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Diabetes Care 24:1821-1833, 2001
© 2001 by the American Diabetes Association, Inc.

Reviews/Commentaries/Position Statements
Review Article

Interventions to Improve the Management of Diabetes in Primary Care, Outpatient, and Community Settings

A systematic review

Carry M. Renders, MSC1, Gerlof D. Valk, MD, PHD1, Simon J. Griffin, MBBS, MSC, DM, MRCGP2, Edward H. Wagner, MD, MPH3, Jacques ThM. Eijk van, PHD4 and Willem J.J. Assendelft, MD, PHD5,6

1 Institute for Research in Extramural Medicine, Department of General Practice, Vrije Universiteit Medical Center, Amsterdam, the Netherlands
2 Department of Public Health and Primary Care, University of Cambridge, Cambridge, U.K.
3 MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Washington
4 Department of Medical Sociology, Universiteit van Maastricht, Maastricht, the Netherlands
5 Dutch Cochrane Centre, Academic Medical Center, Amsterdam, the Netherlands
6 Division of Public Health, Department of General Practice, Academic Medical Center, Amsterdam, the Netherlands

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.

Abbreviations: EPOC, Effective Practice and Organization of Care • ITS, interrupted time series


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