Mathematica, Princeton, New Jersey, USA.
Leicester Real World Evidence Unit, Leicester Diabetes Research Centre, University of Leicester, Leicester, UK.
Diabetes Obes Metab. 2021 Sep;23(9):2137-2154. doi: 10.1111/dom.14455. Epub 2021 Jun 27.
To systematically investigate the effect of interventions to overcome therapeutic inertia on glycaemic control in individuals with type 2 diabetes.
We electronically searched for randomized controlled trials or quasi-experimental studies published between January 1, 2004 and December 31, 2019 evaluating the effect of interventions on glycated haemoglobin (HbA1c) control. Characteristics of included studies and HbA1c difference between intervention and control arms (main outcome) were extracted. Interventions were grouped as: care management and patient education; nurse or certified diabetes educator (CDE); pharmacist; or physician-based.
Thirty-six studies including 22 243 individuals were combined in nonlinear random-effects meta-regressions; the median (range) duration of intervention was 1 year (0.9 to 36 months). Compared to the control arm, HbA1c reduction ranged from: -17.7 mmol/mol (-1.62%) to -4.4 mmol/mol (-0.40%) for nurse- or CDE-based interventions; -13.1 mmol/mol (-1.20%) to 3.3 mmol/mol (0.30%) for care management and patient education interventions; -9.8 mmol/mol (-0.90%) to -6.6 mmol/mol (-0.60%) for pharmacist-based interventions; and -4.4 mmol/mol (-0.40%) to 2.8 mmol/mol (0.26%) for physician-based interventions. Across the included studies, a reduction in HbA1c was observed only during the first year (6 months: -4.2 mmol/mol, 95% confidence interval [CI] -6.2, -2.2 [-0.38%, 95% CI -0.56, -0.20]; 1 year: -1.6 mmol/mol, 95% CI -3.3, 0.1 [-0.15%, 95% CI -0.30, 0.01]) and in individuals with preintervention HbA1c >75 mmol/mol (9%).
The most effective approaches to mitigating therapeutic inertia and improving HbA1c were those that empower nonphysician providers such as pharmacists, nurses and diabetes educators to initiate and intensify treatment independently, supported by appropriate guidelines.
系统研究克服治疗惰性的干预措施对 2 型糖尿病患者血糖控制的影响。
我们电子检索了 2004 年 1 月 1 日至 2019 年 12 月 31 日期间发表的随机对照试验或准实验研究，评估了干预措施对糖化血红蛋白（HbA1c）控制的影响。提取纳入研究的特征和干预组与对照组之间的 HbA1c 差异（主要结局）。干预措施分为：护理管理和患者教育；护士或认证糖尿病教育者（CDE）；药剂师；或基于医生的干预。
36 项研究共纳入 22243 例患者，采用非线性随机效应荟萃回归进行组合分析；干预的中位（范围）持续时间为 1 年（0.9 至 36 个月）。与对照组相比，HbA1c 降低幅度为：护士或 CDE 为 -17.7mmol/mol（-1.62%）至 -4.4mmol/mol（-0.40%）；护理管理和患者教育为 -13.1mmol/mol（-1.20%）至 3.3mmol/mol（0.30%）；药剂师为 -9.8mmol/mol（-0.90%）至 -6.6mmol/mol（-0.60%）；基于医生的干预为 -4.4mmol/mol（-0.40%）至 2.8mmol/mol（0.26%）。在纳入的研究中，HbA1c 降低仅在第一年（6 个月：-4.2mmol/mol，95%置信区间[CI]：-6.2，-2.2[-0.38%，95% CI：-0.56，-0.20]；1 年：-1.6mmol/mol，95% CI：-3.3，0.1[-0.15%，95% CI：-0.30，0.01]）和干预前 HbA1c＞75mmol/mol（9%）的患者中观察到。
最有效的克服治疗惰性和改善 HbA1c 的方法是授权非医师提供者（如药剂师、护士和糖尿病教育者）独立启动和强化治疗，同时辅以适当的指南。
