title: Improving quality of care for persons with diabetes: an overview of systematic reviews - what does the evidence tell us?
abstract: BACKGROUND
  Ensuring high quality care for persons with diabetes remains a challenge for healthcare systems globally with consistent evidence of suboptimal care and outcomes. There is increasing interest in quality improvement strategies to improve diabetes management as reflected by a growing number of systematic reviews. These reviews are of varying quality and dispersed across many sources. In this paper, we present an overview of systematic reviews evaluating the impact of interventions to improve the quality of diabetes care.
  
  
  METHODS
  We searched for systematic reviews evaluating the effectiveness of any intervention intended to improve intermediate patient outcomes and process of care measures for patients with any type of diabetes. Two reviewers independently screened search results, appraised each systematic review using AMSTAR and extracted data from high quality reviews (AMSTAR score ≥ 5). Within reviews, we used vote counting by direction of effect to report the number of studies favouring an intervention for each outcome. We produced summaries of results for each intervention category.
  
  
  RESULTS
  We identified 125 reviews of varying methodological quality and summarised key findings from 50 high quality reviews. We categorised reviews by quality improvement intervention. Eight reviews were broad based (involving a variety of strategies). Other reviews considered: patient education and support (n = 21), telemedicine (n = 10), provider role changes (n = 7), and organisational changes (n = 4). Reviews reported intermediate patient outcomes (e.g. glycaemic control) (n = 49) and process of care outcomes (n = 9). There was evidence of considerable overlap of included studies between reviews.
  
  
  CONCLUSIONS
  There is consistent evidence from high quality systematic reviews that patient education and support, provider role changes, and telemedicine are associated with improvements in glycaemic and vascular risk factor control in patients. There is less evidence about the impact of quality improvement interventions on other key process measures such as screening patients for diabetic complications. This paper provides decision makers with a comprehensive overview of evidence from high quality systematic reviews about the effects of quality improvement interventions on improving diabetes care.
authors: Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada.
authors: Julia
authors: J
authors: Worswick
authors: S Carolyn
authors: SC
authors: Wayne
authors: Rachel
authors: R
authors: Bennett
authors: Michelle
authors: M
authors: Fiander
authors: Alain
authors: A
authors: Mayhew
authors: Michelle C
authors: MC
authors: Weir
authors: Katrina J
authors: KJ
authors: Sullivan
authors: Jeremy M
authors: JM
authors: Grimshaw
mesh_terms: D003695:Delivery of Health Care / Q000592:standards*; D003920:Diabetes Mellitus / Q000628:therapy*; D006801:Humans; D010353:Patient Education as Topic; D024382:Professional Role; D058996:Quality Improvement; D017216:Telemedicine
references: Am J Prev Med. 2002 May;22(4 Suppl):39-66
references: 11985934
references: Health Technol Assess. 2003;7(22):iii, 1-190
references: 13678547
references: Open Med. 2009;3(3):e123-30
references: 21603045
references: Diabet Med. 2010 Nov;27(11):1217-25
references: 20950378
references: Patient Educ Couns. 1990 Dec;16(3):189-215
references: 2149753
references: J Contin Educ Health Prof. 2006 Winter;26(1):13-24
references: 16557505
references: Am J Epidemiol. 2002 Oct 15;156(8):714-9
references: 12370159
references: Endocrinol Metab Clin North Am. 2002 Sep;31(3):633-58
references: 12227125
references: J Adv Nurs. 2010 Dec;66(12):2604-19
references: 20735504
references: PLoS Med. 2007 Mar 27;4(3):e78
references: 17388659
references: Pharmacotherapy. 2008 Apr;28(4):421-36
references: 18363526
references: BMC Endocr Disord. 2011 Jan 06;11:1
references: 21210964
references: J Diabetes Sci Technol. 2009 Nov 01;3(6):1460-71
references: 20144402
references: N Engl J Med. 2000 Apr 6;342(14):1040-2
references: 10749967
references: Res Nurs Health. 1992 Dec;15(6):409-19
references: 1448572
references: J Ambul Care Manage. 2007 Jul-Sep;30(3):218-30
references: 17581434
references: N Engl J Med. 2006 Jul 27;355(4):375-84
references: 16870916
references: Ann Intern Med. 2005 Sep 20;143(6):427-38
references: 16172441
references: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003417
references: 15846663
references: Implement Sci. 2009 Jul 16;4:40
references: 19607700
references: Lancet. 2004 May 15;363(9421):1589-97
references: 15145632
references: Cochrane Database Syst Rev. 2011 Jul 06;(7):CD009255
references: 21735443
references: Health Technol Assess. 2008 Apr;12(9):1-116, iii
references: 18405469
references: Clin Chem. 2011 Apr;57(4):568-76
references: 21368238
references: Diabet Med. 2006 May;23(5):544-56
references: 16681564
references: Health Technol Assess. 2001;5(10):1-79
references: 11319990
references: Diabet Med. 2005 Oct;22(10):1372-8
references: 16176199
references: Curr Med Res Opin. 2009 Dec;25(12):2903-13
references: 19827909
references: Ann Pharmacother. 2007 Oct;41(10):1569-82
references: 17712043
references: Diabetes Care. 2001 Oct;24(10):1821-33
references: 11574449
references: Patient Educ Couns. 2009 Apr;75(1):25-36
references: 19084368
references: Diabetes Care. 2004 May;27(5):1088-94
references: 15111526
references: J Clin Pharm Ther. 2006 Oct;31(5):409-19
references: 16958818
references: Diabet Med. 2011 Apr;28(4):455-63
references: 21392066
references: Qual Saf Health Care. 2003 Aug;12(4):298-303
references: 12897365
references: Diabet Med. 2005 Oct;22(10):1295-305
references: 16176186
references: Diabetes Obes Metab. 2009 Oct;11(10):913-30
references: 19531058
references: J Gen Intern Med. 2006 Apr;21(4):315-9
references: 16686805
references: Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005268
references: 19160249
references: CMAJ. 2011 Feb 8;183(2):E115-27
references: 21149524
references: BMC Med Res Methodol. 2007 Feb 15;7:10
references: 17302989
references: Cochrane Database Syst Rev. 2003;(2):CD003286
references: 12804458
references: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006424
references: 18646153
references: Am J Prev Med. 2007 Oct;33(4):318-35
references: 17888859
references: Patient Educ Couns. 2010 Jul;80(1):29-41
references: 19906503
references: BMJ. 1998 Aug 8;317(7155):390-6
references: 9694757
references: Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004099
references: 17443539
references: Can J Diabetes. 2013 Apr;37 Suppl 1:S1-3
references: 24070926
references: Med Care. 2004 Jun;42(6):610-21
references: 15167329
references: Diabetes Educ. 2003 May-Jun;29(3):488-501
references: 12854339
references: Patient Educ Couns. 2004 Jun;53(3):333-46
references: 15186872
references: JAMA. 2006 Jul 26;296(4):427-40
references: 16868301
references: Diabetes Care. 2001 Mar;24(3):561-87
references: 11289485
references: Diabetes Care. 2006 Jul;29(7):1675-88
references: 16801602
references: Lancet. 2012 Jun 16;379(9833):2252-61
references: 22683130
references: Implement Sci. 2010 Nov 18;5:89
references: 21087505
references: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004095
references: 15846698
references: Patient Educ Couns. 2004 Jan;52(1):97-105
references: 14729296
references: Diabetes Care. 2010 Jan;33 Suppl 1:S11-61
references: 20042772
references: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003638
references: 15846672
references: Diabet Med. 2011 Mar;28(3):250-61
references: 21309833
references: BMJ. 2006 Jul 8;333(7558):65
references: 16803942
references: Pediatr Diabetes. 2009 Nov;10(7):474-83
references: 19490492
references: Evid Rep Technol Assess (Full Rep). 2008 Apr;(166):1-144
references: 18620470
references: Ann Intern Med. 2010 Feb 16;152(4):247-58
references: 20157139
references: Diabetes Care. 2010 Apr;33(4):926-30
references: 20351228
references: Diabet Med. 2007 May;24(5):505-11
references: 17381507
references: Lancet. 2008 Jan 12;371(9607):117-25
references: 18191683
references: Int J Pediatr Endocrinol. 2010;2010:
references: 20886054
references: J Med Internet Res. 2007 Dec 14;9(5):e37
references: 18093904
references: J Clin Epidemiol. 2009 Oct;62(10):1013-20
references: 19230606