be potentially important. Data from the United Kingdom Prospective Diabetes Study showed that a 1% reduction in mean HbA1c results in 21% fewer deaths, 14% fewer myocardial infarctions (MIs), and a 37% decrease in microvascular complications at the population level. Using these data, the reduction in mean HbA1c shown in this meta-analysis could translate into 7% fewer deaths, 5% fewer MIs, and 12% fewer microvascular complications at the population level.