Evaluating the effects of a multi-factorial quality improvement (QI) strategy targeted at primary care health care professionals on management of people with diabetes

Diabetes has now been recognised as an epidemic globally. The burden of the disease and its complications are outstripping health care systems all over the world. The rising prevalence coupled with the increasing life expectancy makes it impossible for specialist centres to cope with the demands of diabetes care, which was the case until 20-30 years ago, thus necessitating a “left shift” to primary care. The aim of this research is to critically appraise the evidence on the effectiveness of interventions targeting primary care professionals on improvement of cardio-metabolic risk factors including glycated Haemoglobin (HbA1c), blood pressure and total or LDL-cholesterol. A further aim is to quantify the effect of intensive glucose lowering either alone or as part of a multifactorial intervention on non-fatal myocardial infarction (MI), non-fatal stroke, cardiovascular disease (CV) mortality and all-cause mortality in patients with type 2 diabetes. Finally, the impact of any interventions effective in controlling the cardio-metabolic risk factors will be considered in a real world restructured diabetes service on non-elective bed days, outpatient attendances and hospitalisation for diabetes and its complications will be assessed. This thesis used 2 methodologies. In the first instance, a systematic review of interventions targeting primary care professionals on improvement of cardio-metabolic risk factors, and another systematic review and meta-analysis of studies on intensive glucose lowering and multifactorial interventions on cardiovascular and mortality outcomes were conducted. Secondly, a before- and-after study of general practices on non-elective bed days, outpatient attendances and hospitalisation for diabetes and its complications was also conducted. Main findings: 1. A systematic review of interventions targeting primary careprofessionals on improvement of cardio-metabolic risk factorsshowed that multifaceted professional interventions were moreeffective than single interventions targeting single primary orcommunity care professionals in improving glycaemic control. 2. A meta-analysis of studies on intensive glucose lowering andmultifactorial interventions on cardiovascular and mortalityoutcomes showed that apart from non-fatal myocardial infarctions,there was no evidence that intensive treatment reduced the risk ofcardiovascular and mortality outcomes. Compared to standardcare, intensive glucose lowering and multi-factorial interventionreduced the risk of non-fatal MI (RR 0.89, 95% CI 0.83 to 0.96) butnot non-fatal stroke (RR 0.96, 95% CI 0.86 to 1.07), CV mortality(RR 1.01, 95% CI 0.91 to 1.13) or all-cause mortality (RR 1.01, 95%CI 0.94 to 1.08). The predictions indicated that, intensive glucoselowering is more likely to be beneficial in populations where thebaseline incidence of CVD mortality is greater than 6.3 deaths per1000 person-years. 3. A before-and-after analysis of a structured diabetes shared careservice redesign, involving enhanced diabetes-skilled primary carephysicians, nurses and health care assistants in primary caresettings was conducted. Compared to an integrated specialist–community care core diabetes service, the new enhanced servicedid not show an increase hospitalisation (the difference betweenthe non-elective bed days in core practices and that in enhancedpractices was not significant, mean = 2.20 per 100 patients, p =0.14)), first outpatients’ attendances (the difference between the mean first outpatient attendance in the core practices and that in enhanced practices was 0.02 per 100 patients p=0.92) and admissions for diabetes related complications (the difference was 0.30 per 100 patients, p=0.55). Conclusion: The rising demand of diabetes care requires a primary care well organised to deliver a diabetes services without compromising quality. A well-organised multidisciplinary diabetes-skilled primary care team, using multi-faceted interventions, can deliver a diabetes service without increasing diabetes related complications, out-patient attendances and hospitalisations. Cardio-metabolic risk factor control is an essential part of diabetes management. Intensive glucose lowering and multifactorial interventions can reduce non-fatal myocardial infarctions.