Controlled Trial of a Multifaceted Intervention for Improving Quality of Care for Rural Patients With Type 2 Diabetes

Abstract

OBJECTIVE -Despite good evidence and clinical practice guidelines, studies document that treatment of type 2 diabetes is less than optimal. Lack of resources or limited access may put patients in rural communities at particular risk for suboptimal care.RESEARCH DESIGN AND METHODS -We conducted a prospective, before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service (intervention) for improving the quality of care for rural patients with type 2 diabetes. Our intervention consisted of six monthly visits by a traveling team of specialist physicians, nurses, dieticians, and a pharmacist. The core of this service was specialist-to-rural primary care physician academic group detailing. Two comparable regions in Northern Alberta were randomly allocated to control or intervention. Data were collected before and 6 months after intervention in a representative volunteer sample. The primary outcome was a 10% improvement in any one of the following: blood pressure, total cholesterol, or HbA 1c .RESULTS -Our analysis included 200 intervention and 179 control subjects; 14 subjects were at all three primary outcome targets at baseline. The intervention was associated with a trend toward improvement in primary outcome at 6 months (44% intervention vs. 37% control; odds ratio 1.32, 95% CI 0.87-1.99). The intervention was associated with a significant improvement in blood pressure (42% intervention vs. 25% control, P ϭ 0.004); however, there were only small, nonsignificant changes in cholesterol or HbA 1c . The intervention was associated with a significant increase in satisfaction with diabetes care. Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results.CONCLUSIONS -A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients. Future studies need to involve longer timelines and larger sample sizes.

Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial

“…21 A Canadian outreach program was effective in lowering blood pressure among people with diabetes living in a rural setting. 22 New strategies and partnerships that include family physicians, nurses and specialists are required if cardiovascular risk factors such as hypertension are to be controlled.…”

Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population

“…Unfortunately, most approaches used to improve diabetes outcome measures have been ineffective in practice. These include: 1) reminding patients about appointments (5,6); 2) providing feedback information on patients to their treating physicians (7)(8)(9)(10), even when treatment recommendations for the patient were included (11,12); 3) case management (when the case manager could not make treatment decisions) (13,14); 4) physician education (15,16); and 5) multifaceted quality improvement interventions in the practice setting (17,18).…”

Effects of an additional pharmaceutical care intervention versus usual care on clinical outcomes of Type 2 diabetes patients in Nigeria: A comparative study

“…These programs were implemented by pharmacists, with the cooperation of the physicians and other health care professionals. Pharmaceutical care and the expanded role of pharmacist are associated with many positive diabetesrelated outcomes, including improved clinical measures (Jaber et al, 1996), improved patient and provider satisfaction (Sadur et al, 1999;Majumdar et al, 2003), and improved cost of management (Sadur et al, 1999;Coast-Senior et al, 1998). The pharmacist can therefore, in collaboration with physicians and other health care professionals, contribute to the improvement of diabetic patients' quality of life by informing and educating patients, answering their questions and, at the same time monitoring the outcomes of their treatment (Hawkins et al, 2002).…”