Multicomponent QI success in resource-poor diabetes clinic
medwireNews: A multicomponent quality improvement (QI) intervention doubles the number of diabetes patients achieving their treatment targets, shows a randomised trial from India and Pakistan.
And the researchers say that there were “sizable spillover effects”, with the influence of the intervention on the treating physicians tending to improve management of patients assigned to receive usual care. This reflects “the real-life nature of QI and practice change”, they say, but also means that the findings probably underestimate the effect of the intervention.
During the 2.5 years of the study, both groups of patients had improvements in control of glycated haemoglobin (HbA1c), blood pressure (BP) and low-density lipoprotein (LDL) cholesterol levels, report Nikhil Tandon (All India Institute of Medical Sciences, New Delhi, India) and study co-authors.
However, 18.2% of the 575 patients randomly assigned to the intervention group achieved the primary outcome of controlled HbA1c plus BP and/or LDL cholesterol, significantly more than the 8.1% of the 571 in the usual care group.
More patients in the intervention versus control group achieved target HbA1c (21.5 vs 11.1%), BP (51.0 vs 45.0%) and LDL cholesterol (56.4 vs 47.1%). Most improvement occurred during the first 12 months, but there were continued positive trends throughout the whole study period.
The QI intervention relied primarily on nonphysician care coordinators, who had two main roles. First, they spoke with patients on a monthly basis about their medication and lifestyle management and also every 3 months to arrange any necessary medical appointments. And second, they entered patient interactions and test results into decision-support software that used algorithms based on current guidelines to generate management prompts, which the care coordinators reviewed with the treating physicians.
Thus, the care coordinators prompted both patients and their physicians to adhere to high-quality diabetes management.
“This study adds to the literature in that the intervention purposefully addressed multiple interacting barriers to care and was implemented in diverse and resource-challenged health care settings”, write the researchers in the Annals of Internal Medicine.
They add that the study sponsorship did not cover any of the patients’ costs apart from the annual study visit, making the results a good indicator of how the intervention would work in normal clinical practice.
Intervention patients also had significantly greater improvements in treatment satisfaction and health-related quality of life than the control group, implying that “they did not mind the intensity and extra follow-up of the intervention.”
The intervention group had more instances of mild hypoglycaemia (133 vs 21), but the researchers suggest that “this undesirable effect may be mitigated through shared decision making between patients and providers, an aspect that is increasingly integrated into QI strategies.”
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