PhD Student/Researcher, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Senior Researcher, Health Technology and Services Research, University of Twente, Enschede, The Netherlands Senior Researcher PhD Student/Researcher Senior Researcher, Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands PhD Student/Researcher Professor, Department of Integrated Care, TRANZO, Tilburg University, Tilburg, The Netherlands Senior Researcher, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands Senior Researcher, Netherlands Institute for Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands.
J Eval Clin Pract. 2013 Oct;19(5):753-62. doi: 10.1111/j.1365-2753.2012.01817.x. Epub 2012 Feb 29.
The study aims to support decision making on how best to redesign diabetes care by investigating three potential sources of heterogeneity in effectiveness across trials of diabetes care management.
Medline, CINAHL and PsycInfo were searched for systematic reviews and empirical studies focusing on: (1) diabetes mellitus; (2) adult patients; and (3) interventions consisting of at least two components of the chronic care model (CCM). Systematic reviews were analysed descriptively; empirical studies were meta-analysed. Pooled effect measures were estimated using a meta-regression model that incorporated study quality, length of follow-up and number of intervention components as potential predictors of heterogeneity in effects.
Overall, reviews (n = 15) of diabetes care programmes report modest improvements in glycaemic control. Empirical studies (n = 61) show wide-ranging results on HbA1c, systolic blood pressure and guideline adherence. Differences between studies in methodological quality cannot explain this heterogeneity in effects. Variety in length of follow-up can explain (part of) the variability, yet not across all outcomes. Diversity in the number of included intervention components can explain 8-12% of the heterogeneity in effects on HbA1c and systolic blood pressure.
The outcomes of chronic care management for diabetes are generally positive, yet differ considerably across trials. The most promising results are attained in studies with limited follow-up (<1 year) and by programmes including more than two CCM components. These factors can, however, explain only part of the heterogeneity in effectiveness between studies. Other potential sources of heterogeneity should be investigated to ensure implementation of evidence-based improvements in diabetes care.
通过调查糖尿病护理管理试验中有效性的三个潜在异质性来源，为如何最佳重新设计糖尿病护理提供决策支持。
在 Medline、CINAHL 和 PsycInfo 上搜索了系统评价和实证研究，重点关注：（1）糖尿病；（2）成年患者；以及（3）至少包含慢性护理模型（CCM）两个组成部分的干预措施。系统评价进行描述性分析；实证研究进行荟萃分析。使用元回归模型估计汇总效果测量值，该模型将研究质量、随访时间和干预措施的数量作为影响异质性的潜在预测因素纳入其中。
总体而言，糖尿病护理方案的综述（n=15）报告血糖控制有适度改善。实证研究（n=61）显示 HbA1c、收缩压和指南依从性的结果差异很大。研究方法质量的差异不能解释这些效果异质性。随访时间的长短差异可以解释（部分）变异性，但并非跨越所有结果。纳入干预措施数量的多样性可以解释 HbA1c 和收缩压效果异质性的 8-12%。
慢性护理管理治疗糖尿病的结果通常是积极的，但在试验之间存在很大差异。在随访时间有限（<1 年）和包含超过两个 CCM 组成部分的方案的研究中，取得了最有希望的结果。然而，这些因素只能解释研究之间有效性异质性的一部分。应该调查其他潜在的异质性来源，以确保在糖尿病护理中实施基于证据的改进。
