Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada.
Lancet. 2012 Jun 16;379(9833):2252-61. doi: 10.1016/S0140-6736(12)60480-2. Epub 2012 Jun 9.
The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA(1c)), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes.
We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias.
We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84,865 patients, and 94 patient randomised controlled trials, including 38,664 patients. In random effects meta-analysis, the QI strategies reduced HbA(1c) by a mean difference of 0·37% (95% CI 0·28-0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05-0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19-4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95-2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA(1c), 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA(1c) control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21-1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01-1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13-1·32), renal function (14 trials; RR 128, 1·13-1·44), and foot abnormalities (22 trials; RR 1·27, 1·16-1·39). However, statin use (ten trials; RR 1·12, 0·99-1·28), hypertension control (18 trials; RR 1·01, 0·96-1·07), and smoking cessation (13 trials; RR 1·13, 0·99-1·29) were not significantly increased.
Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA(1c) control is poor.
Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates--Health Solutions).
质量改进（QI）策略对糖尿病护理的有效性仍不清楚。我们旨在评估 QI 策略对糖化血红蛋白（HbA（1c））、血管风险管理、微血管并发症监测和糖尿病患者戒烟的影响。
我们通过 Medline、Cochrane 有效实践和组织护理数据库（从开始到 2010 年 7 月）以及纳入的随机临床试验的参考文献确定了研究。我们纳入了评估 11 种预先确定的 QI 策略或针对卫生系统、卫生保健专业人员或患者的经济激励措施的试验，以改善成年门诊糖尿病患者的管理。两名评审员独立提取数据并评估偏倚风险。
我们审查了 48 项群组随机对照试验，包括 2538 个群组和 84865 名患者，以及 94 项患者随机对照试验，包括 38664 名患者。在随机效应荟萃分析中，QI 策略使 HbA（1c）平均降低了 0.37%（95%CI 0.28-0.45；120 项试验）、LDL 胆固醇降低了 0.10mmol/L（0.05-0.14；47 项试验）、收缩压降低了 3.13mmHg（2.19-4.06；65 项试验）和舒张压降低了 1.55mmHg（0.95-2.15；61 项试验），与常规护理相比。我们注意到，当基线浓度大于 8.0%的 HbA（1c）、2.59mmol/L 的 LDL 胆固醇、80mmHg 的舒张压和 140mmHg 的收缩压时，效果更大。QI 策略的有效性取决于基线 HbA（1c）控制情况。QI 策略增加了患者接受阿司匹林（11 项试验；相对风险[RR]1.33，95%CI 1.21-1.45）、抗高血压药物（10 项试验；RR 1.17，1.01-1.37）和视网膜病变筛查（23 项试验；RR 1.22，1.13-1.32）、肾功能（14 项试验；RR 128，1.13-1.44）和足部异常（22 项试验；RR 1.27，1.16-1.39）的可能性。然而，他汀类药物的使用（10 项试验；RR 1.12，0.99-1.28）、高血压控制（18 项试验；RR 1.01，0.96-1.07）和戒烟（13 项试验；RR 1.13，0.99-1.29）并未显著增加。
许多 QI 策略试验显示出对糖尿病护理的改善。针对慢性病管理系统的干预措施以及患者介导的 QI 策略应该是旨在改善糖尿病管理的干预措施的重要组成部分。仅针对卫生保健专业人员的干预措施似乎只有在基线 HbA（1c）控制不佳的情况下才有益。
安大略省卫生部和长期护理部以及艾伯塔省遗产基金会医学研究（现为艾伯塔省创新--健康解决方案）。
