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A Meta-Regression Analysis

Kaveh G. Shojania, MD; Sumant R. Ranji, MD; Kathryn M. McDonald, MM; Jeremy M. Grimshaw, MBChB, PhD; Vandana Sundaram, MPH; Robert J. Rushakoff, MD; Douglas K. Owens, MD, MS

JAMA. 2006;296:427-440.

Context  There have been numerous reports of interventions designed to improve the care of patients with diabetes, but the effectiveness of such interventions is unclear.

Objective  To assess the impact on glycemic control of 11 distinct strategies for quality improvement (QI) in adults with type 2 diabetes.

Data Sources and Study Selection  MEDLINE (1966-April 2006) and the Cochrane Collaboration's Effective Practice and Organisation of Care Group database, which covers multiple bibliographic databases. Eligible studies included randomized or quasi-randomized controlled trials and controlled before-after studies that evaluated a QI intervention targeting some aspect of clinician behavior or organizational change and reported changes in glycosylated hemoglobin (HbA_1c) values.

Data Extraction  Postintervention difference in HbA_1c values were estimated using a meta-regression model that included baseline glycemic control and other key intervention and study features as predictors.

Data Synthesis  Fifty randomized controlled trials, 3 quasi-randomized trials, and 13 controlled before-after trials met all inclusion criteria. Across these 66 trials, interventions reduced HbA_1c values by a mean of 0.42% (95% confidence interval [CI], 0.29%-0.54%) over a median of 13 months of follow-up. Trials with fewer patients than the median for all included trials reported significantly greater effects than did larger trials (0.61% vs 0.27%, P = .004), strongly suggesting publication bias. Trials with mean baseline HbA_1c values of 8.0% or greater also reported significantly larger effects (0.54% vs 0.20%, P = .005). Adjusting for these effects, 2 of the 11 categories of QI strategies were associated with reductions in HbA_1c values of at least 0.50%: team changes (0.67%; 95% CI, 0.43%-0.91%; n = 26 trials) and case management (0.52%; 95% CI, 0.31%-0.73%; n = 26 trials); these also represented the only 2 strategies conferring significant incremental reductions in HbA_1c values. Interventions involving team changes reduced values by 0.33% more (95% CI, 0.12%-0.54%; P = .004) than those without this strategy, and those involving case management reduced values by 0.22% more (95% CI, 0.00%-0.44%; P = .04) than those without case management. Interventions in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced values by 0.80% (95% CI, 0.51%-1.10%), vs only 0.32% (95% CI, 0.14%-0.49%) for all other interventions (P = .002).

Conclusions  Most QI strategies produced small to modest improvements in glycemic control. Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias.

Author Affiliations: Ottawa Health Research Institute and Department of Medicine (Drs Shojania and Grimshaw) and Institute of Population Health (Dr Grimshaw), University of Ottawa, Ottawa, Ontario; Department of Medicine (Drs Ranji and Rushakoff) and Division of Endocrinology (Dr Rushakoff), University of California, San Francisco; and Center for Primary Care and Outcomes Research, Stanford University (Mss McDonald and Sundaram and Dr Owens) and VA Palo Alto Health Care System (Ms Sundaram and Dr Owens), Palo Alto, Calif.

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