Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis
Summary Background The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA1c ), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diab...
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| Veröffentlicht in: | The Lancet (British edition) 2012-06, Vol.379 (9833), p.2252-2261 |
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| creator | Tricco, Andrea C, Dr Ivers, Noah M, MD Grimshaw, Jeremy M, Prof Moher, David, PhD Turner, Lucy, MSc Galipeau, James, PhD Halperin, Ilana, MD Vachon, Brigitte, PhD Ramsay, Tim, PhD Manns, Braden, MD Tonelli, Marcello, MD Shojania, Kaveh, MD |
| description | Summary Background The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA1c ), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes. Methods We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias. Findings We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84 865 patients, and 94 patient randomised controlled trials, including 38 664 patients. In random effects meta-analysis, the QI strategies reduced HbA1c by a mean difference of 0·37% (95% CI 0·28–0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05–0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19–4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95–2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA1c , 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA1c control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21–1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01–1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13–1·32), renal function (14 trials; RR 128, 1·13–1·44), and foot abnormalities (22 trials; RR 1·27, 1·16–1·39). However, statin use (ten trials; RR 1·12, 0·99–1·28), hypertension control (18 trials; RR 1·01, 0·96–1·07), and smoking cessation (13 trials; RR 1·13, 0·99–1·29) were not significantly increased. Interpretation Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA1c control is poor |
| doi_str_mv | 10.1016/S0140-6736(12)60480-2 |
| format | Article |
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We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA1c ), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes. Methods We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias. Findings We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84 865 patients, and 94 patient randomised controlled trials, including 38 664 patients. In random effects meta-analysis, the QI strategies reduced HbA1c by a mean difference of 0·37% (95% CI 0·28–0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05–0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19–4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95–2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA1c , 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA1c control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21–1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01–1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13–1·32), renal function (14 trials; RR 128, 1·13–1·44), and foot abnormalities (22 trials; RR 1·27, 1·16–1·39). However, statin use (ten trials; RR 1·12, 0·99–1·28), hypertension control (18 trials; RR 1·01, 0·96–1·07), and smoking cessation (13 trials; RR 1·13, 0·99–1·29) were not significantly increased. Interpretation Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA1c control is poor. Funding Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates—Health Solutions).</description><identifier>ISSN: 0140-6736</identifier><identifier>EISSN: 1474-547X</identifier><identifier>DOI: 10.1016/S0140-6736(12)60480-2</identifier><identifier>PMID: 22683130</identifier><identifier>CODEN: LANCAO</identifier><language>eng</language><publisher>Kidlington: Elsevier Ltd</publisher><subject>adults ; Aged ; antihypertensive agents ; aspirin ; Biological and medical sciences ; biomedical research ; Blood pressure ; Blood Pressure - physiology ; Case management ; Cholesterol ; Cholesterol, LDL - metabolism ; chronic diseases ; Diabetes ; Diabetes Mellitus, Type 1 - physiopathology ; Diabetes Mellitus, Type 1 - therapy ; Diabetes Mellitus, Type 2 - physiopathology ; Diabetes Mellitus, Type 2 - therapy ; Diabetes. Impaired glucose tolerance ; diastolic blood pressure ; disease control ; economic incentives ; Education ; Endocrine pancreas. Apud cells (diseases) ; Endocrinopathies ; Etiopathogenesis. Screening. Investigations. Target tissue resistance ; Female ; General aspects ; Glycated Hemoglobin A - metabolism ; Health care ; health care workers ; hemoglobin ; Humans ; Hypertension ; Internal Medicine ; Intervention ; long term care ; low density lipoprotein cholesterol ; Male ; Medical research ; Medical sciences ; meta-analysis ; Methods ; Microcirculation ; Middle Aged ; monitoring ; patients ; Quality Improvement ; randomized clinical trials ; Randomized Controlled Trials as Topic ; relative risk ; Renal function ; retinal diseases ; Risk management ; screening ; Smoking Cessation ; Statistical analysis ; Studies ; Systematic review ; systolic blood pressure</subject><ispartof>The Lancet (British edition), 2012-06, Vol.379 (9833), p.2252-2261</ispartof><rights>Elsevier Ltd</rights><rights>2012 Elsevier Ltd</rights><rights>2015 INIST-CNRS</rights><rights>Copyright © 2012 Elsevier Ltd. All rights reserved.</rights><rights>Copyright Elsevier Limited Jun 16-Jun 22, 2012</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c554t-4eaf8e472ffe131bf509a438ccf1326fa2b1820f55bc3e6c7dac78575d42556e3</citedby><cites>FETCH-LOGICAL-c554t-4eaf8e472ffe131bf509a438ccf1326fa2b1820f55bc3e6c7dac78575d42556e3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.proquest.com/docview/1023226255?pq-origsite=primo$$EHTML$$P50$$Gproquest$$H</linktohtml><link.rule.ids>314,780,784,3550,27924,27925,45995,64385,64387,64389,72469</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=25991077$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/22683130$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Tricco, Andrea C, Dr</creatorcontrib><creatorcontrib>Ivers, Noah M, MD</creatorcontrib><creatorcontrib>Grimshaw, Jeremy M, Prof</creatorcontrib><creatorcontrib>Moher, David, PhD</creatorcontrib><creatorcontrib>Turner, Lucy, MSc</creatorcontrib><creatorcontrib>Galipeau, James, PhD</creatorcontrib><creatorcontrib>Halperin, Ilana, MD</creatorcontrib><creatorcontrib>Vachon, Brigitte, PhD</creatorcontrib><creatorcontrib>Ramsay, Tim, PhD</creatorcontrib><creatorcontrib>Manns, Braden, MD</creatorcontrib><creatorcontrib>Tonelli, Marcello, MD</creatorcontrib><creatorcontrib>Shojania, Kaveh, MD</creatorcontrib><title>Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis</title><title>The Lancet (British edition)</title><addtitle>Lancet</addtitle><description>Summary Background The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA1c ), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes. Methods We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias. Findings We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84 865 patients, and 94 patient randomised controlled trials, including 38 664 patients. In random effects meta-analysis, the QI strategies reduced HbA1c by a mean difference of 0·37% (95% CI 0·28–0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05–0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19–4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95–2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA1c , 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA1c control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21–1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01–1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13–1·32), renal function (14 trials; RR 128, 1·13–1·44), and foot abnormalities (22 trials; RR 1·27, 1·16–1·39). However, statin use (ten trials; RR 1·12, 0·99–1·28), hypertension control (18 trials; RR 1·01, 0·96–1·07), and smoking cessation (13 trials; RR 1·13, 0·99–1·29) were not significantly increased. Interpretation Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA1c control is poor. Funding Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates—Health Solutions).</description><subject>adults</subject><subject>Aged</subject><subject>antihypertensive agents</subject><subject>aspirin</subject><subject>Biological and medical sciences</subject><subject>biomedical research</subject><subject>Blood pressure</subject><subject>Blood Pressure - physiology</subject><subject>Case management</subject><subject>Cholesterol</subject><subject>Cholesterol, LDL - metabolism</subject><subject>chronic diseases</subject><subject>Diabetes</subject><subject>Diabetes Mellitus, Type 1 - physiopathology</subject><subject>Diabetes Mellitus, Type 1 - therapy</subject><subject>Diabetes Mellitus, Type 2 - physiopathology</subject><subject>Diabetes Mellitus, Type 2 - therapy</subject><subject>Diabetes. Impaired glucose tolerance</subject><subject>diastolic blood pressure</subject><subject>disease control</subject><subject>economic incentives</subject><subject>Education</subject><subject>Endocrine pancreas. Apud cells (diseases)</subject><subject>Endocrinopathies</subject><subject>Etiopathogenesis. Screening. Investigations. Target tissue resistance</subject><subject>Female</subject><subject>General aspects</subject><subject>Glycated Hemoglobin A - metabolism</subject><subject>Health care</subject><subject>health care workers</subject><subject>hemoglobin</subject><subject>Humans</subject><subject>Hypertension</subject><subject>Internal Medicine</subject><subject>Intervention</subject><subject>long term care</subject><subject>low density lipoprotein cholesterol</subject><subject>Male</subject><subject>Medical research</subject><subject>Medical sciences</subject><subject>meta-analysis</subject><subject>Methods</subject><subject>Microcirculation</subject><subject>Middle Aged</subject><subject>monitoring</subject><subject>patients</subject><subject>Quality Improvement</subject><subject>randomized clinical trials</subject><subject>Randomized Controlled Trials as Topic</subject><subject>relative risk</subject><subject>Renal function</subject><subject>retinal diseases</subject><subject>Risk management</subject><subject>screening</subject><subject>Smoking Cessation</subject><subject>Statistical analysis</subject><subject>Studies</subject><subject>Systematic review</subject><subject>systolic blood pressure</subject><issn>0140-6736</issn><issn>1474-547X</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2012</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>8G5</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><sourceid>GUQSH</sourceid><sourceid>M2O</sourceid><recordid>eNqFkUtvEzEUhS0EomngJwCWUKWyGPD12DMTFiBUlYdUiUWpxM668VwHl3m0thOUf4-TCa3UDatZ-LufzpzD2AsQb0FA9e5SgBJFVZfVKcg3lVCNKOQjNgNVq0Kr-udjNrtDjthxjNdCCFUJ_ZQdSVk1JZRixtK5c2ST39BAMfLR8ds1dj5tue9vwrihnobEYwqYaOUpEwNPv4j3OOBqesw3rcclJYrvOfK4jYl6TN7yQBtPfzgOLe8pYZFvum308Rl74rCL9PzwnbOrz-c_zr4WF9-_fDv7dFFYrVUqFKFrSNUyR4QSlk6LBaqysdZBKSuHcgmNFE7rpS2psnWLtm50rVslta6onLPTyZv_5HZNMZneR0tdhwON62hASABZA9QZff0AvR7XIefdU2UuLCszpSfKhjHGQM7cBN9j2GbI7GYx-1nMrnMD0uxnMTLfvTzY18ue2rurfztk4OQAYLTYuYCD9fGe04sFiHoX89XEORwNrkJmri6lAC0EyEWVXXP2cSIoF5vrDyZaT4Ol1oc8tGlH_9-wHx4YbOcHn2P9pi3F-15MlEZMkp0D5N4gy79EBchP</recordid><startdate>20120616</startdate><enddate>20120616</enddate><creator>Tricco, Andrea C, Dr</creator><creator>Ivers, Noah M, MD</creator><creator>Grimshaw, Jeremy M, Prof</creator><creator>Moher, David, PhD</creator><creator>Turner, Lucy, MSc</creator><creator>Galipeau, James, PhD</creator><creator>Halperin, Ilana, MD</creator><creator>Vachon, Brigitte, PhD</creator><creator>Ramsay, Tim, PhD</creator><creator>Manns, Braden, MD</creator><creator>Tonelli, Marcello, MD</creator><creator>Shojania, Kaveh, MD</creator><general>Elsevier Ltd</general><general>Elsevier</general><general>Elsevier Limited</general><scope>FBQ</scope><scope>IQODW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>0TT</scope><scope>0TZ</scope><scope>0U~</scope><scope>3V.</scope><scope>7QL</scope><scope>7QP</scope><scope>7RV</scope><scope>7TK</scope><scope>7U7</scope><scope>7U9</scope><scope>7X7</scope><scope>7XB</scope><scope>88A</scope><scope>88C</scope><scope>88E</scope><scope>88G</scope><scope>88I</scope><scope>8AF</scope><scope>8AO</scope><scope>8C1</scope><scope>8C2</scope><scope>8FE</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AN0</scope><scope>ASE</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BEC</scope><scope>BENPR</scope><scope>BHPHI</scope><scope>C1K</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FPQ</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>H94</scope><scope>HCIFZ</scope><scope>K6X</scope><scope>K9-</scope><scope>K9.</scope><scope>KB0</scope><scope>KB~</scope><scope>LK8</scope><scope>M0R</scope><scope>M0S</scope><scope>M0T</scope><scope>M1P</scope><scope>M2M</scope><scope>M2O</scope><scope>M2P</scope><scope>M7N</scope><scope>M7P</scope><scope>MBDVC</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PSYQQ</scope><scope>Q9U</scope><scope>S0X</scope><scope>7X8</scope></search><sort><creationdate>20120616</creationdate><title>Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis</title><author>Tricco, Andrea C, Dr ; Ivers, Noah M, MD ; Grimshaw, Jeremy M, Prof ; Moher, David, PhD ; Turner, Lucy, MSc ; Galipeau, James, PhD ; Halperin, Ilana, MD ; Vachon, Brigitte, PhD ; Ramsay, Tim, PhD ; Manns, Braden, MD ; Tonelli, Marcello, MD ; Shojania, Kaveh, MD</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c554t-4eaf8e472ffe131bf509a438ccf1326fa2b1820f55bc3e6c7dac78575d42556e3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2012</creationdate><topic>adults</topic><topic>Aged</topic><topic>antihypertensive agents</topic><topic>aspirin</topic><topic>Biological and medical sciences</topic><topic>biomedical research</topic><topic>Blood pressure</topic><topic>Blood Pressure - physiology</topic><topic>Case management</topic><topic>Cholesterol</topic><topic>Cholesterol, LDL - metabolism</topic><topic>chronic diseases</topic><topic>Diabetes</topic><topic>Diabetes Mellitus, Type 1 - physiopathology</topic><topic>Diabetes Mellitus, Type 1 - therapy</topic><topic>Diabetes Mellitus, Type 2 - physiopathology</topic><topic>Diabetes Mellitus, Type 2 - therapy</topic><topic>Diabetes. 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Editorial</collection><collection>MEDLINE - Academic</collection><jtitle>The Lancet (British edition)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Tricco, Andrea C, Dr</au><au>Ivers, Noah M, MD</au><au>Grimshaw, Jeremy M, Prof</au><au>Moher, David, PhD</au><au>Turner, Lucy, MSc</au><au>Galipeau, James, PhD</au><au>Halperin, Ilana, MD</au><au>Vachon, Brigitte, PhD</au><au>Ramsay, Tim, PhD</au><au>Manns, Braden, MD</au><au>Tonelli, Marcello, MD</au><au>Shojania, Kaveh, MD</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis</atitle><jtitle>The Lancet (British edition)</jtitle><addtitle>Lancet</addtitle><date>2012-06-16</date><risdate>2012</risdate><volume>379</volume><issue>9833</issue><spage>2252</spage><epage>2261</epage><pages>2252-2261</pages><issn>0140-6736</issn><eissn>1474-547X</eissn><coden>LANCAO</coden><abstract>Summary Background The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA1c ), vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes. Methods We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias. Findings We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84 865 patients, and 94 patient randomised controlled trials, including 38 664 patients. In random effects meta-analysis, the QI strategies reduced HbA1c by a mean difference of 0·37% (95% CI 0·28–0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05–0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19–4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95–2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA1c , 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA1c control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk [RR] 1·33, 95% CI 1·21–1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01–1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13–1·32), renal function (14 trials; RR 128, 1·13–1·44), and foot abnormalities (22 trials; RR 1·27, 1·16–1·39). However, statin use (ten trials; RR 1·12, 0·99–1·28), hypertension control (18 trials; RR 1·01, 0·96–1·07), and smoking cessation (13 trials; RR 1·13, 0·99–1·29) were not significantly increased. Interpretation Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA1c control is poor. Funding Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates—Health Solutions).</abstract><cop>Kidlington</cop><pub>Elsevier Ltd</pub><pmid>22683130</pmid><doi>10.1016/S0140-6736(12)60480-2</doi><tpages>10</tpages></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0140-6736 |
| ispartof | The Lancet (British edition), 2012-06, Vol.379 (9833), p.2252-2261 |
| issn | 0140-6736 1474-547X |
| language | eng |
| recordid | cdi_proquest_miscellaneous_1021127117 |
| source | MEDLINE; Elsevier ScienceDirect Journals Complete; ProQuest Central UK/Ireland |
| subjects | adults Aged antihypertensive agents aspirin Biological and medical sciences biomedical research Blood pressure Blood Pressure - physiology Case management Cholesterol Cholesterol, LDL - metabolism chronic diseases Diabetes Diabetes Mellitus, Type 1 - physiopathology Diabetes Mellitus, Type 1 - therapy Diabetes Mellitus, Type 2 - physiopathology Diabetes Mellitus, Type 2 - therapy Diabetes. Impaired glucose tolerance diastolic blood pressure disease control economic incentives Education Endocrine pancreas. Apud cells (diseases) Endocrinopathies Etiopathogenesis. Screening. Investigations. Target tissue resistance Female General aspects Glycated Hemoglobin A - metabolism Health care health care workers hemoglobin Humans Hypertension Internal Medicine Intervention long term care low density lipoprotein cholesterol Male Medical research Medical sciences meta-analysis Methods Microcirculation Middle Aged monitoring patients Quality Improvement randomized clinical trials Randomized Controlled Trials as Topic relative risk Renal function retinal diseases Risk management screening Smoking Cessation Statistical analysis Studies Systematic review systolic blood pressure |
| title | Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis |
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