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Interventions to Improve theManagement of Diabetes in PrimaryCare, Outpatient, and Community

SettingsA systematic review

CARRY M. RENDERS, MSC1

GERLOF D. VALK, MD, PHD1

SIMON J. GRIFFIN, MBBS, MSC, DM, MRCGP2

EDWARD H. WAGNER, MD, MPH3

JACQUES THM. EIJK VAN, PHD4

WILLEM J.J. ASSENDELFT, MD, PHD5,6

OBJECTIVE To review the effectiveness of interventions targeted at health care profes-sionals and/or the structure of care in order to improve the management of diabetes in primarycare, outpatient, and community settings.

RESEARCH DESIGN AND METHODS A systematic review of controlled trials eval-uating the effectiveness of interventions targeted at health care professionals and aimed atimproving the process of care or patient outcomes for patients with diabetes was performed.Standard search methods of the Cochrane Effective Practice and Organization of Care Groupwere used.

RESULTS A total of 41 studies met the inclusion criteria. The studies identified wereheterogeneous in terms of interventions, participants, settings, and reported outcomes. In allstudies, the interventions were multifaceted. The interventions were targeted at health careprofessionals only in 12 studies, at the organization of care only in 9 studies, and at both in 20studies. Complex professional interventions improved the process of care, but the effect onpatient outcomes remained less clear because such outcomes were rarely assessed. Organiza-tional interventions that facilitated the structured and regular review of patients also showed afavorable effect on process measures. Complex interventions in which patient education wasadded and/or the role of a nurse was enhanced led to improvements in patient outcomes as wellas the process of care.

CONCLUSIONS Multifaceted professional interventions and organizational interven-tions that facilitate structured and regular review of patients were effective in improving theprocess of care. The addition of patient education to these interventions and the enhancement ofthe role of nurses in diabetes care led to improvements in patient outcomes and the process ofcare.

Diabetes Care 24:18211833, 2001

Diabetes is a major and growinghealth care problem. Primarily be-cause of the increasing prevalence

of type 2 diabetes as well as the increase incases of type 1 diabetes (1), it is expectedthat the number of people with diabeteswill double by the year 2010 (2).

Diabetes accounts for a huge bur-den of morbidity and mortality throughmicro- and macrovascular complications(3,4). However, it is now clear that strictcontrol of blood glucose, blood pressure,and cholesterol can reduce the risk ofdiabetes-related complications (58). Toachieve strict control, structured care isneeded (9).

Over the past 20 years, the responsi-bility for the care of people with diabeteshas shifted away from hospitals to pri-mary care (10,11). During this period,randomized trials have demonstrated that

if regular review of patients is guaranteed,the standard of primary care can be asgood or better than hospital outpatientcare in the short term (9). Several guide-lines and diabetes management programshave been developed nationally and lo-cally to improve diabetes care in the com-munity. However, empirical data suggestthat compliance with diabetes clinicalpractice recommendations is inadequatein primary care (1214) and that a largeproportion of patients with diabetes re-main at high risk (15,16).

Consequently, a wide range of inter-ventions aimed at improving the provi-sion of diabetes care and achieving bettermetabolic control for patients with diabe-tes have been implemented. This reviewaddresses the issue of understanding thebest way to narrow the gap between whatis known to be effective in diabetes careand the care that is currently provided.Therefore, the objective was to determinethe effectiveness of the different interven-tions targeted at health care professionalsand/or the structure of care in order to

From the 1Institute for Research in Extramural Medicine, Department of General Practice, Vrije UniversiteitMedical Center, Amsterdam, the Netherlands; the 2Department of Public Health and Primary Care, Univer-sity of Cambridge, Cambridge, U.K.; the 3MacColl Institute for Healthcare Innovation, Center for HealthStudies, Group Health Cooperative of Puget Sound, Seattle, Washington; the 4Department of MedicalSociology, Universiteit van Maastricht, Maastricht, the Netherlands; the 5DutchCochrane Centre, AcademicMedical Center, Amsterdam, the Netherlands; and the 6Division of Public Health, Department of GeneralPractice, Academic Medical Center, Amsterdam, the Netherlands.

Address correspondence and reprint requests to Carry Renders, MSc, Institute for Research in ExtramuralMedicine, Vrije Universiteit Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Nether-lands. E-mail: [email protected].

Received for publication 29 March 2001 and accepted in revised form 6 July 2001.Abbreviations: EPOC, Effective Practice and Organization of Care; ITS, interrupted time series.

A table elsewhere in this issue shows conventional and Systeme International (SI) units and conversionfactors for many substances.

R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t s

R E V I E W A R T I C L E

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improve the management of patients withdiabetes in primary care, outpatient, andcommunity settings.

RESEARCH DESIGN ANDMETHODS

Identification of studiesThis review was conducted within theEffective Practice and Organization ofCare (EPOC) review group of the Coch-rane Collaboration (17). The CochraneCollaboration is an international organi-zation that aims to help people make well-informed decisions about health care bypreparing, maintaining, and promotingthe accessibility of systematic reviews ofthe effects of health care interventions.Systematic reviews are reviews regardinga well-formulated clinical question thatuse systematic and explicit methods toidentify, select, and critically appraise rel-evant research and to collect and analyzedata from the studies that are included inthe review. Cochrane reviews provide up-to-date, comprehensive, and unbiasedsummaries of the best available evidence.These reviews are published electroni-cally in the Cochrane Library.

The EPOC search strategy was com-bined with free-text words and key wordsregarding diabetes and primary care,community care, or outpatient care.

The following electronic databases weresearched for relevant studies: Medline(1966 2000), Embase (1980 2000),Cinahl (19822000), theEPOC trials reg-ister (1999), and the Cochrane ClinicalTrials Register (1999). Additionally, wescanned the reference lists of all relevantstudies.

Study selectionWe included studies that evaluated theeffectiveness of interventions directed athealth care professionals who care for

nonhospitalized patients with type 1 ortype 2 diabetes in primary care, outpa-tient, or community settings. Studieswere included if they fulfilled the follow-ing EPOC group methodological andquality criteria (18): 1) randomized orquasi-randomized trials randomized bypatient, health care professional, or prac-tice; 2) interrupted time series (ITS) witha clearly defined intervention and at leastthree time points before and three afterthe intervention; and 3) nonrandomizedstudies controlled at a second site with

data before and after the intervention andappropriate choice of control site.

Only studies using a reliable, objec-tive, and predetermined measure of theprocess of healthcare or patient outcomeswere included. Interventions were classi-fied as professional interventions (suchas education, audit, and feedback), or-ganizational interventions (such as revi-sion of professional roles, changes inmedical record systems, and arrange-ments for follow-up), financial interven-tions (such as fee-for service and grants),or combinations of these (18). Studiesthat implemented only patient-orientedinterventions (such as patient educationand consumer participation in a healthcare organization) were excluded.

Data extraction

Data extraction was performed indepen-dently by two reviewers (C.M.R. andG.D.V.) using an adapted version of theEPOC Data Collection Checklist (18).

Any discrepancies between reviewerswere resolved by discussion or were re-ferred to the editors of the EPOC group.The quality of eligible trials was assessedusing the standard criteria described bythe EPOC group. The most important re-corded items were the unit of allocationand analysis, concealment of allocation,blinding, statistical power, follow-up ofprofessionals and patients, comparabilityof baseline measurements, reliability ofmeasurements, protection of the controlgroup against contamination, setting,study population, and follow-up period.

Data analysisWhere possible, data were tabulated interms of means SEM for patient out-comes and proportions for process mea-sures; other data were presented asreported in the original source. Absolutedifferences and relative percentage im-provement were calculated for study out-

comes where possible (17). Baseline datawere recorded to provide some indicationof the comparability of study groups. Forstudies with a unit of analysis error (19),the point estimates of effects were pre-sented without P values or 95% confi-dence intervals.

Because of the heterogeneity of inter-ventions, settings, patient populations,and reported outcomes in combinationwith differences in guidelines, we decideda priori to not statistically pool the resultsof the studies. Instead, a qualitative as-

sessment of the effects of the studies wasmade based on the quality of the studyand the size and direction of the effectobserved.

RESULTS A total of 48 publicationsdescribing 41 studies met the inclusioncriteria. Seven studies were described inmultiple publications (24,25,37,38,41,42,44,45,48,49,64 67). Of the includedstudies, 27 (2124,26 28,3032,36,37,39 41,44,50,51,5355,59 62,64,66)were randomized controlled trials, 12(20,29,3335,46 48,52,56,57,63) had acontrolled before-after design, and 2(43,58) were ITS. A wide range of organi-zational and professional interventionswere evaluated, and in all of the studies,the intervention strategies were multi-faceted.

In 27 studies, the interventions werebased on clinical practice guidelines. In14 (20,21,23,28,29,31,39,44,5153,58,59,64) of these, the guidelines were lo-cally developed, in 11 studies (22,24,26,27,32,35,36,47,55,57,60) they werebased on national guidelines, and in 2studies (46,54) the source of the guide-lines was not specified.

Study qualityAll studies had methodological limita-tions. Of 27 randomized controlled trials,only 6 (22,27,40,41,44,51) had adequateconcealment of allocation. In 15 studies(22,26,33,37,39 41,46,50,51,53,55,62,64,66), patients or health care profession-als were randomized within a clinic orpractice, thereby making them prone tocontamination. In two studies, it waslikely that the control group also receivedthe intervention because it was stated thatboth the intervention and control clinicwere staffed by the same personnel (34)or had a crossover design (61).

Similar baseline measurements be-tween intervention and control groups

were reported in only 13 of 42 studies(21,24,2729,40,44,52,55,56,61,64,66).Outcomes were assessed blindly or wereobjective (assessed by a standardized test)in 21 studies (2224,2730,33,34,36,40,41,47,51,52,56,58,60,61,63,66). In 14studies, blinding of the outcome assess-ment was only partly adequate. In 18studies (21,2729,33,34,36,37,40,41,47,51,52,56,60,61,63,66), the outcomeswere all reliably assessed (outcomes ob-tained from an automated system or a re-ported agreement between two raters

Improving diabetes care in primary care

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90% or 0.8). Furthermore, 15studies (20,22,26,32,35,39,44,46,50,53,54,57,59,62,64) included objective labo-ratory assessment of glycemic control.

Of 27 studies reporting patient out-comes, 11 (29,34,39,40,51,54,56,57,59,6 2 , 6 6 ) h a d o v e r 8 0 % f o l l o w - u p .Follow-up data for the health care profes-sionals/practices were explicitly stated inonly 5 of 24 studies in which these werethe unit of allocation.

In 24 studies (20 24,27,28 35,46 48,52,55,56,59,60,63,64), health careprofessionals or practices were the unit ofallocation, and patients were directly al-located to groups in 15 studies (26,36,37,39 41,44,50,51,53,54,57,61,62,66).Eighteen studies (20,2224,29,30,3235,46 48,52,56,59,63,64) did not usethesame unit for both allocation andanal-

ysis (unit of analysis error). A prioripower calculations were included in onlysix studies (20 22,30,48,66).

Professional interventions versususual care

We identified 12 studies (20 24,2632)in which the effectiveness of professionalinterventions was compared with usualcare (Table 1). In four of these studies(22,23,27,29), the professional interven-tion was combined with patient educa-tion. Postgraduate education of healthcare professionals combined with localconsensus procedures and/or remindersand/or audit and feedback improved theprovision of diabetes care in all studies(20,21,23,24,26,27,31,32) that did notdemonstrate a good standard of care atbaseline. The effect on patient outcomeswas less clear because such outcomeswere rarely assessed. Improvements weredescribed for glycemic control and seri-ous foot lesions (20,23,26), although sta-tistical significance was only achieved andreported in one study (23).

The three studies (22,29,30) evaluat-ing education for both health care profes-sionals and patients showed conflictingresults. In one study (29), the interven-tion improved HbA

1c, BMI, and triglycer-

ides. In another (22), there was nosignificant effect on HbA1c and an appar-ently detrimental effect on BMI and tri-glycerides. The final study (30) wasunable to demonstrate significant im-provements because only 19% of the pro-fessionals successfully applied theintervention.

Organizational interventions versususual careNine studies (3337,39 41,43) com-pared organizational interventions withusual care (Table2). Five (35,39 41) alsoincluded patient-oriented interventions,such as patient education and a learner-centered counseling approach, allowingpatients to identify problems andagreeonpotential solutions (34).

Studies (34,39) in which a nurse orpharmacist assumed part of the physi-cians role and provided diabetes care incombination with a patient-oriented in-tervention were associated with a smallbeneficial effect on glycemic control.However, because of the poor quality ofthese studies, the results have to be inter-preted with caution. The effect on theprocess of care of the general practitioner

and nurse jointly reviewing patients re-mains unclear because no statistical anal-ysis was performed (43).

Arra ngements for fo llow-up im-proved the process of care in terms ofscheduled visits and rates of diabetic eyeexaminations, although there was varia-tion with the type and intensity of the in-tervention used (36,41). Telephone callsfor rescheduling missed appointmentswere more effective than sending multiplereminders to patients, which only affectedprocess measures in the short term (36).The effectiveness of arrangements for fol-low-up on patient outcomes was rarelyassessed. However, in two studies (35,40)in which multidisciplinary teams wereimplemented in combination with ar-rangements for follow-up and patient ed-ucation, glycemic control and cholesterolimproved significantly.

Combined professional andorganizational interventions versususual careTwenty studies (44,46 48,50 64,66)implemented a complex intervention,

consisting of a combination of profes-sional and organizational interventions(Table 3). In 15 studies, in combinationwith organizational interventions, healthcare professionals received educationthrough distribution of educational mate-rials, through educational meetings, orthrough both. A common strategy tar-geted at the organization of care was achange in medical record systems(46,48,51,52,54,55,57,60,63). The sys-tems were used for arranging follow-up(46,51,52), audit and feedback (48), gen-

erating reminders to the health care pro-fessional (55,60), or a combination ofthese (54,57,63). In six studies (44,47,56,62,64,66), patient education was addedto professional and organizational inter-ventions.

Computerized reminders, audit andfeedback, or a combination of bothseemed to improve process measures(48,54,55,60,63,64). However, only twostudies (54,64) assessed the effects on pa-tient outcomes and these produced con-flicting results.

A centrally organized computerizeddatabase, which was used in combinationwith professional interventions to makearrangements for follow-up, to track pa-tient appointments, and/or to generate re-minder cards for patients, was associatedwith improvements in process measures

(51,57). The addition of a nurse to thisintervention led to improvements in pa-tient outcomes (57). In studies in whichpatient outcomes were assessed, thosethat featured a greater involvement ofnurses in diabetes management reportedpositive effects on these outcomes(44,50,52,56,57,66). Another recurringtheme was that studies that reported apositive effect on patient outcomes oftenincluded patient education (44,56,57,66).

The effectiveness of using a telecom-munication system (professional inter-vention) to assist in the outpatientmanagement of insulin treatment in com-bination with organizational interven-tions remains unclear (53,61) because ofcontradictoryresults and limited method-ological quality of the studies.

CONCLUSIONS This review wasperformed to identify effective interven-tion strategies to improve the manage-ment of patients with diabetes in primarycare, outpatient, and community settings.In addition to randomized controlled tri-

als, studies with controlled before-afterstudy and ITS design that fulfilled theEPOC group methodological and qualitycriteria and were published from 1966 to2000 are included. Consequently, studiesthat did not fulfill the inclusion criteria orwere published after the review time-frame were excluded. A total of 41 heter-ogeneous studies of variable quality metthe inclusion criteria. In almost all of thestudies included, postgraduate educationwas part of the complex interventions.The addition of postgraduate education

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might be important in providing practi-tioners with the skills and knowledge toimprove their performance, but theymust be convinced of the importance ofchanging their practice and must be mo-tivated to carry it out. In addition to theskills, knowledge, and motivations of in-dividual care providers, organizational orother barriers can impede the implemen-tation of change by care providers andmust therefore be addressed. In thepresent review, postgraduate educationseemed to improve the process of carewhen combined with other professionalinterventions. Moreover, interventionstargeting arrangements for follow-up alsoimproved process measures. This wasachieved by central computerized track-ing systems or by nurses who regularlycontacted patients. This intervention may

also decrease the number of patients lostto follow-up, which is particularly impor-tant because loss to follow-up is associ-ated with an increased risk of diabeticcomplications (68).

Central computerized systems can beof additional value, as they may providefeedback to providers and can generatereminders to providers concerning themanagement of their patients. Further-more, the data can be used to measureimprovements in the performance ofhealth care professionals and patient out-comes.

In particular, combining patient edu-cation, a nurse, or both with arrangementsfor follow-up or multiple professionalinterventions led to improvements inpatient outcomes as well as the process ofcare. Nurses can liaise with the patientand the physician, help facilitate patientand practitioner adherence, provide pa-tient education, and, if they are trainedand if detailed management protocolsare available, even assume some of theresponsibilities of the physician. Patienteducation might be important for involv-

ing patients more in their own diabetesmanagement and for improving self-management and compliance to therapy.Moreover, it might encourage patients tochange their lifestyle with regard to diet,smoking habit, and physical exercise, allof which help to achieve good glycemiccontrol and to postpone or prevent thedevelopment of complications.

Previous reviews of the effectivenessof interventions in improving profes-sional practice have focused on preven-tive services, prescribing practices, andC

arlson(32)1991,

Sweden

RCT

i)educationalmeetings;localcon-

sensusp

rocessestoidentifyprob-

lemsand

tocreateplansto

improve

diabetescare;educa-

tionalou

treachvisits

c)nointervention

a)?(physicians,nurses,

nurseassistantsmanag-

ers,administrators,and

laboratorytechn

icians)

b)4,4

92(measurements

onprofessional

practice)

566(measurementson

HbA1c

)

c)34

primaryhealthcarecenter;

salary

12

glyc(0)#

glyc()#

microv()#

patient0

process

Benjamin(20)1999,

U.S.

CBA

i)educationalmaterials/meetings;

localcon

sensusprocesses;audit

andfeed

back

c)nointervention

a)?(physicians,residents,

nurses,andnutritionist)

b)144

c)2

free-standingacademicpri-

marycareclinic;variable

insurancearrangements

15

glyc()#

chol()#

microv()#

patient

processwithin

Pieber(29)1995,

Austria

CBA

i)educationalmaterials/meetings;

patiente

ducation

c)nointervention

a)14GPs

b)94

c)14

primarycarephysicianoffice;

fee-for-service

6

glyc()#

bp(0)#

chol(0)#

BMI()#

microv()#within

NA

patient

*IntheU.S.,mostpractices,whetherhospital-basedornot,careforpatientsunderavarietyofinsurancearrangements:government(Medicare,Medicaid)orprivate(HMOorindemn

ity[fee-for-service]).?,

notreported;,positiveeffect;0,noeffect;,negativeeffect;/,e

ffectunclear;NA,notapplicable;#,possibleunitofanalysiserror;within,d

ifferencesarestatisticallytestedwithingr

oupsonly,notbetween

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loodpressure;comp,compliancecareprovider;CBA,controlledbefore-afterstud

y;creat,creatinine;glyc,g

lycemiccontrol;HM

O,healthmaintenance

organization;hlthsurv,

healthsurvey;hosp,

hospitalizations;macrov,macrovascularcom

plications;microv,microvascularcomplications;quallife,qualityoflife;RCT,randomizedc

ontrolledtrial.




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ordering of diagnostic tests rather than ona specific condition (69,70). Neverthe-less, their findings that combinations ofdifferent interventions are the most effec-tive are consistent with this review.

Methodological issuesOn the basis of interventions, partici-pants, settings, guidelines, and outcomes,this review has highlighted the heteroge-neity of studies that determine the effec-tiveness of interventions to improvediabetes management. Even when oneoutcome, such as glycemic control, wasassessed in several studies, a variety of dif-ferent methods and reference values wereused. This limited the degree to which theresults could be compared and a uniformeffect size could be calculated.

The methodological quality of the in-cluded studies was often limited; therewas risk of contamination betweengroups, frequently no allocation conceal-ment at outcome, high drop-out rates thatpotentially reduced power and intro-duced bias, andunit of analysis errors thatincreased the apparent precision of esti-mates (19). Also, information about con-cealment of allocation and the number ofprofessionals included in the study wasoften missing. The follow-up period of 25of the studies was 1 year; it is thereforeunclear whether the positive effects of the

complex and often intensive interven-tions can be maintained in the long term.On the other hand, in some studies theevaluation may have been premature, aspatients had not been exposed to the in-tervention for a sufficient amount of timeto produce the anticipated benefits.

Although our literature search wasextensive, we did not identify any unpub-lished studies. The apparent effectivenessof some of the interventions may havebeen overestimated due to the possibilityof publication bias (71).

GeneralizabilityThe studies in this review often includedselected practitioners who were willing toimplement sometimes very complex in-terventions. In addition, the representa-tiveness of the health care professionalsand practices was variable, ranging fromonly one practice with one provider (58)to almost all local practices in a wide geo-graphical area (31). Participating patientswere a selected group that was motivatedto consent to join the study. They are of-

ten younger, less ill, and more accommo-dating than thegeneral population (72). Itis not clear how well they represent thepopulation of patients with diabetes.Studies were carried out in various pri-mary care, outpatient, and communitysettings in the context of different localand national health care systems. Thus,conclusions from this review should begeneralized to different settings withcaution.

Implications for practice andresearchIn many ways, diabetes is a good modelfor the care of many chronic diseases(73,74). Changes in organization prac-tice, such as enhancing the role of thenurse or implementing central computer

systems that improve the delivery of com-plex packages of care, are likely to have animpact on the provision of care for a widerange of other conditions.

In the present review, only 15 of 41identified studies reported both patientoutcomes and process measures. Mea-sures at both levels contribute to a betterunderstanding of how to improve thequality of care. Measuring the process ofcare contributes to understanding heter-ogeneity in patient outcomes.Poor imple-mentation of complex interventions(masked in the absence of process mea-sures) may undermine adequately pow-ered and well-designed and -conductedstudies. Thus, process measures and pa-tient outcomes should be measured infuture research.

Reported outcomes were correctedfor clustering at the health care profes-sional or practice level in only one study(22). Theissue of clustering is particularlyrelevant because many of the interven-tions were directed at the health careprofessional or practice. Therefore, ob-servations of patients within one health

care professional or practice were not in-dependent of each other. This issue shouldbe taken into consideration for both sam-ple size calculations and analysis.

More research on the long-term effec-tiveness of the different intervention strat-egies is needed, as the follow-up in mostof the studies in the present review wasshort. The most frequently measured pa-tient outcome was glycemic control,which only accounts for a proportion ofthe micro- and macrovascular risk in dia-betes (6 8). Future studies should at-

fessionals;changestothe

setting/siteofservicedeliv-

ery;changesinmedical

recordssystems;patient

educa

tion

c)nointervention

Sullivan(43)1991,

U.K.

ITS

i)clinica

lmultidisciplinary

teams

(AjointGP/nurse

review

system);arrange-

mentsoffollow-up

c)nointervention

a)5(4GPsandpractice

nurse)

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1984:51,

1985:56,

1986:61,

1987:67,

1988:70

c)1

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36

NA

glyc(/)

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*IntheU.S.,mostpractices,whetherhospital-basedornot,careforpatientsunderavarietyofinsurancearrangements:government(Medicare,Medicaid)orprivate(HMOorindemn

ity[fee-for-service]).?,

notreported;,positiveeffect;0,noeffect;,negativeeffect;/,e

ffectunclear;NA,notapplicable;#,possibleunitofanalysiserror;within,d

ifferencesarestatisticallytestedwithingr

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lbumin;attpat,attendancepatients;bp,b

loodpressure;comp,compliancecareprovider;CBA,controlledbefore-afterstud

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lycemiccontrol;HM

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organization;hlthsurv,

healthsurvey;hosp,

hospitalizations;macrov,macrovascularcom

plications;microv,microvascularcomplications;quallife,qualityoflife;RCT,randomizedc

ontrolledtrial.




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Shultz(61)1992,

U.S.

RCT

i)atelecommunicationsystem;

changesinfacilitiesandequip-

ment;changesinmedicalrecord

systems

c)nointervention

a)?(physicians)

b)30

c)1

VeteransAdministration

hospitalclinic;federal

program

15

glyc()

NA

patient

Stein(62)1974,

U.S.

RCT

i)educa

tionalmaterials;revisionof

professionalroles;patienteduca-

tion

c)nointervention

a)nursepractitio

ner

clinicphysician(s)

b)28

c)1

hospital-basedprimary

careclinic;variable


6

glyc(0)

weight(0)

NA

patient0

Vinicor(64)1987

Mazzuca(65)1988;

U.S.

RCT

Forpatientoutcomes(39)

i1)patienteducation

i2)physicianeducation:educa-

tionalmaterials;localconsensus

proce

sses;auditandfeed-

back;reminders;communication

andc

asediscussionbetween

distanthealthprofessionals;

i3)patienteducation

physician

education

c)nointervention

Forprocessmeasures(58a)

i)i2i3

c)i1c

a)86residents

b)532

c)1

hospital-basedacademic

primarycareclinic;

variableinsurancear-

rangements

process

measures:

11

patient:

26

glyc(

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3)#

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weight(i1,i3)#

glyc()#

bp(0)#

chol()#

creat(0)#

microv(0)#

patient

process

Weinberger(66)1995

Kirkman(67)1994;

U.S.

RCT

i)patien

tmediatedinterventions

(nursesattemptedtotelephone

patientstofacilitatecompliance,

monitorpatientshealthstatus,

facilitateresolutionofidentified

problems,facilitateaccesstopri-

mary

care);arrangementsfor

follow

up;patienteducation

c)nointervention

a)?

b)275

c)1

VeteransAdministration

hospitalclinic;federal

program

12

glyc()

chol(0)

weight(0)

quallife(0)

NA

patient

Boucher(46)1987,

U.K.

CBA

i)educa

tionalmaterials;educa-

tionalmeetings;arrangements

forfo

llowup;communication

andc

asediscussionbetween

distanthealthprofessionals;

chang

esinmedicalrecordsystems

c)nointervention

a)?(physicians,sup-

portedbynurses)

b)217

c)3

generalmedicineclinic;

capitationanditemof

service

24

glyc()#within

attpat(/)nostatistical

analysesbutapositive

trend

patientwithin

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statisticalanalyses

butapositivetrend

Deeb(47)1988,

U.S.

CBA

i)educa

tionalmaterials;educa-

tionalmeetings;educationalout-

reach

visits;clinical

multidisciplinaryteam;patient

education

c)nointervention

a)?(physiciannurses)

b)1,0

29wereide

ntified

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werereviewed

at

baseline.Only

636

ofthepatients

were

seenduringth

eyear

aftertheinterv

ention

c)6

federallyfundedprimary

carecenters;variable


12

NA

bp(0)#

microv()#

processwithin




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tempt to directly measure the risk ofcardiovascular risk. Given the potential ofthese interventions for health gain, theymerit rigorous evaluation.

Acknowledgments This study was fundedby Grant 940-20-096 from the Dutch Organi-zation for Scientific Research (NWO) Qualityand Care Program.

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