In 2005, an estimated 8.8% of Ontario's population had diabetes, representing more than 816,000 Ontarians. Our review shows an increase in research incorporating task sharing into health system interventions for type 2 diabetes in these settings. Standard lifestyle recommendations, metformin, and placebo are given to people who are at high risk for type 2 diabetes. Writing – review & editing, Affiliation This aspect reflects a limitation of the evidence generated rather than one of the analysis itself. The underlying disorder for type 2 diabetes is usually insulin insensitivity combined with a failure We performed systematic searches in several bibliographic databases. This site needs JavaScript to work properly. Two studies involved nursing case management interventions. The intensity of interventions was incompletely reported but ranged from 3 to 16 telephone calls or face-to-face visits. Therefore, we conducted a systematic review and meta-analysis to examine the impact of health system interventions that aimed to improve outcomes of glycemic (i.e., blood glucose) change, mortality, health-related quality of life, or cost-effectiveness for adults with type 2 diabetes in LMICs. Writing – review & editing, Affiliations | Everyone with Type 1 diabetes, and some people with Type 2 diabetes, need to take insulin to control their blood glucose (sugar) levels. Finally, although there were substantial similarities within intervention types, individual studies varied by setting and population, limiting our ability to make conclusions with high degrees of certainty. Home telemonitoring for type 2 diabetes: an evidence-based analysis. Writing – review & editing, Affiliations Despite the existence of cost-effective and evidence-based clinical treatments for type 2 diabetes [3], health systems in LMICs have difficulty meeting the rising need for quality care [4]. While these studies showed that depending on the progression of the disease, Type 2 diabetes remission may be possible with intense, medically-supervised interventions. We extracted study elements including the 4 outcomes, country, setting, duration and follow-up, number of participants enrolled, intervention description, and comparator. Formal analysis, Fourteen studies were classified as pharmacist task-sharing interventions, which we defined as studies in which patients received activities performed by pharmacists such as care coordination, medication review and counseling, and prescription suggestions to physicians [28,33–35,37,38,41,42,47,48,50,51,55,57]. Two health system interventions involved physician clinical training alone [65,66]. While traditional programs were didactic models with the goal of improving patients' knowledge of their disease, current models focus on behavioural approaches aimed at providing patients with the skills and strategies required to promote and change their behaviour. Interventions for Type 2 Diabetes Literature Review. A dramatic example of this effect was the Happy Life Club trial in China, in which both trial arms experienced 3.7% within-group HbA1c improvement over 18 months [32]. Methods. Behavioral interventions to improve self-management in Iranian adults with type 2 diabetes: a systematic review and meta-analysis. Level 1 – Universal … Formal analysis, Background: Type 2 diabetes mellitus has been identified as one of the … 2003). Writing – review & editing, Affiliation Difference in change-from-baseline HbA 1c values between behavioural interventions and usual care control…, Figure A6:. 2018. We included 39 trials in the narrative review and 35 trials in the meta-analysis of glycemic change. Investigation, Please enable it to take advantage of the complete set of features! The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality (based on the Consort Checklist). eCollection 2018 Dec. Diabetes Spectr. As quantitative data were reliably reported for only 1 of our 4 included outcomes, we limited our meta-analysis to the glycemic outcome of hemoglobin A1c (HbA1c) change. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Our review has limitations. We included RCTs of health system interventions targeting non-pregnant, ambulatory adults with type 2 diabetes in LMICs. Our review complements prior meta-analyses of studies primarily from HICs showing the benefit of systems-level quality improvement interventions on surrogate outcomes such as HbA1c, blood pressure, and cholesterol [7–9]. Software, Are behavioural interventions effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics (e.g. Despite physicians' and patients' knowledge of the importance of glycemic control, Canadian data has shown that only 38% of patients with diabetes have HbA1C levels in the optimal range of 7% or less. Type 2 diabetes is often associated with obesity. Examples of health system interventions include quality and safety programs, health information systems, health worker incentives, and changes in scope of practice [5]. Data curation, Multicomponent clinic-based interventions were modestly effective in improving glycemic control, with moderate certainty of evidence. Data curation, We analyzed data in Stata (version 16.0). Despite differences in individual needs to cope with diabetes, there is general agreement for the necessity of supportive programs for patient self-management. For each area, an economic analysis was completed where appropriate and is described in a separate report.To review these titles within the Diabetes Strategy Evidence series, please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM: Summary of Evidence-Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics: An Evidence-Based Analysis Behavioural Interventions for Type 2 Diabetes: An Evidence-Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY: An Evidence-Based Summary Community-Based Care for the Management of Type 2 Diabetes: An Evidence-Based Analysis Home Telemonitoring for Type 2 Diabetes: An Evidence-Based Analysis Application of the Ontario Diabetes Economic Model (ODEM) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario. Databases were chosen to be inclusive of international and interdisciplinary literature. Only 1 study reported quality of life as a primary outcome [51]. ". • type 2 diabetes • secondary diabetes (from pancreatic damage, hepatic cirrhosis, endocrinological disease/ therapy, or anti-viral/anti-psychotic therapy) • gestational diabetes (diabetes of pregnancy). To our knowledge, no review has systematically assessed evidence from randomized controlled trials (RCTs) or conducted a meta-analysis. Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). Motivational interviewing techniques were incorporated in 2 studies [32,46]. randomized controlled trial; SMS, The study by Mash et al. Findings will be evaluated using the nursing outcomes "self-management: diabetes" and "social support" from the Nursing Outcomes Classification (NOC). We systematically reviewed the literature and identified 39 RCTs of health system interventions for adults with type 2 diabetes in LMICs that assessed glycemic control, mortality, health-related quality of life, or cost-effectiveness. Writing – original draft, Search strategy: This statistic … Two authors (DF and JH) independently screened studies by title and abstract and, subsequently, by full-text review. Methodology, 2009;9(20):1-58. We thank the following authors of included studies for contributing supplementary information used in this review: María Cecilia Anzaldo-Campos, MD, MBA; Anna Chapman, PhD; Jeroen De Man; Shaun Wen Huey Lee, PhD; Aditya Khetan, MD; Professor Dr. Anis Safura Ramli; Professor Hong-Mei Wang, PhD; and Xuefeng Zhong, MD, MPH, PhD. However, it’s unclear how these treatments would work in a real-life setting. Eight trials were classified as clinic-based multicomponent interventions, which we defined as studies involving multiple types of health workers implementing a bundle of quality improvement or health system strengthening interventions [30,31,58–63]. We used language proficiency among the members of our review team and Google Translate to abstract data from non-English trials [16]. No study reported cost-effectiveness as a primary outcome. Department of Epidemiology, University of Washington, Seattle, Washington, United States of America, Affiliations Is the Subject Area "Low and middle income countries" applicable to this article? Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan United States of America. Methodology, However, in those with type 2 diabetes, the degree of glycaemic control and type and dose of diabetes medication should be coordinated with dietary intake.12 With some dietary interventions, such as very low calorie or low carbohydrate diets, people with diabetes would usually stop or reduce their diabetes medication and be monitored closely, as reviewed in a later section. Type 2 diabetes accounts for 90-95% of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older, prevalence in younger populations is increasing due to a rise in obesity and physical inactivity in children. There was statistical evidence for publication bias and substantial differences in the quality of underlying studies that limited the certainty of evidence of glycemic benefit for intervention types including pharmacist task-sharing interventions. Division of General Internal Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America, 11th Feb 2020 Nursing Literature Review Reference this Tags: health. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. Formal analysis, Medicine-Pediatrics Residency Program, University of Minnesota, Minneapolis, Minnesota, United States of America, Roles Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States of America, Roles Studies with larger numbers of deaths appeared to have generally similar mortality between trial arms though a formal meta-analysis was not conducted due to sparseness of data [29,31,53,58]. Importantly, we included diabetes education or support trials that primarily changed the behavior of health workers within the health system, and we excluded lifestyle trials focusing on patient behavior alone without systems-level change. The overall funnel plot and Egger test for the HbA1c meta-analysis suggested possible bias (Egger p < 0.001; S8 Appendix), but there was little evidence of bias within subgroups of intervention types (S9 Appendix). Formal analysis, There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Most studies reported gender with a mean percentage of females of approximately 67%. Inclusion criteria: . This systematic review and meta-analysis was conducted based on guidance from Cochrane Effective Practice and Organisation of Care (EPOC), a group focusing on reviews of the delivery of health services [14]. No study’s primary outcome was mortality. Ont Health Technol Assess Ser. Yes Akturan and colleagues trained physicians on a therapeutic interviewing technique [65]. (2)Faculty Practice & Community Engagement, West Virginia University, Morgantown, WV, 26506, USA. Effective health system interventions are needed to implement type 2 diabetes care in settings with different resources, cultures, and population risk factors [6]. We observed differences across studies relating to task sharing such as type of health worker, training, and assigned tasks. https://doi.org/10.1371/journal.pmed.1003434.g002. 1. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes. 3. A search was performed in OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published between January 1996 and August 2008. COVID-19 is an emerging, rapidly evolving situation. English Language Published between January 1996 to August 2008 Type 2 diabetic adult population (>18 years)Randomized controlled trials (RCTs)Systematic reviews, or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control (HbA1c) with extractable data Studies with a minimum of 6-month follow up, Exclusion criteria: This trial involved an intervention for diabetes and hypertension involving SMS educational messages and appointment reminders, community-based screening, and deployment of electronic clinical tools for physicians and nurses [64]. Previous reviews of trials predominantly conducted in HICs have suggested task sharing with pharmacists as an effective strategy [8]. Using the trim-and-fill method, we estimated that there were 8 missing studies, and inclusion of these imputed studies resulted in an estimated overall HbA1c mean difference of −0.28% (95% CI −0.43% to −0.13%; S10 Appendix). The EPOC domains of delivery arrangements and implementation strategies were most commonly involved in the included interventions. Ramallo-Fariña Y, García-Bello MA, García-Pérez L, Boronat M, Wägner AM, Rodríguez-Rodríguez L, de Pablos-Velasco P, Llorente Gómez de Segura I, González-Pacheco H, Carmona Rodríguez M, Serrano-Aguilar P; INDICA Team. (ABSTRACT TRUNCATED), Figure 1:. We defined these interventions as diabetes education or support alone. Improving and scaling up care in LMICs is an urgent global health priority. Characteristics or processes that appear to enhance behavioral and clinical effectiveness in Hispanics with type 2 diabetes include multimodal interventions, at least some in-person delivery (versus telephone only), and greater adherence to the intervention (high attendance and low attrition). In order to provide comprehensive pathway of weight management support for those at risk and with type 2 diabetes, we recommend adopting a tiered approach to weight management programmes which relates to the level of risk for an individual. Of the 11 studies reporting quality of life, 6 studies reported no significant differences between the intervention and comparator arms [29,32,45,46,52,59], and 5 studies showed improved quality of life in the intervention arm [33,40,51,58,62]. Comprehensive weight management service for the prevention, early detection and early intervention of type 2 diabetes. School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America, Roles Both individual and group sessions were used to deliver interventions. Ont Health Technol Assess Ser. high-income countries; LMICs, Other types of interventions had few included studies. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings. The search dates were from database inception through February 24, 2020. https://doi.org/10.1371/journal.pmed.1003434.t001. The intervention arms were combined in the study by Anzaldo-Campos and colleagues [59]. There was considerable heterogeneity in the overall pooled analysis that was partially explained by intervention type and baseline HbA1c. Competing interests: The authors have declared that no competing interests exist. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Systematic Review for the U.S. Preventive Services Task Force [Internet]. Background: To provide a range of the effects of individual studies, we calculated an overall prediction interval [24]. The meta-analysis was performed with random effects using the DerSimonian–Laird method for mean between-group HbA1c difference. When multiple reports were identified, we linked the reports together for extraction and analysis. The health workers in these studies varied between and within studies and included peers [49,53,56], community health workers [43,46,53], nurses [32,39,40,53,54], psychologists [32], and physicians [32,39,54]. Two studies described the comparator group as enhanced usual care, where the enhancement consisted of clinical training for health professionals [30,31], and in 1 study the medical fees were waived in the comparator arm [32]. Patnode CD, Evans CV, Senger CA, Redmond N, Lin JS. Our review was supplemented with unpublished data received from multiple study authors, and we were able to pool HbA1c statistical estimates reported differently across studies. Studies with a control group other than usual care Studies with a sample size <30 Studies without a clearly defined intervention, Primary outcome: The work is made available under the Creative Commons CC0 public domain dedication. Further studies in LMICs are needed to assess non-glycemic outcomes and, given the wide prediction intervals, to determine the specific components and details of health system interventions most likely to promote effectiveness and limit potential harms. 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