Table 3—

Professional and organizational interventions versus usual care

Author YearDesignIntervention i) intervention group c) control groupa) Number of providers b) Number of patients c) Number of practicesSettingFollow-up (months)Results
Conclusion
Patient outcomesProcess measures
Aubert (44) 1998 Sikka (45) 1999; U.S.RCTi) educational materials (detailed management algorithms); revision of professional roles (nurse case management); arrangements for follow-up; patient education c) no interventiona) ? (nurse) b) 138 c) 2capitated group/staff model HMO12glyc (+) bp (0) chol (0) BMI (0) s-rep health (+)microv (+)patient + process +
Hoskins (50) 1992, AustraliaRCTi) educational materials; educational outreach visits; arrangements for follow up (shared care) c1) routine care by GP c2) routine care by specialist diabetic clinica) ? (physician+nurse) b) 206 c) ?shared care: primary care physician office and hospital; fee-for-service12glyc (+)within all groups bp (+)within all groups weight (+)within shared care groupatt pat (−)within all groupspatient + I) for all three groups that were compared process − within groups
Hurwitz (51) 1993, U.K.RCTi) educational meetings; arrangements for follow-up; changes in medical record systems c) no interventiona) ? (physicians) b) 181 c) 38 general practices and 2 hospital outpatient clinicsprimary care physician office; capitation and item of service30glyc (0) microv (0) hosp (0)glyc (+) microv (+) alb (+) att pat (+)patient 0 process +
Marrero (53) 1995, U.S.RCTi) educational materials; a telecommunication system; skill mix changes; case management; changes in facilities and equipment; changes in medical record systems c) no interventiona) ? (nurse practitioners) b) 106 c) 1free-standing non-academic primary care practice; variable insurance arrangements*12glyc (0) qual life (0) hosp (0)NApatient 0
Naji (54) 1994, U.K.RCTi) educational materials; reminders; arrangements for follow up; changes in medical record systems c) patients received reminders for routine appointmentsa) ? (GPs + clinic staff involved in diabetes care) b) 274 c) 1 clinic + 3 general practicesshared care: primary care physician office and hospital; capitation and item of service, and fee-for-service (specialist ambulatory care)24glyc (0) bp (0) BMI (0) creat (0)glyc (+) bp (+) creat (0) microv (+) att pat (+)patient 0 process +
Nilasena (55) 1995, U.S.RCTi) educational materials; reminders; changes in medical record systems c) no interventiona) 35 b) 164 c) 2hospital-based academic primary care clinic; federal program6 NAcompl (0)between groups, but within both groups (+)process +within both groups
Rutten (59) 1990, the NetherlandsRCTi) educational materials; case management c) no interventiona) ? (GPs supported by nurses) b) 149 c) 8primary care physician office; capitation (social)+ fee-for-service (private)12glyc (+)# weight (0)#NApatient +
See Tai (60) 1999, U.K.RCTi) reminders; changes in medical record system (implementation of new diabetes templates) c) usual diabetes care (usual basic template), but implementation of new asthma templatesa) 17 GPs and 11 practice nurses b) 167 c) 6primary care physician office; capitation and item of service12NAcompl (+)process +not statistically tested, but a positive trend
Shultz (61) 1992, U.S.RCTi) a telecommunication system; changes in facilities and equipment; changes in medical record systems c) no interventiona) ? (physicians) b) 30 c) 1Veteran’s Administration hospital clinic; federal program15glyc (+)NApatient +
Stein (62) 1974, U.S.RCTi) educational materials; revision of professional roles; patient education c) no interventiona) nurse practitioner + clinic physician(s) b) 28 c) 1hospital-based primary care clinic; variable insurance arrangements6glyc (0) weight (0)NApatient 0
Vinicor (64) 1987 Mazzuca (65) 1988; U.S.RCTFor patient outcomes (39) i1) patient education i2) physician education: educational materials; local consensus processes; audit and feedback; reminders; communication and case discussion between distant health professionals; i3) patient education + physician education c) no intervention For process measures (58) i) i2+i3 c) i1+ca) 86 residents b) 532 c) 1hospital-based academic primary care clinic; variable insurance arrangementsprocess measures: 11 patient: 26glyc (+i1,i2,i3)# bp (+i1)# weight (+i1,i3)#glyc (+)# bp (0)# chol (+)# creat (0)# microv (0)#patient + process +
Weinberger (66) 1995 Kirkman (67) 1994; U.S.RCTi) patient mediated interventions (nurses attempted to telephone patients to facilitate compliance, monitor patients’ health status, facilitate resolution of identified problems, facilitate access to primary care); arrangements for follow up; patient education c) no interventiona) ? b) 275 c) 1Veteran’s Administration hospital clinic; federal program12glyc (+) chol (0) weight (0) qual life (0)NApatient +
Boucher (46) 1987, U.K.CBAi) educational materials; educational meetings; arrangements for follow up; communication and case discussion between distant health professionals; changes in medical record systems c) no interventiona) ? (physicians, supported by nurses) b) 217 c) 3general medicine clinic; capitation and item of service24glyc (+)#withinatt pat (+/−)no statistical analyses but a positive trendpatient +within process +/−no statistical analyses but a positive trend
Deeb (47) 1988, U.S.CBAi) educational materials; educational meetings; educational outreach visits; clinical multidisciplinary team; patient education c) no interventiona) ? (physician+nurses) b) 1,029 were identified and their records were reviewed at baseline. Only 636 of the patients were seen during the year after the intervention c) 6federally funded primary care centers; variable insurance arrangements12NAbp (0)# microv (+)#process +within
Hartmann (48) 1995 Hartmann (49) 1995; GermanyCBAi) educational materials; educational meetings; audit and feedback; changes in medical record systems c) no interventiona) 17 (physicians) b) 403 c) 17primary care physician office; fee-for-service12NAglyc (0)# bp (0)# chol (+)# weight (0)# creat (+)# microv (+)#process 0(documented quarterly) process +(docu- ment ed yearly)
Legorreta (52) 1996, U.S.CBAi) educational materials; educational meetings; clinical multidisciplinary teams; skill mix changes; arrangements for follow up; changes in medical records systems c) no interventiona) ? (physicians + nurses/physician assistant) b) Site A: 205, Site B: 195 c) ?practices affiliated with Network or Independent Practice Association (IPA) HMO18glyc (+)#NApatient +
O’Connor (56) 1995, U.S.CBAi) local consensus procedures; skill mix changes; more aggressive educational outreach to patients c) no interventiona) ? (physicians + nurses) b) 267 c) 2 clinicscapitated group/staff model HMO18glyc (+)#glyc (+)#within both groups, no difference between both groups att pat (+/−)#patient + process +within both groups, not statistically tested
Peters (57) 1998, U.S.CBAi) educational materials; audit and feedback; revision of professional roles; arrangements for follow up; changes in medical record systems c) no interventiona) providers- ? (nurse practitioners) b) 164 c) 1 medical center vs. 1 HMOpractices affiliated with Network or Independent Practice Association (IPA) HMO36glyc (+) chol (+)within interv groupglyc (+) chol (+) microv (+)patient + process +not statis- tically tested
Taplin (63) 1998, U.S.CBAi) educational materials; local consensus processes; audit and feedback; reminders; marketing (establishing a team and after that, regular team meetings to discuss and achieve clinical goals); clinical multidisciplinary team; changes in medical record systems c) no interventiona) ? (physicians supported by nurses) b)? (the number of patients that visited the practice for diabetes care is not reported separately). In total, 9,754 patients were included for studying compliance with guidelines for different areas c) 6capitated group/staff model HMO24NAcompl microv (0)#process 0
Rith-Najarian (58) 1998, U.S.ITSi) educational materials; reminders; clinical multidisciplinary teama) 1 physician + 3 nurses (+nutritionist +registrar) b) 449 c) 1Indian Health service clinic; federal program36microv (0)microv (0)patient 0 process 0
  • *

    * In the U.S., most practices, whether hospital based or not, care for patients under a variety of insurance arrangements: government (Medicare, Medicaid) or private (HMO or indemnity [fee-for-service]). ?, not reported; +, positive effect; 0, no effect; −, negative effect; +/−, effect unclear; NA, not applicable; #, possible unit of analysis error; within, differences are statistically tested within groups only, not between groups; alb, albumin; att pat, attendance patients; bp, blood pressure; comp, compliance care provider; CBA, controlled before-after study; creat, creatinine; glyc, glycemic control; HMO, health maintenance organization; hlth surv, health survey; hosp, hospitalizations; macrov, macrovascular complications; microv, microvascular complications; qual life, quality of life; RCT, randomized controlled trial.