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Diabetes Management: Team-Based Care for Patients with Type 2 Diabetes

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What the Task Force Found

About The Systematic Review

The Task Force recommendation is based on evidence from a systematic review of 35 studies (search period 1960–October 2015) that evaluated the impact of team-based care on blood glucose, blood pressure, and lipids. Included studies came from the reference list of a systematic review published in 2012 (Tricco et al, search period 1960 – 2010, 24 studies), an updated search for evidence (search period 2010 – October 2015, 8 studies), and reference lists of included studies (3 studies).

The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes prevention and control.

Context

There is no information for this section.

Summary of Results

More details about study results are available in the Task Force Finding and Rationale Statement pdf icon [PDF - 855 kB].

Compared with usual care, team-based care improved health outcomes:

  • Blood glucose
    • A1c levels decreased by a mean of 0.5% (25 studies)
  • Blood pressure
    • Systolic blood pressure decreased by a mean of 5.5mmHg (18 studies)
    • Diastolic blood pressure decreased by a mean of 3.2mmHg (17 studies)
  • Lipids
    • High-density level (HDL) cholesterol increased by a mean of 0.7mg/dL (9 studies)
    • Low-density level (LDL) cholesterol decreased by a mean of 8.0mg/dL (14 studies)
    • Total cholesterol level decreased by a mean 7.4mg/dL (12 studies)
    • Triglycerides levels decreased by a mean of 13.3mg/dL (7 studies)

Compared with usual care, team-based care increased the proportion of patients reaching target blood glucose, blood pressure, and lipid levels. Target health outcomes are benchmarks that, when reached, show significant health benefits for the patient.

  • Blood glucose
    • The proportion of patients who reached an A1c level below 7.0% increased by a median of 15.1 percentage points (7 studies).
    • The proportion of patients who reached an A1c level below 7.5% increased by a median of 18.0 percentage points (1 study).
  • Blood pressure
    • The proportion of patients who reached a blood pressure below 130/80mmHg increased by a median of 15.0 percentage points (10 studies).
    • The proportion of patients who reached a systolic blood pressure below 130mmHg increased by a median of 4.4 percentage points (3 studies).
    • The proportion of patients who reached a diastolic blood pressure below 80mmHg decreased by a median of 1.0 percentage point (3 studies).
  • Lipids
    • The proportion of patients who reached an HDL level above 35mg/dL decreased by a median of 3.2 percentage points (1 study).
    • The proportion of patients who reached an HDL level above 40mg/dL increased by a median of 0.6 percentage points (1 study).
    • The proportion of patients who reached above 43mg/dL for males or above 50mg/dL for females increased by a median of 2.0 percentage points (1 study).
    • The proportion of patients who reached an LDL level below 130mg/dL increased by a median of 16.7 percentage points (5 studies).
    • The proportion of patients who reached a total cholesterol level below 200mg/dL increased by a of median 14.0 percentage points (1 study).

Team Composition

  • Greater reductions in patients’ blood glucose levels were reported when pharmacists (13 studies) rather than nurses (19 studies) were added to the team.
  • The addition of either a pharmacist or nurse led to improved blood glucose levels.

Team Operation

Changing patient medications

  • Programs that allowed team members to make suggestions for medication changes with primary care provider approval (4 studies) led to greater reductions in diastolic blood pressure than did programs that only allowed primary care providers to make medication changes (11 studies).

Communicating between team members

  • Studies with explicit communication (15 studies) showed more favorable blood pressure outcomes than studies with implicit communication (4 studies).
    • Explicit communication—team members actively share information during team meetings or other formal channels
    • Implicit communication—team members share information passively through notes in patient records or status updates in doctors’ folders

Accessing patient medical records

  • Studies that allowed all team members to access patients’ medical records (21 studies) showed more favorable reductions in blood glucose when compared to studies that did not (3 studies).

Delivery of Care

Patients experienced greater reductions in blood glucose levels when care services were delivered both in-person and remotely (10 studies), rather than just in-person (12 studies) or remotely (3 studies).

Summary of Economic Evidence

Content is in development.

Applicability

Based on results for interventions in different settings and populations, findings should be applicable to the following:

  • High income countries
  • Urban environments
  • Clinics, hospitals, pharmacies, or Veterans Affairs facilities
  • Adults and older adults who have type 2 diabetes with or without diabetes-related complications or high risk for developing complications
  • Women and men
  • All examined racial and ethnic groups
  • People with different socioeconomic statuses (SES)
  • Patients with health insurance

Based on results for interventions with different characteristics, findings should be applicable to interventions that formed the teams by adding:

  • One, two, or more team members to the patient and primary care provider relationship,
  • A nurse or pharmacist, and
  • Members by hiring new people or expanding the roles of existing staff.

Evidence Gaps

Additional research and evaluation are needed to answer the following questions and fill existing gaps in the evidence base. (What are evidence gaps?)

  • What are intervention effects on diabetes-related complications and healthcare use?
  • How effective are interventions with the following populations?
    • People with type 1 diabetes
    • Younger people with diabetes
    • Uninsured people with diabetes
    • People with diabetes living in rural settings
  • How do team composition and operation influence intervention outcomes?
    • What services (e.g. education, counseling, goal setting, medication modification) are provided by team members?
    • How do team members communicate? Do teams use electronic records or meetings or other means of communication?
    • Do programs provide protocols to delineate the team roles and responsibilities?
    • Who is the team lead? The primary care provider, or the team member providing the majority of services?
    • Who would be the most effective primary contact for patients? The primary care provider, the team member providing the majority of services, or someone else?

Study Characteristics

Interventions were implemented in the following settings:

  • The United States (25 studies), Canada (3 studies), the United Kingdom (2 studies), Hong Kong (1 study), the Netherlands (1 study), Switzerland (1 study), Taiwan (1 study), and United Arab Emirates (1 study)
  • Clinics (22 studies), hospitals (5 studies), pharmacies (4 studies), or Veterans Affairs facilities (4 studies)
  • Urban (22 studies), suburban (1 study), rural (1 study), or mixed settings (urban/ suburban/ rural; 8 studies); Three studies did not provide this information.

Study participants had the following demographic characteristics:

  • Mean age of 58.4 years (31 studies)
  • 52.2% female (34 studies)
  • Type 2 diabetes (25 studies), type 1 or type 2 diabetes (3 studies), or unreported diabetes type (7 studies)
  • Low-income or underserved population (7 studies); too few studies reported on socioeconomic status, and the metrics were too various to be summarized
  • Median of 51.3% had less than high school education (8 studies)
  • Race/ Ethnicity (20 studies):
    • White (median 61.5%; 15 studies)
    • African Americans (median 16.5%; 12 studies)
    • Hispanic/Latino (median 19.2%; 8 studies)
    • Asian American (median 2.9%; 3 studies)
    • American Indian/Alaskan Native (median 2.9%; 3 studies)
    • Other (median 3.8%; 5 studies).
    • Five studies targeted specific races or ethnicities, including African American (3 studies), Samoan (1 study), and Hispanic (1 study) populations.

Intervention characteristics;

  • Services delivered
    • Education component (33 studies)
    • Continuing education/counseling component (32 studies)
    • Regular testing and monitoring (29 studies)
    • Medication modification (24 studies)
    • Patient goal setting and creation of an action plan to achieve those goals (16 studies)
  • Intervention duration ranged from less than 6 months to more than 3 years.
  • Team composition and operation
    • In addition to the patient and primary care provider, teams added one member (23 studies), two members (9 studies), or three or more members (3 studies).
    • Teams added a nurse (20 studies), pharmacist (14 studies), or other type of healthcare provider (12 studies).
    • Studies added team members by hiring new people (22 studies) or expanding the roles of existing staff (6 studies).

Publications

There are no publications for this systematic review.