Health system interventions can help address this gap by improving the delivery of diabetes care within health systems. We included RCTs of health system interventions targeting non-pregnant, ambulatory adults with type 2 diabetes in LMICs. Difference in change-from-baseline HbA 1c values between behavioural interventions and usual care control…, NLM When multiple reports were identified, we linked the reports together for extraction and analysis. Despite the existence of cost-effective and evidence-based clinical treatments for type 2 diabetes , health systems in LMICs have difficulty meeting the rising need for quality care . Logistical challenges in conducting randomized studies within health systems likely explain why we identified few interventions testing financial or governance arrangements. In the meta-analysis of HbA1c in 35 trials, there were 10,060 total participants when accounting for the design effect of cluster RCTs (5,240 in intervention arms and 4,820 in comparator arms). (ABSTRACT TRUNCATED), Figure 1:. Psychobehavioural model of variables influencing…, Figure 1:. Difference in change-from-baseline HbA1c values…, Figure A6:. We observed differences across studies relating to task sharing such as type of health worker, training, and assigned tasks. While health system interventions improve type 2 diabetes outcomes in HICs [7–9], the evidence from LMICs is limited. Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan United States of America. 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]. Both the intervention and comparator arm in this trial had out-of-pocket medical fees waived, which may have contributed to catalyzing participants to seek medical care. Yes Data curation, Randomised controlled trials with a pre-test/post-test design that evaluated a diabetes self-management programme compared with no intervention in adults (at least 18 years) with type 2 diabetes were eligible for inclusion. EAR is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K23DK118207. Methodology, Joshi A, Mitra A, Anjum N, Shrivastava N, Khadanga S, Pakhare A, Joshi R. Med Sci (Basel). Our review shows an increase in research incorporating task sharing into health system interventions for type 2 diabetes in these settings. In the sensitivity analysis of studies not at high risk of bias (n = 21 trials), the overall HbA1c mean difference was −0.20% (95% CI −0.32% to −0.08%, I2 71.8% [95% CI 56.2% to 81.8%]; S11–S13 Appendices). JMIR Mhealth Uhealth. Writing – review & editing, Affiliation Competing interests: The authors have declared that no competing interests exist. To provide a range of the effects of individual studies, we calculated an overall prediction interval . DePue and colleagues conducted a cluster RCT in American Samoa that primarily used home visits and individual rather than group sessions . Type 2 diabetes is often associated with obesity. 23 studies of adults (out of 25 studies) used CBT as an intervention in relation to diabetes control in type 2 diabetes. Report No. The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years. Disclaimer: This work has been submitted by a student. We conducted 2 sensitivity analyses. Much of this cost arises from the serious long-term complications associated with the disease including: coronary heart disease, stroke, adult blindness, limb amputations and kidney disease. Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan United States of America, Roles Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan United States of America, Supervision, Software, This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry's newly released Diabetes Strategy.After an initial review of the strategy and consultation with experts, the secretariat identified five key areas in which evidence was needed. 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. Interventions focusing solely on implementing diabetes education or support within the health system also were effective in improving glycemic control, but the certainty of evidence was low. Multicomponent clinic-based interventions were modestly effective in improving glycemic control, with moderate certainty of evidence. Difference in change-from-baseline HbA 1c…, Figure A2:. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). One study was classified as a nurse task-sharing intervention . At the same time, the wide prediction interval overlapping 0 in the meta-analysis of HbA1c showed that there was a wide range of effectiveness across studies, and some health system interventions may not be effective in all settings. Funding: DF is supported by the National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy & Innovation. Prevention of type 2 diabetes in relatives and partners of people with the condition is under researched. We justify our use of the EPOC definition as reasonable given its use in prior Cochrane EPOC reviews on health systems in LMICs. 2003). A medical librarian (SJB) downloaded all records, removed duplicates, and imported records to the review management tool Covidence. 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). Clipboard, Search History, and several other advanced features are temporarily unavailable. Treatments for people with Type 1 diabetes Insulin pumps. We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs. Further research is needed to assess other outcomes beyond glycemic control, especially in rural areas and in low- or lower-middle-income countries. The work is made available under the Creative Commons CC0 public domain dedication. 2019 Mar 25;7(3):52. doi: 10.3390/medsci7030052. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The DPP showed that lifestyle changes (reduced fat and calories in the diet and increased physical activity) leading to modest weight loss reduced the rate of type 2 diabetes in high-risk adults by 58 percent, compared with placebo. Consistent with EPOC, we excluded studies of patient behavior change alone if the intervention did not primarily target healthcare professionals . 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. RCTs are not the only form of evidence generation in the field of health policy and research , and diverse research strategies are needed in conditions like type 2 diabetes that have a strong clinical evidence base yet weak evidence on implementation [3,78]. The proportion of participants from low- and middle-income countries was inferred to be 60% in the study by Reutens and colleagues . An enormous demand is, therefore, placed on patients to self-manage the physical, emotional and psychological aspects of living with a chronic illness. Ob Supervision, Behavioral interventions to improve self-management in Iranian adults with type 2 diabetes: a systematic review and meta-analysis. Standard lifestyle recommendations, metformin, and placebo are given to people who are at high risk for type 2 diabetes. Ethical approval was not required as the research used publicly available data. Only 1 study reported quality of life as a primary outcome . However, health system interventions designed and tested in HICs may not be generalizable to LMICs . Effective Practice and Organisation of Care; HbA1c, The absence of high-quality trials resulted in a low certainty of evidence for pharmacist task-sharing studies despite their sizeable pooled HbA1c estimate in the meta-analysis. To ensure high search quality, a second reference librarian peer-reviewed the search terms. 2020 Nov;98:106157. doi: 10.1016/j.cct.2020.106157. low- and middle-income countries; RCT, 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: Investigation, Difference in change-from-baseline HbA 1c values between behavioural interventions and usual care control…, Figure A6:. The potential to prevent type 2 diabetes in high-risk individuals by lifestyle intervention has been firmly established by several randomized controlled trials; based on a meta-analysis by Gillies et al. Multiple reports from the same study were identified by reviewing the country setting, intervention details, and authorship list. (2)Faculty Practice & Community Engagement, West Virginia University, Morgantown, WV, 26506, USA. Our review was restricted to studies with at least 6 months of follow-up and 100 enrolled participants. In the overall meta-analysis of HbA1c from 35 trials, we found that health system interventions modestly improved glycemic control on average. However, it’s unclear how these treatments would work in a real-life setting. Roles For example, an intervention training healthcare professionals on diabetes education was included; however, an intervention aiming to improve outcomes solely through individualized diabetes education was excluded . Difference in change-from-baseline HbA 1c…, Figure A9:. In contrast to clinical therapies for individual patients, health system interventions emphasize the behavior of health workers and the way healthcare is practiced and delivered . The certainty of evidence using the GRADE/EPOC approach for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types (S15 Appendix). Previous reviews of trials predominantly conducted in HICs have suggested task sharing with pharmacists as an effective strategy . Data curation, No study reported cost-effectiveness as a primary outcome. They are: Focus 1 – Important Past Health Information. Study selection. | Writing – review & editing, Affiliations We excluded non-randomized study designs given the challenge in attributing causality for outcomes and inconsistent reporting of these designs in pilot searches. In HICs, components with the largest effect sizes have been team change, patient education or patient self-management, electronic registries, and promotion of patient–provider communication . STUDY CHARACTERISTICS: The studies were conducted between 2002 and 2008. 2018. Our review adds to the literature by focusing on clinical and patient-oriented outcomes from the increasing number of randomized trials conducted in these settings. 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. Only the health literacy intervention arm was included in the study by Wang and colleagues . Our search strategy identified 12,921 references (Fig 1). Conducted in South Africa, this intervention involved authorizing, training, and supporting nurses to independently prescribe a set of drugs for several noncommunicable diseases including diabetes using an algorithmic management tool . 2. An advantage of including only RCTs is that we are able to offer robust evidence of the impact of health system interventions on glycemic control and reveal the limited data on other outcomes. DURATION, INTENSITY AND MODE OF DELIVERY: Intervention durations ranged from 2 days to 1 year, with many falling into the range of 6 to 10 weeks. https://doi.org/10.1371/journal.pmed.1003434.s001, https://doi.org/10.1371/journal.pmed.1003434.s002, https://doi.org/10.1371/journal.pmed.1003434.s003, https://doi.org/10.1371/journal.pmed.1003434.s004, https://doi.org/10.1371/journal.pmed.1003434.s005, https://doi.org/10.1371/journal.pmed.1003434.s006, https://doi.org/10.1371/journal.pmed.1003434.s007, https://doi.org/10.1371/journal.pmed.1003434.s008, https://doi.org/10.1371/journal.pmed.1003434.s009, https://doi.org/10.1371/journal.pmed.1003434.s010, https://doi.org/10.1371/journal.pmed.1003434.s011, https://doi.org/10.1371/journal.pmed.1003434.s012, https://doi.org/10.1371/journal.pmed.1003434.s013, https://doi.org/10.1371/journal.pmed.1003434.s014, https://doi.org/10.1371/journal.pmed.1003434.s015, https://doi.org/10.1371/journal.pmed.1003434.s016. Patients were recruited from several settings: six studies from primary or general medical practices, three studies from the community (e.g. No, Is the Subject Area "Quality of life" applicable to this article? Project administration, There were 21,080 total participants enrolled across included studies. Difference in change-from-baseline HbA 1c…, Figure A7:. Seven different scales were used to assess quality of life, and only the EuroQol EQ-5D was used in more than 1 study [29,45,46,52,58]. Conceptualization, We found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies were available from rural areas or low- or lower-middle-income countries. Of the estimated 463 million adults worldwide with type 2 diabetes, approximately 80% reside in LMICs . via advertisements), and two from outpatient diabetes clinics. 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