OBJECTIVE —To review the effectiveness of interventions targeted at health care professionals and/or the structure of care in order to improve the management of diabetes in primary care, outpatient, and community settings. RESEARCH DESIGN AND METHODS —A systematic review of controlled trials evaluating the effectiveness of interventions targeted at health care professionals and aimed at improving the process of care or patient outcomes for patients with diabetes was performed. Standard search methods of the Cochrane Effective Practice and Organization of Care Group were used. RESULTS —A total of 41 studies met the inclusion criteria. The studies identified were heterogeneous in terms of interventions, participants, settings, and reported outcomes. In all studies, the interventions were multifaceted. The interventions were targeted at health care professionals only in 12 studies, at the organization of care only in 9 studies, and at both in 20 studies. Complex professional interventions improved the process of care, but the effect on patient outcomes remained less clear because such outcomes were rarely assessed. Organizational interventions that facilitated the structured and regular review of patients also showed a favorable effect on process measures. Complex interventions in which patient education was added and/or the role of a nurse was enhanced led to improvements in patient outcomes as well as the process of care. CONCLUSIONS —Multifaceted professional interventions and organizational interventions that facilitate structured and regular review of patients were effective in improving the process of care. The addition of patient education to these interventions and the enhancement of the role of nurses in diabetes care led to improvements in patient outcomes and the process of care.

https://care.diabetesjournals.org/content/diacare/24/10/1821.full.pdf

Interventions to Improve the Management of Diabetes in Primary Care, Outpatient, and Community Settings: A systematic review

OBJECTIVE
To review the effectiveness of interventions targeted at health care professionals and/or the structure of care in order to improve the management of diabetes in primary care, outpatient, and community settings.


RESEARCH DESIGN AND METHODS
A systematic review of controlled trials evaluating the effectiveness of interventions targeted at health care professionals and aimed at improving the process of care or patient outcomes for patients with diabetes was performed. Standard search methods of the Cochrane Effective Practice and Organization of Care Group were used.


RESULTS
A total of 41 studies met the inclusion criteria. The studies identified were heterogeneous in terms of interventions, participants, settings, and reported outcomes. In all studies, the interventions were multifaceted. The interventions were targeted at health care professionals only in 12 studies, at the organization of care only in 9 studies, and at both in 20 studies. Complex professional interventions improved the process of care, but the effect on patient outcomes remained less clear because such outcomes were rarely assessed. Organizational interventions that facilitated the structured and regular review of patients also showed a favorable effect on process measures. Complex interventions in which patient education was added and/or the role of a nurse was enhanced led to improvements in patient outcomes as well as the process of care.


CONCLUSIONS
Multifaceted professional interventions and organizational interventions that facilitate structured and regular review of patients were effective in improving the process of care. The addition of patient education to these interventions and the enhancement of the role of nurses in diabetes care led to improvements in patient outcomes and the process of care.

Interventions to improve the management of diabetes in primary care, outpatients, and community settings : a systemic review

Diabetic foot is a severe public health issue, yet rare studies investigated its global epidemiology. Here we performed a systematic review and meta-analysis through searching PubMed, EMBASE, ISI Web of science, and Cochrane database. We found that that global diabetic foot ulcer prevalence was 6.3% (95%CI: 5.4-7.3%), which was higher in males (4.5%, 95%CI: 3.7-5.2%) than in females (3.5%, 95%CI: 2.8-4.2%), and higher in type 2 diabetic patients (6.4%, 95%CI: 4.6-8.1%) than in type 1 diabetics (5.5%, 95%CI: 3.2-7.7%). North America had the highest prevalence (13.0%, 95%CI: 10.0-15.9%), Oceania had the lowest (3.0%, 95% CI: 0.9-5.0%), and the prevalence in Asia, Europe, and Africa were 5.5% (95%CI: 4.6-6.4%), 5.1% (95%CI: 4.1-6.0%), and 7.2% (95%CI: 5.1-9.3%), respectively. Australia has the lowest (1.5%, 95%CI: 0.7-2.4%) and Belgium has the highest prevalence (16.6%, 95%CI: 10.7-22.4%), followed by Canada (14.8%, 95%CI: 9.4-20.1%) and USA (13.0%, 95%CI: 8.3-17.7%). The patients with diabetic foot ulcer were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot ulceration. Our results provide suggestions for policy makers in deciding preventing strategy of diabetic foot ulceration in the future. Key messages Global prevalence of diabetic foot is 6.3% (95%CI: 5.4-7.3%), and the prevalence in North America, Asia, Europe, Africa and Oceania was 13.0% (95%CI: 10.0-15.9%), 5.5% (95%CI: 4.6-6.4%), 5.1% (95%CI: 4.1-6.0%), 7.2% (95%CI: 5.1-9.3%), and 3.0% (95% CI: 0.9-5.0%). Diabetic foot was more prevalent in males than in females, and more prevalent in type 2 diabetic foot patients than in type 1 diabetic foot patients. The patients with diabetic foot were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot.

https://www.tandfonline.com/doi/pdf/10.1080/07853890.2016.1231932

Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis†

Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care. Objectives To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings. Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes were used. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability. Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes.

/pdf/interventions-to-improve-the-management-of-diabetes-mellitus-3m2wcfyuof.pdf

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.

The evidence suggested that SMBG is of limited clinical effectiveness in improving glycaemic control in people with T2DM on oral agents, or diet alone, and is therefore unlikely to be cost-effective. SMBG may lead to improved glycaemic control only in the context of appropriate education - both for patients and health-care professionals - on how to respond to the data, in terms of lifestyle and treatment adjustment. Also, SMBG may be more effective if patients are able to self-adjust drug treatment. Further research is required on the type of education and feedback that are most helpful, characteristics of patients benefiting most from SMBG, optimal timing and frequency of SMBG, and the circumstances under which SMBG causes anxiety and/or depression.

/pdf/self-monitoring-of-blood-glucose-in-type-2-diabetes-45kw710uqp.pdf

Self-monitoring of blood glucose in type 2 diabetes: systematic review.

A diabetes protocol characterized by self-monitoring of blood glucose was introduced in four general practices with the aim of making the frequency of consultations dependent on the metabolic regulation and emphasizing body weight reduction. The feasibility of the programme was investigated and the results after 1 year were compared with those of conventional care in four control practices. In the experimental practices, 13 patients switched from a medical specialist's to a general practitioner's supervision, 20 remained under supervision of their GP and 33 started self-monitoring. The self-monitoring rate, the consultation frequency according to protocol, the low number of dropouts and inadequate referrals and adherence to the therapeutic scheme showed that the protocol was feasible for both the GPs and the patients. At the initial assessment, the regulation of the diabetes was worse in patients of the experimental group, compared with those of the control group (mean HbA1 9.7% vs 8.9%; p less than 0.05). On average, patients in the experimental group (n = 56) lost 0.4 kg of body weight, whereas those in the control group (n = 73) gained 0.1 kg (n.s.). The mean change in HbA1, adjusted for the initial value, was -0.4% in the experimental and +0.5% in the control group (p less than 0.05). The results of the protocol can be attributed to a combination of greater participation of the patient, the individualized consultation frequency and the prescription of oral hypoglycaemic agents according to body weight development.

Feasibility and effects of a diabetes type II protocol with blood glucose self-monitoring in general practice.

The aim of this study was to assess the prevalence of long-term complications in all patients with non-insulin-dependent diabetes mellitus, who were known to their general practitioners (GPs). During one year 19 GPs in the area of Hoogeveen in the Netherlands examined their non-insulin-dependent (NIDDM) patients, including those under specialist's care. A detailed protocol was used; the GPs were trained in the diagnostic procedures. Complications were either already known from the records or newly discovered during screening. In a population of 41,940 14.5/1000 patients with diabetes were identified: 12/1000 NIDDM and 2.5/1000 insulin-dependent diabetes mellitus (IDDM). Of the 509 NIDDM patients, 387 (76%) could be screened for late complications. Signs and symptoms of late complications were found in many patients: retinopathy (14%), nephropathy (57%), neuropathy (68%) and macroangiopathy (53%). The prevalence of serious complications was: proliferative retino- and maculopathy (3.3%); diabetic foot (2.6%); renal failure (2.5%). The systemic screening revealed a high number of previously unknown cases. It is concluded that many patients with NIDDM develop signs and symptoms of late complications. Most cases are identified by systemic screening only. More long-term studies of the prognosis of late complications in NIDDM are needed.

Diabetes and its Long-term Complications in General Practice: a Survey in a Well-defined Population

In the oral glucose tolerance test (OGTT), divergent doses of glucose remain in use by virtue of the prevailing conviction that the size of the loading dose hardly affects the outcome of the test. We compared the results of OGTTs with 100-gm. and 50-gm. loads in 85 patients, who were selected for slightly impaired glucose tolerance (plasma glucose at 120 minutes after 100 gm. of glucose was between 130 and 200 mg./dl.) The mean between-load difference in this group appeared to be nearly three times as great (54 mg./dl. at 120 minutes) as reported in the literature for normal subjects. The small impact of the dose in normal subjects could be confirmed in a group of 22 controls. As subjects with normal and with slightly impaired glucose tolerance react divergently to a change in the glucose dose, tests with different loads are not comparable and select different populations. The results can therefore also not be converted to one another by conversion formulas. The finding might be explained by the delay of the additional rise of the plasma insulin in patients after the higher load.

The Size of the Loading Dose as an Important Determinant of the Results of the Oral Glucose Tolerance Test: A Study in Subjects with Slightly Impaired Glucose Tolerance

We studied erythrocyte sodium-lithium countertransport in 33 patients with Type 1 (insulin-dependent) diabetes mellitus with diabetic nephropathy, 18 patients with Type 1 diabetes without diabetic nephropathy and in 42 nondiabetic patients with various other renal diseases. No significant differences were found in sodium-lithium countertransport between these three groups (median (range) 322 (162–676) vs 321 (189–627) vs 300 (142–655) μmol·1 cells−1·h−1). We conclude, that sodium-lithium countertransport cannot be used as a marker for diabetic nephropathy.

/pdf/erythrocyte-sodium-lithium-countertransport-is-not-different-2g5muvbwc8.pdf

E. de Nobel

Papers

Feasibility and effects of a diabetes type II protocol with blood glucose self-monitoring in general practice.

Diabetes and its Long-term Complications in General Practice: a Survey in a Well-defined Population

The Size of the Loading Dose as an Important Determinant of the Results of the Oral Glucose Tolerance Test: A Study in Subjects with Slightly Impaired Glucose Tolerance

Erythrocyte sodium-lithium countertransport is not different in type 1 (insulin-dependent) diabetic patients with and without diabetic nephropathy.

Preservation of blood-glucose strips.