Chronic Disease

Most quality improvement strategies produce only small to modest improvements in glycemic control among patients with diabetes

Diabetes is reaching epidemic proportions in the United States. Efforts to improve diabetes care to minimize serious diabetes-related complications result in many interventions; however, most quality improvement (QI) strategies examined in a recent study produced only small to modest improvements in glycemic (blood-sugar) control among patients with diabetes. Case management in which nurse or pharmacist case managers could make independent medication changes was associated with substantially larger improvements in glycemic control than any other strategy.

Researchers systematically reviewed studies to assess the impact of 11 QI strategies on the glycemic control of adults with type 2 diabetes. They measured improved glycemic control based on the difference between baseline and post-QI intervention HbA1c (glycemic) values. Across 66 studies, QI interventions reduced HbA1c values by a mean of 0.42 percent over a median of 13 months of followup. QI strategies in trials with patients whose diabetes was poorly controlled (mean baseline HbA1c values of 8 percent or greater) reported significantly greater effects (0.54 vs. 0.20 percent).

Two of the 11 categories of QI strategies studied were associated with reduction in HbA1c values of at least 0.50 percent: team changes (0.67 percent) and case management (0.52 percent). QI programs involving team changes reduced HbA1c values by 0.33 percent more than those without team changes. Those involving case management reduced values by 0.22 percent more than those without case management. QI strategies in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced HbA1c values by 0.80 percent versus only 0.32 percent for all other strategies.

See "Effects of quality improvement strategies for type 2 diabetes on glycemic control," by Kaveh G. Shojania, M.D., Sumant R. Ranji, M.D., Kathryn M. McDonald, M.M., and others, in the July 26, 2006, Journal of the American Medical Association 296(4), pp. 427-440.

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