Reducing cardiovascular disease risk in diabetes: a randomised controlled trial of a quality improvement initiative

Abstract

Objectives: To describe the management of cardiovascular disease (CVD) risk in Australian patients with diabetes; to compare the effectiveness of a quality improvement initiative for people with and without diabetes. Research design and methods: Subgroup analyses of patients with and without diabetes participating in a cluster randomised trial. Setting and participants: Indigenous people (≥ 35 years old) and non‐Indigenous people (≥ 45 years old) who had attended one of 60 Australian primary health care services at least three times during the preceding 24 months and at least once during the past 6 months. Intervention: Quality improvement initiative comprising point‐of‐care electronic decision support with audit and feedback tools. Main outcome measures: Adherence to CVD risk screening and prescribing guidelines. Results: Baseline rates of guideline‐recommended screening were higher for 8829 patients with diabetes than for 44 335 without diabetes (62.0% v 39.5%; P < 0.001). Baseline rates of guideline‐recommended prescribing were greater for patients with diabetes than for other patients at high risk of CVD (55.5% v 39.6%; P < 0.001). The proportions of patients with diabetes not attaining recommended treatment targets for blood pressure, low‐density lipoprotein‐cholesterol or HbA1c levels who were not prescribed the corresponding therapy at baseline were 28%, 44% and 24% respectively. The intervention was associated with improved screening rates, but the effect was smaller for patients with diabetes than for those without diabetes (rate ratio [RR], 1.14 v 1.28; P = 0.01). It was associated with improved guideline‐recommended prescribing only for undertreated individuals at high risk; the effect size was similar for those with and without diabetes (RR, 1.63 v 1.53; P = 0.28). Conclusions: Adherence to CVD risk management guidelines was better for people with diabetes, but there is room for improvement. The intervention was modestly effective in people with diabetes, but further strategies are needed to close evidence–practice gaps. Australian and New Zealand Clinical Trials Registry number: ACTRN12611000478910.

Management of patients with type 2 diabetes and cardiovascular disease in primary care

“…In line with a previous Australian study of patients with diabetes and CVD, it was found that one-third of patients did not have a record of all three guidelinerecommended treatments for reduction of cardiovascular risk. 5 Results seen in this study are also broadly similar to 4,31 or higher 6,[8][9][10] than those seen in other Australian studies of patients with CVD (with or without diabetes). Any differences seen between this study and previous studies may reflect true differences, or be due to disparate study designs, sampling methodologies or definitions of T2D and/or CVD.…”

“…Australian data also show that many patients with diabetes and/or CVD do not meet guideline recommendations for prescribing, 4-10 monitoring and treatment targets for managing cardiovascular risk. 5,7 Blood glucose-lowering medicine (GLM) selection is also increasingly complex because of the increase in available medicines, and the focus on cardiovascular safety since the US Food and Drug Administration mandated in 2008 that all new studies must demonstrate cardiovascular safety. 11 Several trials have shown not only cardiovascular safety, but also additional cardiovascular and renal benefits over placebo.…”

Findings and lessons learnt implementing a cardiovascular disease quality improvement program in Australian primary care: a mixed method evaluation

“…A qualitative review of QI programs in Australia similarly identified the need for external support, accurate data and reporting, education and change champions in addition to financial incentives [ 18 ]. Government-funded initiatives such as heart health assessments, health assessments for 45–49-year-olds, GP management plans and home medication reviews have only had partial uptake and mixed evidence of success [ 8 , 27 , 28 ]. One potential driver of their mixed success is that they are still fee-for-service activities and do not support GPs to adopt quality-focused models of care [ 29 , 30 ].…”

Risk factor management in a contemporary Australian population at increased cardiovascular disease risk

“…In addition to therapeutic inertia, failure to meet BP targets has been attributed to underuse of combination therapies and undetected non‐adherence, together with failure to inform clinicians of the likely need for treatment intensification and the advantages of adding an additional BP drug instead of up‐titrating existing therapy . Other strategies that may improve risk factor control include pay‐for‐performance incentive, pharmacist intervention, telephone support and point‐of‐care electronic decision support with audit and feedback tools …”

“…35 Other strategies that may improve risk factor control include pay-for-performance incentive, 36 pharmacist intervention, 37 telephone support 38 and point-of-care electronic decision support with audit and feedback tools. 39 Overweight and obesity contribute to the burden of CVD, diabetes and CKD. 2 The Australian Institute of Health and Welfare estimates that 6% of future disease burden in 2020 due to overweight and obesity could be avoided if current increases in overweight and obesity were halted (maintained at 2011 levels).…”