Ottawa Hospital Research Institute, The Ottawa Hospital-General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
Implement Sci. 2018 May 2;13(1):65. doi: 10.1186/s13012-018-0754-5.
National diabetes audits in the UK show room for improvement in the quality of care delivered to people with type 2 diabetes in primary care. Systematic reviews of quality improvement interventions show that such approaches can be effective but there is wide variability between trials and little understanding concerning what explains this variability. A national cohort study of primary care across 99 UK practices identified modifiable predictors of healthcare professionals' prescribing, advising and foot examination. Our objective was to evaluate the effectiveness of an implementation intervention to improve six guideline-recommended health professional behaviours in managing type 2 diabetes in primary care: prescribing for blood pressure and glycaemic control, providing physical activity and nutrition advice and providing updated diabetes education and foot examination.
Two-armed cluster randomised trial involving 44 general practices. Primary outcomes (at 12 months follow-up): from electronic medical records, the proportion of patients receiving additional prescriptions for blood pressure and insulin initiation for glycaemic control and having a foot examination; and from a patient survey of a random sample of 100 patients per practice, reported receipt of updated diabetes education and physical activity and nutrition advice.
The implementation intervention did not lead to statistically significant improvement on any of the six clinical behaviours. 1,138,105 prescriptions were assessed. Intervention (29% to 37% patients) and control arms (31% to 35%) increased insulin initiation relative to baseline but were not statistically significantly different at follow-up (IRR 1.18, 95%CI 0.95-1.48). Intervention (45% to 53%) and control practices (45% to 50%) increased blood pressure prescription from baseline to follow-up but were not statistically significantly different at follow-up (IRR 1.05, 95%CI 0.96 to 1.16). Intervention (75 to 78%) and control practices (74 to 79%) increased foot examination relative to baseline; control practices increased statistically significantly more (OR 0.84, 95%CI 0.75-0.94). Fewer patients in intervention (33%) than control practices (40%) reported receiving updated diabetes education (OR = 0.74, 95%CI 0.57-0.97). No statistically significant differences were observed in patient reports of having had a discussion about nutrition (intervention = 73%; control = 72%; OR = 0.98, 95%CI 0.59-1.64) or physical activity (intervention = 57%; control = 62%; OR = 0.79, 95%CI 0.56-1.11). Development and delivery of the intervention cost £1191 per practice.
There was no measurable benefit to practices' participation in this intervention. Despite widespread use of outreach interventions worldwide, there is a need to better understand which techniques at which intensity are optimally suited to address the multiple clinical behaviours involved in improving care for type 2 diabetes.
ISRCTN, ISRCTN66498413 . Registered April 4, 2013.
英国的全国糖尿病审计显示，初级保健机构在提供 2 型糖尿病患者护理方面还有改进的空间。系统评价质量改进干预措施表明，此类方法可能有效，但试验之间存在很大差异，并且对于导致这种差异的原因了解甚少。对英国 99 个实践中的初级保健进行的全国队列研究确定了医疗保健专业人员处方、建议和足部检查的可修改预测因子。我们的目标是评估一项实施干预措施的有效性，该干预措施旨在改善六项指南推荐的健康专业人员行为，以管理初级保健中的 2 型糖尿病：为血压和血糖控制开处方、提供身体活动和营养建议以及提供更新的糖尿病教育和足部检查。
一项涉及 44 家普通诊所的双臂群组随机试验。主要结果（12 个月随访）：从电子病历中评估，接受额外血压处方和胰岛素起始治疗血糖控制以及接受足部检查的患者比例；以及从每个实践的随机 100 名患者的患者调查中评估，报告接受更新的糖尿病教育和身体活动和营养建议。
实施干预措施并没有导致任何 6 项临床行为的统计学显著改善。评估了 1138105 张处方。干预组（29%至 37%的患者）和对照组（31%至 35%的患者）与基线相比增加了胰岛素起始治疗，但在随访时没有统计学显著差异（IRR 1.18，95%CI 0.95-1.48）。干预组（45%至 53%）和对照组（45%至 50%）从基线到随访期间增加了血压处方，但在随访时没有统计学显著差异（IRR 1.05，95%CI 0.96 至 1.16）。干预组（75%至 78%）和对照组（74%至 79%）与基线相比增加了足部检查；对照组的增加具有统计学显著意义（OR 0.84，95%CI 0.75-0.94）。与对照组（40%）相比，接受更新的糖尿病教育的患者比例（33%）在干预组中较少（OR = 0.74，95%CI 0.57-0.97）。在患者关于营养（干预组= 73%；对照组= 72%；OR = 0.98，95%CI 0.59-1.64）或体力活动（干预组= 57%；对照组= 62%；OR = 0.79，95%CI 0.56-1.11）的讨论方面，两组之间没有统计学显著差异。干预措施的开发和实施成本为每个实践 1191 英镑。
实践参与该干预措施没有带来可衡量的益处。尽管全世界广泛使用外展干预措施，但需要更好地了解哪种技术在何种强度下最适合解决改善 2 型糖尿病护理所涉及的多种临床行为。
ISRCTN，ISRCTN66498413。2013 年 4 月 4 日注册。
