A multicomponent intervention improved diabetes care in primary care practices
Does a multicomponent intervention improve diabetes care in primary care practices?
cluster-randomised controlled trial (TRANSLATE). ClinicalTrials.gov NCT00108927.
24 family medicine or general internal medicine primary care practices (238 physicians) in Minnesota, USA. Practices were excluded if they already had electronic medical records or an electronic diabetes registry, or had recently participated in a diabetes-specific quality improvement programme.
8405 community-dwelling patients 18–89 years of age (mean age 63 y, 50% men) who had type 2 diabetes that was managed or co-managed by a physician in 1 of the primary care practices.
TRANSLATE intervention (12 practices, 4587 patients) or usual quality improvement (12 practices, 3818 patients). Components of the TRANSLATE intervention were Target high-risk patients; create an electronic diabetes Registry; set up Administration to oversee changes; Notify patients of targets and appointments and remind providers with patient-specific alerts; identify a Site coordinator; identify a Local physician champion; Audit monthly and provide feedback; Track process measures and patient outcomes; and Educate staff in evidence-based diabetes management.
proportions of patients achieving recommended targets for systolic blood pressure (SBP, <130 mm Hg), glycated haemoglobin concentration (HbA1c, <7.0%), and low-density lipoprotein cholesterol concentration (LDL-C, <2.6 mmol/l); and change in diabetes performance measures.
84% (intention-to-treat analysis).
Patients in intervention practices were more likely than those in control practices to achieve targets for SBP, HBA1c, LDL-C, and all 3 combined (table). Compared with control practices, intervention practices increased renal testing by 29%, annual eye examinations by 26%, foot examinations by 35%, HbA1c testing by 8.1%, and LDL-C testing by 8.6% (absolute differences, p<0.001 for all).
A multicomponent intervention improved diabetes care and patient outcomes in primary care practices.
Peterson KA, Radosevich DM, O’Connor PJ, et al. Improving diabetes care in practice: findings from the TRANSLATE trial. Diabetes Care 2008;31:2238–43.
▸ Clinical impact ratings: Endocrinology 6/7; Family/general practice 6/7; General/internal medicine 6/7
Source of funding: National Institute of Diabetes, Digestive, and Kidney Disorders and National Institutes of Health.
Translating evidence-based recommendations for managing diabetes to clinical care is essential for improving outcomes in adults with diabetes. The TRANSLATE intervention, which targeted organisational factors, improved diabetes care processes (completing recommended screening) and increased the proportion of patients meeting goals for metabolic, blood pressure, and lipid control compared with standard care. However, the proportion of patients in the TRANSLATE intervention group meeting individual goals ranged from 43% to 49%, with only 13% meeting goals across all parameters.
Peterson et al noted that process measures often improve more quickly and easily than clinical outcomes. Evaluation of intermediate links in the chain of effect, such as patient adherence to medications and active participation in self-management, is needed. 1 In addition, interventions targeting patient self-management are essential to improving outcomes in diabetes care. Fisher et al proposed that self-management and quality clinical care are dependent on each other for improving clinical outcomes.2 Without quality clinical care, self-management can not be optimised. Without self-management interventions, quality clinical care will not reach its full potential. The complexity of diabetes care merits the kind of multifaceted organisational intervention used in the TRANSLATE trial to improve clinical processes, in combination with ongoing self-management interventions to improve patient adherence to medications, health behaviours, and psychosocial adjustment.