10779/rcsi.10777499.v1 Mark E. Murphy Mark E. Murphy Molly Byrne Molly Byrne Rose Galvin Rose Galvin Fiona Boland Fiona Boland Tom Fahey Tom Fahey Susan M. Smith Susan M. Smith Improving risk factor management for patients with poorly controlled type 2 diabetes: a systematic review of healthcare interventions in primary care and community settings. Royal College of Surgeons in Ireland 2019 Blood Glucose Cardiovascular Diseases Community Health Services Diabetes Mellitus Type 2 Glycated Hemoglobin A Health Promotion Humans Primary Health Care Quality Improvement Randomized Controlled Trials as Topic Risk Factors Risk Management Family Care 2019-11-22 15:57:46 Journal contribution https://repository.rcsi.com/articles/journal_contribution/Improving_risk_factor_management_for_patients_with_poorly_controlled_type_2_diabetes_a_systematic_review_of_healthcare_interventions_in_primary_care_and_community_settings_/10777499 <p><strong>OBJECTIVES:</strong> Poorly controlled type 2 diabetes mellitus (T2DM) is a major international health problem. Our aim was to assess the effectiveness of healthcare interventions, specifically targeting patients with poorly controlled T2DM, which seek to improve glycaemic control and cardiovascular risk in primary care settings.</p> <p><strong>DESIGN:</strong> Systematic review.</p> <p><strong>SETTING:</strong> Primary care and community settings.</p> <p><strong>INCLUDED STUDIES:</strong> Randomised controlled trials (RCTs) targeting patients with poor glycaemic control were identified from Pubmed, Embase, Web of Science, Cochrane Library and SCOPUS. Poor glycaemic control was defined as HbA1c over 59 mmol/mol (7.5%).</p> <p><strong>INTERVENTIONS:</strong> Interventions were classified as organisational, patient-oriented, professional, financial or regulatory.</p> <p><strong>OUTCOMES:</strong> Primary outcomes were HbA1c, blood pressure and lipid control. Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Meta-analyses were undertaken where appropriate using random-effects models. Subgroup analysis explored the effects of intervention type, baseline HbA1c, study quality and study duration. Meta-regression analyses were undertaken to investigate identified heterogeneity.</p> <p><strong>RESULTS:</strong> Forty-two RCTs were identified, including 11 250 patients, with most undertaken in USA. In general, studies had low risk of bias. The main intervention types were patient-directed (48%) and organisational (48%). Overall, interventions reduced HbA1c by -0.34% (95% CI -0.46% to -0.22%), but meta-analyses had high statistical heterogeneity. Subgroup analyses suggested that organisational interventions and interventions on those with baseline HbA1c over 9.5% had better improvements in HbA1c. Meta-regression analyses suggested that only interventions on those with population HbA1c over 9.5% were more effective. Interventions had a modest improvement of blood pressure and lipids, although baseline levels of control were generally good.</p> <p><strong>CONCLUSIONS:</strong> This review suggests that interventions for T2DM, in primary care, are better targeted at individuals with very poor glycaemic control and that organisational interventions may be more effective.</p>