22706 名澳大利亚人 2 型糖尿病综合护理模式的溢出效应：一项开放队列分步楔形试验。

Spillover effects from a type 2 diabetes integrated model of care in 22,706 Australians: an open cohort stepped wedge trial.

机构信息

Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia.

School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.

出版信息

BMC Endocr Disord. 2024 Sep 10;24(1):183. doi: 10.1186/s12902-024-01692-4.

DOI:10.1186/s12902-024-01692-4

PMID:39256722

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11384678/

Abstract

BACKGROUND

Many Australian adults are not receiving timely or effective diabetes management to prevent or delay the onset of diabetes related complications. Integrated care, a worldwide trend in healthcare reform, aims to reduce the fragmented delivery of health services and improve outcomes. This study aimed to test whether a specialist-led integrated model of care provided to a small subset of patients in general practices leads to spillover clinical improvements in all patients of the practice with type 2 diabetes.

METHODS

Seventy-two general practice sites (clusters) in New South Wales, Australia received the Diabetes Alliance intervention, creating a non-randomised open cohort stepped wedge trial. The intervention comprised of case conferencing, delivered directly to a small proportion of adults with type 2 diabetes (n = 1,072) of the general practice sites; as well as practice feedback, education and training. Spillover clinical improvements were assessed on all adults with type 2 diabetes within the general practice sites (n = 22,706), using practice level data recorded in the MedicineInsight electronic database, compared before and after the intervention. Outcome measures included frequency of diabetes screening tests in line with the Annual Cycle of Care, and clinical results for weight, blood pressure, HbA1c, lipids, and kidney function.

RESULTS

Compared to before Diabetes Alliance, the odds of all practice patients receiving screening tests at or above the recommended intervals were significantly higher for all recommended tests after Diabetes Alliance (odds ratio range 1.41-4.45, p < 0.0001). Significant improvements in clinical outcomes were observed for weight (absolute mean difference: -1.38 kg), blood pressure (systolic - 1.12 mmHg, diastolic - 1.18 mmHg), HbA1c (-0.03% at the mean), total cholesterol (-0.11 mmol/L), and triglycerides (-0.02 mmol/L) (p < 0.05). There were small but significant declines in kidney function.

CONCLUSIONS

Integrated care delivered to a small subset of patients with type 2 diabetes across a large geographic region has spillover benefits that improve the process measures and clinical outcomes for all practice patients with type 2 diabetes.

TRIAL REGISTRATION

ACTRN12622001438741; 10th November 2022, retrospectively registered: https://www.anzctr.org.au/ACTRN12622001438741.aspx .

摘要

背景

许多澳大利亚成年人未能及时获得有效的糖尿病管理，以预防或延缓糖尿病相关并发症的发生。综合护理是医疗改革的全球趋势，旨在减少卫生服务的碎片化提供，并改善结果。本研究旨在测试在一般实践中为一小部分患者提供专家主导的综合护理模式是否会导致所有 2 型糖尿病患者的临床改善。

方法

澳大利亚新南威尔士州的 72 个普通实践地点（集群）接受了糖尿病联盟干预，创建了一个非随机开放楔形试验。该干预包括案例会议，直接提供给普通实践地点的一小部分 2 型糖尿病成年人（n=1072）；以及实践反馈、教育和培训。使用 MedicineInsight 电子数据库记录的普通实践地点内所有 2 型糖尿病成人的实践水平数据（n=22706），评估干预前后的临床改善。结果测量包括符合年度护理周期的糖尿病筛查测试频率，以及体重、血压、HbA1c、血脂和肾功能的临床结果。

结果

与糖尿病联盟前相比，所有实践患者接受所有推荐测试的筛查测试的频率均显著高于所有推荐测试（比值比范围为 1.41-4.45，p<0.0001）。体重（绝对平均差异：-1.38 公斤）、血压（收缩压-1.12 毫米汞柱，舒张压-1.18 毫米汞柱）、HbA1c（平均下降 0.03%）、总胆固醇（-0.11 毫摩尔/升）和甘油三酯（-0.02 毫摩尔/升）（p<0.05）观察到显著改善。肾功能略有下降但有统计学意义。