title: [Interventions to improve the management of diabetes mellitus in primary health care and outpatient community settings].
abstract: This review should be cited as: Renders CM, Valk GD, Griffin S. Wagner EH, Eijk JThM van, Assendelft WJJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings (Cochrane Review). In: The Cochrane Library, Issue 2, 2001. Oxford: Update Software. A substantive amendment to this systematic review was last made on 29 June 2000. Cochrane reviews are regularly checked and updated if necessary.
  
  
  BACKGROUND
  Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles.
  
  
  METHODS
  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. 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.
  
  
  METHODS
  Two reviewers independently extracted data and assessed study quality.
  
  
  RESULTS
  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 organization 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. REVIEWERS' CONCLUSION: Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.
authors.affiliation: Central Forskningsenhed for Almen Praksis og Afdeling for Almen Medicin, Panum Instituttet, Københavns Universitet, DK-2200 København N. L.Hansen@gpract.ku.dk
authors.forename: Lars Jørgen
authors.initials: LJ
authors.lastname: Hansen
authors.forename: Thomas B
authors.initials: TB
authors.lastname: Drivsholm
mesh_terms: D003151:Community Health Centers / Q000458:organization & administration / Q000592:standards*; D018849:Controlled Clinical Trials as Topic; D016206:Databases, Bibliographic; D003922:Diabetes Mellitus, Type 1 / Q000451:nursing / Q000628:therapy*; D003924:Diabetes Mellitus, Type 2 / Q000451:nursing / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D015201:Meta-Analysis as Topic; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration / Q000592:standards*; D010353:Patient Education as Topic / Q000458:organization & administration / Q000592:standards; D018802:Patient-Centered Care; D016032:Randomized Controlled Trials as Topic; D017749:Total Quality Management / Q000379:methods*