Could non-physician clinical care have a role in the UK?

It is clear that to reduce both the microvascular and macrovascular complications of type 2 diabetes requires good blood pressure control, good blood glucose control and good control of lipid levels. However, we also know that large gaps exist in the achievement of these care goals in real-life practice across the globe.

In England and Wales in 2014/15, the achievement of a combined intermediate outcome goal of blood pressure at or below 140/80 mmHg, HbA_1c at or below 58 mmol/mol (7.5%) and a total cholesterol level below 5 mmol/L was achieved in 41% of people with type 2 diabetes (Health and Social Care Information Centre, 2016).

Quality improvement (QI) schemes have been developed and implemented to try to drive up standards. They may have components directed at patients (such as reminders), directed at care providers (such as guideline prompts) and directed at health systems (such as institutionalising a culture of quality).

Evidence of the effectiveness of QI interventions comes from research that mostly has looked at a single QI intervention, and has assessed benefit only in the short term. In a meta-analysis of 48 cluster and 94 randomised controlled trials of diabetes QI interventions, the largest trial only included 206 participants and the longest follow-up was just 12 months (Tricco et al, 2012).

In the paper by Ali and colleagues (summarised alongside), 1146 patients with type 2 diabetes from specialist diabetes clinic populations in India and Pakistan were recruited into this CARRS (Center for cArdiometabolic Risk Reduction in South Asia) randomised controlled trial. While 571 received usual care, 575 were given a multicomponent QI strategy comprising non-physician care coordinators (CCs) and decision-support electronic health record (DS-EHR) software. The CCs contacted the participants monthly to discuss self-management, adherence to diet, exercise and medication use. Treatment was aligned with evidence-based guidelines through individualised computer-generated clinical prompts. The CCs had distinct access to the DS-EHR and used this to record their interactions with participants.

The baseline characteristics were similar in the intervention and control groups. The mean HbA_1c was 85 mmol/mol (9.9%) and blood pressure (BP) was 143.3/81.7 mmHg. Over a median of 28 months, 18.2% of people in the intervention group achieved the primary outcome of HbA_1c below 53 mmol/mol (7%), plus BP less than 130/80 mmHg and/or LDL-cholesterol level less than 2.59 mmol/L (100 mg/dL), as compared to 8.1% in the usual care control group.

Those in the intervention group achieved greater reductions in the individual components of the primary outcome and reported higher scores in health-related quality-of-life and treatment satisfaction scores.

This is a well-conducted study with very interesting results. The authors say that their results “offer an encouraging demonstration of the implementation of comprehensive diabetes management and QI in low- and middle-income country settings.”

I wonder whether the idea of using non-physician clinical CCs might have a role in improving diabetes care in the UK.
To read the article summaries, please download the PDF
 

Roger Gadsby
In the spring of 2001, the first issue of Diabetes Digest was published. The section on the management and prevention of type 2 diabetes was edited by Dr Roger Gadsby. Sixty issues later, Roger has decided to retire as Section Editor. Dr David Kerr and the Publisher would like to extend our warmest wishes to Roger, and thank him for sharing his wisdom and insight with our readers for the last 15 years.