[Interventions to improve the management of diabetes mellitus in primary health care and outpatient community settings]. The Winchester falls project: a randomised controlled trial of secondary prevention of falls in older people. Multifactorial intervention in individuals with type 2 diabetes and microalbuminuria: the Microalbuminuria Education and Medication Optimisation (MEMO) study. Cardiovascular risk outcome and program evaluation of a cluster randomised controlled trial of a community-based, lay peer led program for people with diabetes The New Zealand Diabetes Passport Study: a randomized controlled trial of the impact of a diabetes passport on risk factors for diabetes-related complications. Can primary care team-based transition to insulin improve outcomes in adults with type 2 diabetes: the stepping up to insulin cluster randomized controlled trial protocol Effect of hospital-based telephone coaching on glycaemic control and adherence to management guidelines in type 2 diabetes, a randomised controlled trial. Improving Diabetes care through Examining, Advising, and prescribing (IDEA): protocol for a theory-based cluster randomised controlled trial of a multiple behaviour change intervention aimed at primary healthcare professionals A cluster randomized controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD): study protocol for a randomized controlled trial A randomized trial of a community-based approach to dyslipidemia management Community-based care for the management of type 2 diabetes: an evidence-based analysis. Movement as Medicine for Type 2 Diabetes: protocol for an open pilot study and external pilot clustered randomised controlled trial to assess acceptability, feasibility and fidelity of a multifaceted behavioural intervention targeting physical activity in primary care Managing behavioural and psychological symptoms in community dwelling older people with dementia: 1. A systematic review of the effectiveness of interventions Sustaining better diabetes care in remote indigenous Australian communities The Effectiveness of Pharmacist Interventions on Cardiovascular Risk: The Multicenter Randomized Controlled RxEACH Trial. Strategies for the introduction and implementation of a guideline for the treatment of type 2 diabetics by general practitioners (GPs) of the Lazio region of Italy (IMPLEMEG study): Protocol for a cluster randomised controlled trial [ISRCTN80116232] No clear effect of diabetes education on glycaemic control for Turkish type 2 diabetes patients: a controlled experiment in general practice. Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project. Rationale and design of the ADDITION-Leicester study, a systematic screening programme and Randomised Controlled Trial of multi-factorial cardiovascular risk intervention in people with Type 2 Diabetes Mellitus detected by screening A Community-Based Diabetes Prevention Program Text message-based diabetes self-management support (SMS4BG): study protocol for a randomised controlled trial Trial protocol to compare the efficacy of a smartphone-based blood glucose management system with standard clinic care in the gestational diabetic population Effects of the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) on biomedical outcomes, observed cardiovascular events and cardiovascular risks in primary care: a longitudinal comparative study Effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes: a systematic review Efforts to improve subsequent treatment of cardiovascular risk factors in older patients with diabetes hospitalized for a cardiac event. Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. The Sydney Diabetes Prevention Program: A community-based translational study WITHDRAWN: Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation - the CASCADE study. Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial
UNLABELLED This review should be cited as : Renders CM , Valk GD , Griffin S. Wagner EH , Eijk JThM van , Assendelft WJJ . Interventions to improve the management of  diabetes mellitus  in primary care , outpatient and community setting s ( Cochrane Review ) . In : The Cochrane Library , Issue 2 , 2001 . Oxford : Up date Software . A substantive amendment to this systematic review was last made on 29 June 2000 . Cochrane review s are regularly checked and up date d if necessary . BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care . Different systems have been proposed to manage diabetes care . OBJECTIVES To assess the effects of different interventions , targeted at health professionals or the structure in which they deliver care , on the management of patients with diabetes in primary care , outpatient and community setting s. SEARCH STRATEGY We search ed the Cochrane Effective Practice and Organisation of Care Group specialised register , the Cochrane Controlled Trials Register ( Issue 4 1999 ) , MEDLINE ( 1966 - 1999 ) , EMBASE ( 1980 - 1999 ) , Cinahl ( 1982 - 1999 ) , and reference lists of articles . SELECTION CRITERIA R and omised trials ( RCTs ) , controlled clinical trials ( CCTs ) , controlled before and after studies ( CBAs ) and interrupted time series ( ITS ) analyses of professional , financial and organisational strategies aim ed at improving care for people with Type 1 or Type 2 diabetes . The participants were health care professionals , including physicians , nurses and pharmacists . The outcomes included objective ly measured health professional performance or patient outcomes , and self-report measures with known validity and reliability . DATA COLLECTION AND ANALYSIS Two review ers independently extracted data and assessed study quality . MAIN RESULTS Forty-one studies were included involving more than 200 practice s and 48,000 patients . Twenty-seven studies were RCTs , 12 were CBAs , and two were ITS . The studies were heterogeneous in terms of interventions , participants , setting s and outcomes . The method ological quality of the studies was often poor . In all studies the intervention strategy was multifaceted . In 12 studies the interventions were targeted at health professionals , in nine they were targeted at the organization of care , and 20 studies targeted both . In 15 studies patient education was added to the professional and organisational interventions . A combination of professional interventions improved process outcomes . The effect on patient outcomes remained less clear as these were rarely assessed . Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes . Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes . REVIEW ERS ' CONCLUSION : Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .  Organisational interventions that improve regular prompted recall and review of patients  ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management . The addition of patient-oriented interventions can lead to improved patient health outcomes . Nurses can play an important role in patient-oriented interventions , through patient education or facilitating adherence to treatment BACKGROUND the mortality and morbidity of falls in older people is significant , with recurrent fallers being at an increased risk . The most effective way to reduce falls in this group is not clear . OBJECTIVE to determine the effectiveness of two interventions , one based in primary care and the other in secondary care , at preventing further falls in recurrent fallers . DESIGN cluster r and omised controlled trial . PARTICIPANTS sixty-five years or over , living in the community , two or more falls in the previous year and not presenting to an emergency department with index fall . SETTING Mid Hampshire , UK . INTERVENTION eighteen general practice s were r and omly allocated to one of three groups . The primary care group was assessed by nurses in the community , using a risk factor review and subsequent targeted referral to other professionals . The secondary care group received a multi-disciplinary assessment in a day hospital followed by identified appropriate interventions . The control group received usual care . Follow-up was for 1 year . RESULTS five hundred and five participants were recruited . Follow-up was completed in 83 % ( 421/505 ) . The proportion of participants who fell again was significantly lower in the secondary care group ( 75 % , 158/210 ) compared to the control group [ 84 % , 133/159 , adjusted odds ratio ( OR ) 0.52 ( 95 % CI 0.35 - 0.79 ) P = 0.002 ] . The primary care group showed similar results to the control group [ 87 % , 118/136 , adjusted OR 1.17 ( 95 % CI 0.57 - 2.37 ) P = 0.673 ] . CONCLUSION a structured multi-disciplinary assessment of recurrent fallers significantly reduced the number experiencing further falls , but a community-based nurse-led assessment with targeted referral to other professionals did not AIMS To determine whether tighter cardiovascular risk factor control with structured education in individuals with type 2 diabetes ( T2DM ) and microalbuminuria benefits cardiovascular risk factors . METHODS Participants from a multiethnic population , recruited from primary care and specialist clinics were r and omised to intensive intervention with structured patient ( DESMOND model ) education ( n=94 ) or usual care by own health professional ( n=95 ) . PRIMARY OUTCOME change in HbA1c at 18months . SECONDARY OUTCOMES changes in blood pressure ( BP ) , cholesterol , albuminuria , proportion reaching risk factor targets , modelled cardiovascular risk scores . RESULTS Mean ( SD ) age and diabetes duration of participants were 61.5 ( 10.5 ) and 11.5 ( 9.3 ) years , respectively . At 18months , intensive intervention showed significant improvements in HbA1c ( 7.1(1.0 ) vs. 7.8(1.4)% , p<0.0001 ) , systolic BP ( 129(16 ) vs. 139(17 ) mmHg , p<0.0001 ) , diastolic BP ( 70(11 ) vs. 76(12 ) mmHg , p<0.001 ) , total cholesterol ( 3.7(0.8 ) vs. 4.1(0.9 ) mmol/l , p=0.001 ) . Moderate and severe hypoglycaemia was 11.2 vs. 29.0 % ; p=0.001 and 0 vs. 6.3 % ; p=0.07 , respectively . More intensive participants achieved ≥3 risk factor targets with greater reductions in cardiovascular risk scores . CONCLUSIONS Intensive intervention showed greater improvements in metabolic control and cardiovascular risk profile with lower rates of moderate and severe hypoglycaemia . Intensive glycaemic interventions should be underpinned by structured education promoting self-management in T2DM Background The 2013 Global Burden of Disease Study demonstrated the increasing burden of diabetes and the challenge it poses to the health systems of all countries . The chronic and complex nature of diabetes requires active self-management by patients in addition to clinical management in order to achieve optimal glycaemic control and appropriate use of available clinical services . This study is an evaluation of a “ real world ” peer support program aim ed at improving the control and management of type 2 diabetes ( T2DM ) in Australia . Methods The trial used a r and omised cluster design with a peer support intervention and routine care control arms and 12-month follow up . Participants in both arms received a st and ardised session of self-management education at baseline . The intervention program comprised monthly community-based group meetings over 12 months led by trained peer supporters and active encouragement to use primary health care and other community re sources and supports related to diabetes .  Clinical , behavioural and other measures were collected at baseline , 6 and 12 months . The primary outcome was the predicted 5 year cardiovascular disease risk using the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) Risk Equation at 12 months . Secondary outcomes included clinical measures , quality of life , measures of support , psychosocial functioning and lifestyle measures . Results Eleven of 12 planned groups were successfully implemented in the intervention arm . Both the usual care and the intervention arms demonstrated a small reduction in 5 year UKPDS risk and the mean values for biochemical and anthropometric outcomes were close to target at 12 months . There were some small positive changes in self-management behaviours . Conclusions The positive changes in self-management behaviours among intervention participants were not sufficient to reduce cardiovascular risk , possibly because approximately half of the study participants already had quite well controlled T2DM at baseline . Future research needs to address how to enhance community based programs so that they reach and benefit those most in need of re sources and supports to improve metabolic control and associated clinical outcomes .Trial registration Australian New Zeal and Clinical Trials Registry ( ANZCTR ) ACTRN12609000469213 . Registered 16 June 2009 AIMS To assess the efficacy ( change in HbA1c ) of a patient-held communication , self-empowerment and educational device for people with diabetes  ( the New Zeal and Diabetes Passport ) in patients with poor glycaemic control . RESEARCH DESIGN AND METHODS A 12-month , multicentre , general practice -based r and omized controlled trial in urban , provincial and rural New Zeal and involving 398 people with poorly controlled Type 1 or Type 2 diabetes . The intervention included a specifically design ed and piloted New Zeal and Diabetes Passport including information relating to diabetes knowledge , self- assessment s , and guidance concerning how to engage with diabetes health professionals . The primary end point was change in HbA1c . Assessment s were made at 0 , 6 and 12 months . RESULTS Two hundred and twenty-two patients received the Passport , 176 the control booklet , coming from 69 and 66 general practitioners , respectively . Use of the Passport was associated with a relative reduction in HbA1c of 0.4 % ( P = 0.017 ) and a relative increase in weight of 1.0 kg/m2 ( P = 0.028 ) , but no changes in diabetes knowledge , attitudes to diabetes or risk factors for diabetic tissue damage . CONCLUSIONS The dissemination of the New Zeal and Diabetes Passport , in isolation , was not associated with improvements in either diabetes knowledge or self-empowerment . While a small improvement in glycaemic control occurred , this was probably due to changes in insulin therapy in the intervention group . It is possible that linking the use of the Passport with other behavioural and educational interventions may make the Passport more useful . Further study is required to confirm the effect of such multifaceted interventions Background Type 2 diabetes ( T2D ) brings significant human and healthcare costs . Its progressive nature means achieving normoglycaemia is increasingly difficult , yet critical to avoiding long term vascular complications . Nearly one-half of people with T2D have glycaemic levels out of target . Insulin is effective in achieving glycaemic targets , yet initiation of insulin is often delayed , particularly in primary care . Given limited access to specialist re sources and the size of the diabetes epidemic , primary care is where insulin initiation must become part of routine practice . This would also support integrated holistic care for people with diabetes . Our Stepping Up Program is based on a general practitioner ( GP ) and practice nurse ( PN ) model of care supported appropriately by endocrinologists and credentialed diabetes educator-registered nurses . Pilot work suggests the model facilitates integration of the technical work of insulin initiation within ongoing generalist care . Methods This protocol is for a cluster r and omized controlled trial to examine the effectiveness of the Stepping Up Program to enhance the role of the GP-PN team in initiating insulin and improving glycaemic outcomes for people with T2D . 224 patients between the ages of 18 and 80 years with T2D , on two or more oral hypoglycaemic agents and with an HbA1c ≥7.5 % in the last six months will be recruited from 74 general practice s. The unit of r and omization is the practice . Primary outcome is change in glycated haemoglobin HbA1c ( measured as a continuous variable ) . We hypothesize that the intervention arm will achieve an absolute HbA1c mean difference of 0.5 % lower than control group at 12 months follow up . Secondary outcomes include the number of participants who successfully transfer to insulin and the proportion who achieve HbA1c measurement of < 7.0 % . We will also collect data on patient psychosocial outcomes and healthcare utilization and costs . Discussion The study is a pragmatic translational study with important potential implication s for people with T2D , healthcare professionals and funders of healthcare though making better use of scarce healthcare re sources , improving timely access to therapy that can improve disease outcomes .Trial registration Australian and New Zeal and Clinical Trials Registry BACKGROUND Failure to achieve treatment targets is common among people with type 2 diabetes . Cost-effective treatments are required to delay the onset and slow the progression of diabetes-related complications . AIMS This study aim ed to measure the effect of a 6-month telephone coaching intervention on glycaemic control , risk factor status and adherence to diabetes management practice s at the intervention 's conclusion ( 6 months ) and at 12 months . METHOD This r and omised controlled trial recruited 94 adults with type 2 diabetes and an HbA1C > 7 % from the Diabetes Clinic of St Vincent 's Hospital Melbourne . People who were non-English speaking , cognitively impaired , severely hearing impaired or without telephone access were excluded . Participants were r and omised to receive usual care plus 6 months of telephone coaching focusing on achieving treatment targets and complication screening , or usual care only . The primary outcome was HbA1C at 6 months ; secondary outcomes included other physiological and monitoring measures . RESULTS Significant interaction effects were observed between group and time at 6 months , demonstrating improvement in HbA1C , fasting glucose , diastolic blood pressure and physical activity . The intervention 's effect on these parameters was not sustained at 12 months . Intervention group participants also improved compliance with foot examinations and pneumococcal vaccination by 6 months and retinal screening by 12 months . CONCLUSIONS Telephone coaching improved glycaemic control and adherence to complication screening in people with type 2 diabetes , for the duration of its delivery , but these effects were not maintained on withdrawal of the intervention . Strategies that assist patients to sustain these benefits are required Background New clinical research findings may require clinicians to change their behaviour to provide high- quality care to people with type 2 diabetes , likely requiring them to change multiple different clinical behaviours . The present study builds on findings from a UK-wide study of theory-based behavioural and organisational factors associated with prescribing , advising , and examining consistent with high- quality diabetes care . Aim To develop and evaluate the effectiveness and cost of an intervention to improve multiple behaviours in clinicians involved in delivering high- quality care for type 2 diabetes . Design / methods We will conduct a two-armed cluster r and omised controlled trial in 44 general practice s in the North East of Engl and to evaluate a theory-based behaviour change intervention . We will target improvement in six underperformed clinical behaviours highlighted in quality st and ards for type 2 diabetes : prescribing for hypertension ; prescribing for glycaemic control ; providing physical activity advice ; providing nutrition advice ; providing on-going education ; and ensuring that feet have been examined . The primary outcome will be the proportion of patients appropriately prescribed and examined ( using anonymised computer records ) , and advised ( using anonymous patient surveys ) at 12 months . We will use behaviour change techniques targeting motivational , volitional , and impulsive factors that we have previously demonstrated to be predictive of multiple health professional behaviours involved in high- quality type 2 diabetes care . We will also investigate whether the intervention was delivered as design ed ( fidelity ) by coding audiotaped workshops and interventionist delivery reports , and operated as hypothesised ( process evaluation ) by analysing responses to theory-based postal question naires . In addition , we will conduct post-trial qualitative interviews with practice teams to further inform the process evaluation , and a post-trial economic analysis to estimate the costs of the intervention and cost of service use . Discussion Consistent with UK Medical Research Council guidance and building on previous development research , this pragmatic cluster r and omised trial will evaluate the effectiveness of a theory-based complex intervention focusing on changing multiple clinical behaviours to improve quality of diabetes care . Trial registration IS RCT N66498413 Abstract Background World-wide healthcare systems are faced with an epidemic of type 2 diabetes . In the United Kingdom , clinical care is primarily provided by general practitioners ( GPs ) rather than hospital specialists . Intermediate care clinics for diabetes ( ICCD ) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors . This study aims to ( 1 ) compare patients with type 2 diabetes registered with practice s that have access to an ICCD service with those that have access only to usual hospital care ; ( 2 ) assess the cost-effectiveness of the intervention ; and ( 3 ) explore the views and experiences of patients , health professionals and other stakeholders . Methods / Design This two-arm cluster r and omized controlled trial ( with integral economic evaluation and qualitative study ) is set in general practice s in three UK Primary Care Trusts . Practice s are r and omized to one of two groups with patients referred to either an  ICCD ( intervention ) or to hospital care ( control ) . Intervention group : GP practice s in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist . Patients are review ed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice .or Control group : St and ard GP care , with referral to secondary care as required , but no access to ICCD .  Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control . The primary outcome is the proportion of participants reaching three risk factor targets : HbA1c ( ≤7.0 % ) ; blood pressure ( < 140/80 ) ; and cholesterol ( < 4 mmol/l ) , at the end of the 18-month intervention period . The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD ) and stroke assessed by the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) risk engine . Other secondary outcomes include body mass index and waist circumference , use of medication , reported smoking , emotional adjustment , patient satisfaction and views on continuity , costs and health related quality of life . We aim ed to r and omize 50 practice s and recruit 2,555 patients . Discussion Forty-nine practice s have been r and omized , 1,997 patients have been recruited to the trial , and 20 patients  have been recruited to the qualitative study . Results will be available late 2012.Trial registration [ Clinical Trials.gov : Identifier NCT00945204 Background : Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed . Pharmacists are accessible primary care professionals and with exp and ed scopes of practice ( including prescribing ) , could identify and manage patients with dyslipidemia . We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol ( LDL-c ) levels . Methods : We conducted a r and omized controlled trial in 14 community pharmacies in Alberta , Canada . We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines . Intervention was pharmacist-directed dyslipidemia care , including assessment of cardiovascular risk , review of LDL-c , prescribing of medications , health behaviour interventions and follow-up every 6 weeks for 6 months . Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist . Primary outcome was the proportion of participants achieving their target LDL-c ( < 2 mmol/L or ≥50 % reduction ) at 6 months between groups . Results : We enrolled 99 patients with a mean ( SD ) age of 63 ( 13 ) years , 49 % male and baseline LDL-c of 3.37 mmol/L ( 0.98 ) . Proportion of patients achieving LDL-c target was 43 % intervention versus 18 % control ( p = 0.007 ) . Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group ( p = 0.031 ) , who also achieved greater reduction in LDL-c ( 1.12 mmol/L , SE = 0.112 ) versus control ( 0.42 mmol/L , SE = 0.109 ) , for an adjusted mean difference of 0.546 mmol/L ( SE = 0.157 ) , p < 0.001 . Conclusion : Pharmacist prescribing result ed in > 3-fold more patients achieving target LDL-c levels . This could have major public health implication UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . 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 . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes  : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups Background Physical activity ( PA ) and nutrition are the cornerstones of diabetes management . Several review s and meta-analyses report that PA independently produces clinical ly important improvements in glucose control in people with Type 2 diabetes . However , it remains unclear what the optimal strategies are to increase PA behaviour in people with Type 2 diabetes in routine primary care . Methods This study will determine whether an evidence -informed multifaceted behaviour change intervention ( Movement as Medicine for Type 2 Diabetes ) targeting both consultation behaviour of primary healthcare professionals and PA behaviour in adults with Type 2 diabetes is both acceptable and feasible in the primary care setting . An open pilot study conducted in two primary care practice s ( phase one ) will assess acceptability , feasibility and fidelity . Ongoing feedback from participating primary healthcare professionals and patients will provide opportunities for systematic adaptation and refinement of the intervention and study procedures . A two-arm parallel group clustered pilot r and omised controlled trial with patients from participating primary care practice s in North East Engl and will assess acceptability , feasibility , and fidelity of the intervention ( versus usual clinical care ) and trial processes over a 12-month period . Consultation behaviour involving fidelity of intervention delivery , diabetes and PA related knowledge , attitudes/beliefs , intentions and self-efficacy for delivering a behaviour change intervention targeting PA behaviour will be assessed in primary healthcare professionals . We will rehearse the collection of outcome data ( with the focus on data yield and quality ) for a future definitive trial , through outcome assessment at baseline , one , six and twelve months . An embedded qualitative process evaluation and treatment fidelity assessment will explore issues around intervention implementation and assess whether intervention components can be reliably and faithfully delivered in routine primary care . Discussion Movement as Medicine for Type 2 Diabetes will address an important gap in the evidence -base , that is , the need for interventions to increase free-living PA behaviour in adults with Type 2 diabetes . The multifaceted intervention incorporates an online accredited training programme for primary healthcare professionals and represents , to the best of our knowledge , the first of its kind in the United Kingdom . This study will establish whether the multifaceted behavioural intervention is acceptable and feasible in routine primary care . Trial registration Movement as Medicine for Type 2 Diabetes ( MaMT2D ) was registered with Current Controlled Trials on the 14th January 2012 : IS RCT N67997502 . The first primary care practice was r and omised on the 5th October 2012 Background Two-thirds of people living with dementia live at home in the UK and many experience distressing behavioural and psychological symptoms . This systematic review evaluates the effectiveness of non-pharmacological interventions for behavioural and psychological symptoms among community-dwelling people living with dementia . Methods This two-stage review undertook an initial mapping of the literature followed by a systematic review of relevant r and omised controlled trials . We search ed electronic data bases for pertinent studies reporting outcomes from interventions from January 2000 to March 2015 and up date d search es in October 2016 . We included studies that considered behavioural and psychological symptom management for older people living with dementia who live at home and excluded studies conducted in long-term care setting s. This paper presents findings from a narrative synthesis of 48 r and omised controlled trials evaluating interventions for people living with dementia alone , family carers alone and patient-carer dyads . Results We retrieved 17,871 de-duplicated records and screened them for potential inclusion . Evidence from 48 r and omised controlled trials suggests that family carer training and educational programmes that target problem behaviours and potential triggers can improve outcomes . Nurses and occupational therapists appear to help people with dementia with behavioural and psychological symptoms , but professional comparisons are lacking and there is no shared language about or underst and ing of behavioural and psychological symptoms amongst professionals , or between professionals and family carers . Conclusions Future research should focus on the effectiveness of components of multi-faceted programmes and their cost effectiveness and include qualitative data to better target interventions for behavioural and psychological symptoms . It is important to consider family carer readiness to use non-pharmacological strategies and to develop a shared language about the inherent needs and communications of behavioural and psychological symptoms Abstract Problem : Inhabitants of Torres Strait Isl and s have the highest prevalence of diabetes in Australia and many preventable complications . In 1999 , a one year r and omised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers , recall and reminder systems , and basic diabetes care plans , supported by a specialist outreach service . This study looked at whether those improvements were sustained two years after the end of the trial . Design : Three year follow up clinical audit of 21 primary healthcare centres , and review of admissions to hospital in the previous 12 months . Background and setting : Remote indigenous communities in far north east Australia , population about 9600 , including 921 people with diabetes . Key measures for improvement Number of people on registers , care processes ( regular measures of weight , blood pressure , haemoglobin A 1c , urinary protein concentration , and concentrations of serum lipids and creatinine ) , appropriate clinical interventions ( drug treatment and vaccinations ) , and intermediate patient outcome measures ( weight , blood pressure , and glycaemic control ) . Admissions to hospital . Strategies for change : Audit and feedback to clinicians and managers ; provision of clinical guidelines and a clear management structure ; workshops and training . Effects of change : The number of people on registers increased from 555 in 1999 to 921 in 2002 . Most care processes and clinical interventions improved . The proportion of people with good glycaemic control ( haemoglobin A 1c ≤ 7 % ) increased from 18 % to 25 % in line with increased use of insulin ( from 7 % to 16 % ) . The proportion of those with well controlled hypertension ( < 140/90 ) increased from 40 % to 64 % . The proportion admitted to hospital with a diabetes related condition fell from 25 % to 20 % . Mean weight increased from 87 kg to 91 kg . Lessons learnt : In remote setting s , appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes , control of blood pressure , and preventable complications that result in admission to hospital . Control of weight and glycaemia are more difficult and requires more active community engagement . Priorities now include increasing the availability and affordability of good food , achieving weight loss , and increasing appropriate use of hypoglycaemic agents , including insulin BACKGROUND Despite the cardiovascular disease ( CVD ) risk associated with hypertension , diabetes , dyslipidemia , and smoking , these risk factors remain poorly identified and controlled . OBJECTIVES The study sought to evaluate the effectiveness of a community pharmacy-based case finding and intervention on cardiovascular risk . METHODS The RxEACH ( Alberta Vascular Risk Reduction Community Pharmacy Project ) study was a r and omized trial conducted in 56 community pharmacies . Participants were recruited by their pharmacist , who enrolled adults at high risk for CVD . Patients were r and omized to usual care ( usual pharmacist care with no specific intervention ) or intervention , comprising a Medication Therapy Management review from their pharmacist and CVD risk assessment and education . Pharmacists prescribed medications and ordered laboratory tests as per their scope of practice to achieve treatment targets . Subjects received monthly follow-up visits for 3 months . The primary outcome was difference in change in estimated CVD risk between groups at 3 months . CVD risk was estimated using the greater of the Framingham , International , or United Kingdom Prospect i ve Diabetes Study risk scores . RESULTS We enrolled 723 patients ( mean 62 years of age ; 58 % male , and 27 % smokers ) . After adjusting for baseline values and center effect , there was a 21 % difference in change in risk for CVD events ( p < 0.001 ) between the intervention and usual care groups . The intervention group had greater improvements in low-density lipoprotein cholesterol ( -0.2 mmol/l ; p < 0.001 ) , systolic blood pressure ( -9.37 mm Hg ; p < 0.001 ) , glycosylated hemoglobin ( -0.92 % ; p < 0.001 ) , and smoking cessation ( 20.2 % ; p = 0.002 ) . CONCLUSIONS The RxEACH study was the first large r and omized trial of CVD risk reduction by community pharmacists , demonstrating a significant reduction in risk for CVD events . Engagement of community pharmacists with an exp and ed scope of practice could have significant public health implication s. ( The Alberta Vascular Risk Reduction Community Pharmacy Project : RxEACH [ RxEACH ] ; NCT01979471 ) Background Despite broad agreement on the necessity to improve quality of diabetic care through implementation of clinical guidelines , in Italy many people with diabetes still lack adequate care in general practice . In addition there is little evidence to support the choice of implementation strategies , especially in the Lazio region ( central Italy ) , where comparative studies among general practitioners ( GPs ) are uncommon . The primary objective of the study is to assess the effectiveness of different strategies for the implementation of an  evidence -based guideline for the management of  non-complicated type 2 diabetes mellitus ( DM ) among GPs of the Lazio region . Methods / Design Three-arm cluster-r and omised trial ( C- RCT ) . 252 GPs were r and omised either to arm 1 ( comprising a training module and administration of the guideline ) , or to arm 2 ( administration of guideline without training ) , or to arm 3 ( control arm ) , continuing current practice . Arm 1 participants attended a two-day course with CME credits . Data collection will be performed using current information systems . Patients ' health data was also collected to describe diabetic population s cared for by GP participants . Process outcomes will be measured at the patient level and at the cluster level one year after the intervention . We will assess GPs ' adherence to guideline recommendations for diabetes management relative to : 1 ) pharmacological management of diabetes ; 2 ) pharmacological management of cardiovascular risk factors ( hypertension and dislypidaemia ) ; 3 ) measurement of glycosilated haemoglobin as the principal indicator of glycaemic control ; 4 ) micro- and macrovascular complications assessment tests . Outcomes will be expressed as proportions of patients cared for by GPs who will have prescriptions of drugs , requests for tests and for outpatient appointment visits . To estimate the efficiency of re source use associated with the intervention a cost-effectiveness analysis will be carried out . The design of the study is based on three Cochrane and one Health Technology Assessment systematic review s of guideline dissemination and implementation strategies BACKGROUND In Turkish immigrant diabetics , problems with communication and cultural differences may hinder delivery of diabetes care . METHODS In a prospect i ve controlled study , the effect of an ethnic-specific diabetes education programme on glycaemic control and cardiovascular risk factors in Turkish type 2 diabetes patients was assessed , by comparing  Turkish diabetics who were offered the education programme with Turkish diabetics offered routine care only ( control group ) .  From 16 general practice s ( 31 GPs ) in Rotterdam , 104 Turkish type 2 diabetes patients were recruited , 85 of whom could be assessed at one-year follow-up .  Glycaemic control , lipid concentrations , blood pressure and body mass index were measured . RESULTS Compared with the control group , mean HbA(1C ) in the intervention group decreased by 0.3 % ( 95 % CI -0.8 to 0.2 ) . A significant decrease in HbA(1C ) was observed in women with HbA(1C ) > 7 % at baseline ( -0.9 % ; 95 % CI -1.73 to -0.09 ) but not in the other subgroups studied . serum lipid concentrations , blood pressure and body mass index remained unchanged in the intervention group . CONCLUSION Ethnic-specific diabetes education by Turkish female educators has no obvious beneficial effect on glycaemic control or cardiovascular risk profile . More focus on specific patient selection and gender e quality between educators/ patients may prove worthwhile BACKGROUND with increasing prevalence of diabetes in older people , it is important to underst and factors that affect their outcomes . The Informatics for Diabetes Education and Telemedicine ( IDEATel ) project is a demonstration project to evaluate the feasibility and effectiveness of telemedicine with diverse , medically underserved , older diabetes patients . Subjects were r and omised to telemedicine case management or usual care .  This intervention has been shown to result in improved medical outcomes and self-efficacy . Self-efficacy refers to one 's belief that (s)he can successfully engage in a behaviour . Self-efficacy has been shown to relate to behaviour change and glycaemic control in middle-aged individuals , but not studied in older individuals . OBJECTIVES to assess whether ( a ) diabetes self-efficacy relates to the primary medical outcome of glycaemic control , and to secondary outcomes ( blood pressure and cholesterol ) , and ( b ) whether , after an intervention , change in diabetes self-efficacy relates to change in these medical outcomes in a group of older , ethnically diverse individuals . METHODS three waves of longitudinal data from participants in IDEATel were analysed . RESULTS diabetes self-efficacy at baseline correlated with glycaemic control , blood pressure and cholesterol . An increase in diabetes self-efficacy over time was related to an improvement in glycaemic control ( P < 0.0001 ) , but not in blood pressure and lipid levels . The intervention was significantly related to improved self-efficacy over time ( P < 0.0001 ) , and both directly ( P = 0.022 ) and indirectly through self-efficacy ( P < 0.001 ) to improved glycaemic control . The mediation effect of self-efficacy was also significant ( P < 0.004 ) . CONCLUSIONS diabetes self-efficacy is a relevant construct for older diabetes patients . Thus , interventions that target enhanced self-efficacy may also result in improved glycaemic control Background Earlier diagnosis followed by multi-factorial cardiovascular risk intervention may improve outcomes in Type 2 Diabetes Mellitus ( T2DM ) . Latent phase identification through screening requires structured , appropriately targeted population -based approaches . Providers responsible for implementing screening policy await evidence of clinical and cost effectiveness from r and omised intervention trials in screen-detected T2DM cases . UK South Asians are at particularly high risk of abnormal glucose tolerance and T2DM . To be effective national screening programmes must achieve good coverage across the population by identifying barriers to the detection of disease and adapting to the delivery of earlier care . Here we describe the rationale and methods of a systematic community screening programme and r and omised controlled trial of cardiovascular risk management within a UK multiethnic setting ( ADDITION-Leicester ) . Design A single-blind cluster r and omised , parallel group trial among people with screen-detected T2DM comparing a protocol driven intensive multi-factorial treatment with conventional care . Methods ADDITION-Leicester consists of community-based screening and intervention phases within 20 general practice s coordinated from a single academic research centre . Screening adopts a universal diagnostic approach via repeated 75g-Oral Glucose Tolerance Tests within an eligible non-diabetic population of 66,320 individuals aged 40 - 75 years ( 25 - 75 years South Asian ) . Volunteers also provide detailed medical and family histories ; complete health question naires , undergo anthropometric measures , lipid profiling and a proteinuria assessment . Primary outcome is reduction in modelled Coronary Heart Disease ( UKPDS CHD ) risk at five years .  Seven thous and ( 30 % of South Asian ethnic origin ) volunteers over three years will be recruited to identify a screen-detected T2DM cohort ( n = 285 ) powered to detected a 6 % relative difference ( 80 % power , alpha 0.05 ) between treatment groups at one year . R and omisation will occur at practice -level with newly diagnosed T2DM cases receiving either conventional ( according to current national guidelines ) or intensive ( algorithmic target-driven multi-factorial cardiovascular risk intervention ) treatments . Discussion ADDITION-Leicester is the largest multiethnic ( targeting > 30 % South Asian recruitment ) community T2DM and vascular risk screening programme in the UK . By assessing feasibility and efficacy of T2DM screening , it will inform national disease prevention policy and contribute significantly to our underst and ing of the health care needs of UK South Asians . Trial registration Clinical trial.gov ( NCT00318032 ) Purpose With growing numbers of people at risk for diabetes and cardiovascular disease , diabetes educators report increasing referrals for intervention in prevention of these conditions . Diabetes educators have expertise in diabetes self-management education ; however , they are generally not prepared for delivery of chronic disease primary prevention . The purpose of this project was to determine if individuals at risk for diabetes who participate in an intervention delivered by trained diabetes educators in existing diabetes self-management education community-based programs can reduce risk factors for diabetes and cardiovascular disease . Methods Diabetes educators in 3 outpatient-hospital programs ( urban , suburban , and rural ) received training and support for implementation of the Group Lifestyle Balance program , an adaptation of the Diabetes Prevention Program lifestyle intervention , from the Diabetes Prevention Support Center of the University of Pittsburgh . Adults with prediabetes and /or the metabolic syndrome were eligible to enroll in the program with physician referral . With use of existing diabetes educator networks , recruitment was completed via on-site physician in-services , informative letters , and e-mail contact as well as participant-directed newspaper advertisement . Results Eighty-one participants enrolled in the study ( 71 women , 10 men ) .  Mean overall weight loss was 11.3 lb ( 5.1 % , P < .001 ) ; in addition , significant decreases were noted in fasting plasma glucose , low-density lipoprotein cholesterol , triglycerides , and blood pressure . Conclusions These results suggest that the Group Lifestyle Balance program delivered by diabetes educators was successful in reducing risk for diabetes and cardiovascular disease in high-risk individuals . Furthermore , diabetes educators , already integrated within the existing health care system , provide yet another re source for delivery of primary prevention programs in the community Background Addressing the increasing prevalence , and associated disease burden , of diabetes is a priority of health services internationally . Interventions to support patients to effectively self-manage their condition have the potential to reduce the risk of costly and debilitating complications . The utilisation of mobile phones to deliver self-management support allows for patient-centred care at the frequency and intensity that patients desire from outside the clinic environment . Self-Management Support for Blood Glucose ( SMS4BG ) is a novel text message-based intervention for supporting people with diabetes to improve self-management behaviours and achieve better glycaemic control and is tailored to individual patient preferences , demographics , clinical characteristics , and culture . This study aims to assess whether SMS4BG can improve glycaemic control in adults with poorly controlled diabetes . This paper outlines the rationale and methods of the trial . Methods / design A two-arm , parallel , r and omised controlled trial will be conducted across New Zeal and health districts . One thous and participants will be r and omised at a 1:1 ratio to receive SMS4BG , a theoretically based and individually tailored automated text message-based diabetes self-management support programme ( intervention ) in addition to usual care , or usual care alone ( control ) . The primary outcome is change in glycaemic control ( HbA1c ) at 9 months . Secondary outcomes include glycaemic control at 3 and 6 months , self-efficacy , self-care behaviours , diabetes distress , health-related quality of life , perceived social support , and illness perceptions . Cost information and healthcare utilisation will also be collected as well as intervention satisfaction and interaction . Discussion This study will provide information on the effectiveness of a text message-based self-management support tool for people with diabetes . If found to be effective it has the potential to provide individualised support to people with diabetes across New Zeal and ( and internationally ) , thus extending care outside the clinic environment . Trial registration Australian New Zeal and Clinical Trials Registry : ACTRN12614001232628 Introduction The prevalence of gestational diabetes mellitus ( GDM ) is rising in the UK . Good glycaemic control improves maternal and neonatal outcomes . Frequent clinical review of patients with GDM by healthcare professionals is required owing to the rapidly changing physiology of pregnancy and its unpredictable course . Novel technologies that allow home blood glucose ( BG ) monitoring with results transmitted in real time to a healthcare professional have the potential to deliver good- quality healthcare to women more conveniently and at a lower cost to the patient and the healthcare provider compared to the conventional face-to-face or telephone-based consultation . We have developed an integrated GDm-health management system and aim to test the impact of using this system on maternal glycaemic control , costs , patient satisfaction and maternal and neonatal outcomes compared to st and ard clinic care in a single large publicly funded ( National Health Service ( NHS ) ) maternity unit . Methods and analysis Women with confirmed gestational diabetes in a current pregnancy are individually r and omised to either the GDm-health system and half the normal clinic visits or normal clinic care . Primary outcome is mean BG in each group from recruitment to delivery calculated , with adjustments made for number of BG measurements , proportion of prepr and ial and postpr and ial readings and length of time in study , and compared between the groups . The secondary objective will be to compare the two groups for compliance to the allocated BG monitoring regime , maternal and neonatal outcomes , glycaemic control using glycated haemoglobin ( HbA1c ) and other BG metrics , and patient attitudes to care assessed using a question naire and re source use . Ethics and dissemination Thresholds for treatment , dietary advice and clinical management are the same in both groups . The results of the study will be published in a peer- review ed journal and disseminated electronically and in print . Trial registration number NCT01916694 ; Pre- results Background To assess whether the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus ( RAMP-DM )  led to improvements in biomedical outcomes , observed cardiovascular events and predicted cardiovascular risks after 12-month intervention in the primary care setting . Methods A r and om sample of 1,248 people with diabetes enrolled to RAMP-DM for at least 12 months was selected and 1,248 people with diabetes under the usual primary care were matched by age , sex , and HbA1c level at baseline as the usual care group . Biomedical and cardiovascular outcomes were measured at baseline and at 12-month after the enrollment . Difference-in-differences approach was employed to measure the effect of RAMP-DM on the changes in biomedical outcomes , proportion of subjects reaching treatment targets , observed and predicted cardiovascular risks . Results Compared to the usual care group , RAMP-DM group had lower cardiovascular events incidence ( 1.21 % vs 2.89 % , P = 0.003 ) , and net decrease in HbA1c ( −0.20 % , P < 0.01 ) , SBP ( −3.62 mmHg , P < 0.01 ) and 10-year cardiovascular disease ( CVD ) risks ( total CVD risk , −2.06 % , P < 0.01 ; coronary heart disease ( CHD ) risk , −1.43 % , P < 0.01 ; stroke risk , −0.71 % , P < 0.01 ) . The RAMP-DM subjects witnessed significant rises in the proportion of reaching treatment targets of HbA1c , and SBP/DBP . After adjusting for confounding variables , the significance remained for HbA1c , predicted CHD and stroke risks . Conclusions The RAMP-DM result ed in greater improvements in HbA1c and reduction in observed and predicted cardiovascular risks at 12 months follow-up , which indicated a risk-stratification multidisciplinary intervention was an effective strategy for managing Chinese people with diabetes in the primary care setting .Trial registry Clinical Trials.gov , Executive summary Background As a chronic condition , the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications , an essential component of self‐management , has been shown to improve glycaemic control . However compliance with oral medication adherence remains poor . Educating people with Type 2 diabetes is an important strategy to enhance self‐management ability , including medication‐taking behaviour . Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes . Inclusion criteria Types of participants Studies involving adults over 18 years old with Type 2 diabetes , with or without co‐morbidities , currently taking oral hypoglycaemic medication without insulin treatment , and with aglycated haemoglobin ( HbA1c ) > 7.0 % prior to the intervention were considered . Aglycated haemoglobin ( HbA1c ) concentration of less than 7.0 % , is important in order to delay or prevent diabetes‐related complications . Participants could be from the primary , tertiary or acute care setting . Types of intervention The review focused on various forms of educational interventions delivered by healthcare professionals aim ed at improving participants ’ knowledge . Types of outcomes The review evaluated outcomes measuring oral hypoglycaemic adherence including HbA1c , fasting blood glucose levels and other relevant indicators . Types of studies Studies that were r and omized controlled trials ( RCTs ) or case‐control studies were considered . Search strategy A three‐stage search strategy was employed . Papers in English and between the years 1990‐2009 were search ed in the following data bases : CINAHL , Medline , Mosby 's Nursing Consult , PsycINFO , PubMed , ScienceDirect , Scopus , TRIP and Web of Science . Full text was retrieved when the titles and abstract s of studies fulfilled the inclusion criteria . Method ological quality Full papers were assessed for method ological quality independently by two review ers using critical appraisal checklists from the Joanna Briggs Institute ( JBI ) . A third review er was consulted whenever there were disagreements between the two review ers . Data collection / extraction Details of each study included in the review were extracted using st and ardized data extraction forms developed by JBI . Extraction was conducted independently by two review ers . Data synthesis Meta‐ analysis was not possible due to method ological and statistical heterogeneity of the included studies . Hence study findings are presented in narrative form . Results Seven studies included in the final review consisted of seven RCTs . Five studies concluded that the educational intervention was effective in promoting oral hypoglycaemic adherence compared to usual care . These included pharmacist‐led interventions , individual diabetes education provided by nurses and diabetes group education based on a self‐management approach . Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions . However , small sample s in some studies limited generalization of results . Conclusions Implication s for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence . Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence . Educational interventions focusing on self‐management strategies appear more likely to achieve positive outcomes . Implication s for research Further trials involving larger sample s and population s with poor glycaemic control are needed . The effects of educational interventions , influence of additional take‐home written material , the optimal interval length of follow‐up and duration of education sessions , and specific processes of individual or group education which have been identified as effective need further exploration OBJECTIVE To improve the treatment of risk factors of cardiovascular disease ( CVD ) for older patients with diabetes after a cardiac event by using a low-literacy reminder card describing these risk factors in community setting s. STUDY DESIGN A multicenter , r and omized , interventional study . METHODS Patients aged 55 years or older with diabetes hospitalized with an acute myocardial infa rct ion , congestive heart failure exacerbation , or unstable angina were eligible to enter the study . Control and experimental patients were recruited from 4 sites and were enrolled in the study before discharge from the hospital . Experimental subjects received education and a reminder card describing risk factors of CVD . They were instructed to discuss the risk factors described on the reminder card with their primary care physician on their first appointment after discharge . Control subjects did not receive any intervention but were given consent to be able to review their charts . RESULTS One hundred sixty patients completed the study , 82 in the control group and 78 in the experimental group . At the end of the study there was no difference in blood pressure control , lipid levels , and glycosylated hemoglobin levels between the control and experimental patients . Aspirin use and ACE inhibitor use were found to be significantly higher in the control group ( P = .001 and .03 , respectively ) . CONCLUSIONS Reminder cards given to patients to discuss with their primary care providers in community setting s did not improve process measures of CVD risk in patients with documented CVD and diabetes . Other approaches will be needed to improve the treatment of risk factors in these high-risk patients AIMS Cardiovascular disease ( CVD ) is the leading cause of morbidity and mortality in people with diabetes in South Asia . The CARRS Translation Trial tests the effectiveness , cost-effectiveness , and sustainability of a clinic-based multi-component CVD risk reduction intervention among people with diabetes in India and Pakistan . METHODS We r and omly assigned 1146 adults with diabetes recruited from 10 urban clinic sites , to receive usual care by physicians or to receive an integrated multi-component CVD risk reduction intervention . The intervention involves electronic health record management , decision-support prompts to the healthcare team , and the support of a care coordinator to actively facilitate patient and provider adherence to evidence -based guidelines . The primary outcome is a composite of multiple CVD risk factor control ( blood glucose and either blood pressure or cholesterol , or all three ) . Other outcomes include control of the individual CVD risk factors , process and patient-centered measures , cost-effectiveness , and acceptability/feasibility . CONCLUSION The CARRS Translation Trial tests a low-cost diabetes care delivery model in urban South Asia to achieve comprehensive cardio-metabolic disease case-management of high-risk patients ( clinical trials.gov number : NCT01212328 ) Background Type 2 diabetes is a major public health problem in Australia with prevalence increasing in parallel with increasing obesity . Prevention is an essential component of strategies to reduce the diabetes burden . There is strong and consistent evidence from r and omised controlled trials that type 2 diabetes can be prevented or delayed through lifestyle modification which improves diet , increases physical activity and achieves weight loss in at risk people . The current challenge is to translate this evidence into routine community setting s , determine feasible and effective ways of delivering the intervention and providing on-going support to sustain successful behavioural changes . Methods / Design The Sydney Diabetes Prevention Program ( SDPP ) is a translational study which will be conducted in 1,550 participants aged 50 - 65 years ( including 100 indigenous people aged 18 years and older ) at high risk of future development of diabetes . Participants will be identified through a screening and recruitment program delivered through primary care and will be offered a community-based lifestyle modification intervention . The intervention comprises an initial individual session and three group sessions based on behaviour change principles and focuses on five goals : 5 % weight loss , 210 min/week physical activity ( aerobic and strength training exercise ) , limit dietary fat and saturated fat to less than 30 % and 10 % of energy intake respectively , and at least 15 g/1000 kcal dietary fibre . This is followed by 3-monthly contact with participants to review progress and offer ongoing lifestyle advice for 12 months . The effectiveness and costs of the program on diabetes-related risk factors will be evaluated . Main outcomes include changes in weight , physical activity , and dietary changes ( fat , saturated fat and fibre intake ) . Secondary outcomes include changes in waist circumference , fasting plasma glucose , blood pressure , lipids , quality of life , psychological well being , medication use and health service utilization . Discussion This translational study will ascertain the reach , feasibility , effectiveness and cost-effectiveness of a lifestyle modification program delivered in a community setting through primary health care . If demonstrated to be effective , it will result in recommendations for policy change and practical methods for a wider community program for preventing or delaying the onset of type 2 diabetes in high risk people Background Patients with type 2 diabetes mellitus ( T2D ) have an increased risk of cardiovascular disease and mortality compared to the background population . Observational studies report an association between reduced blood glucose and reduced risk of both micro- and macrovascular complications in patients with T2D . Our previous systematic review of intensive glycaemic control versus conventional glycaemic control was based on 20 r and omised clinical trials that r and omised 29 , 986 participants with T2D . We now report our up date d review . Objectives To assess the effects of targeted intensive glycaemic control compared with conventional glycaemic control in patients with T2D . Search methods Trials were obtained from search es of The Cochrane Library , MEDLINE , EMBASE , Science Citation Index Exp and ed , LILACS , and CINAHL ( all until December 2012 ) . Selection criteria We included r and omised clinical trials that prespecified targets of intensive glycaemic control versus conventional glycaemic control targets in adults with T2D . Data collection and analysis Two authors independently assessed the risk of bias and extracted data . Dichotomous outcomes were assessed by risk ratios ( RR ) and 95 % confidence intervals ( CI ) . Health-related quality of life and costs of intervention were assessed with st and ardized mean differences ( SMD ) and 95 % Cl . Main results Twenty-eight trials with 34,912 T2D participants r and omised 18,717 participants to intensive glycaemic control  versus 16,195 participants to  conventional glycaemic control . Only two trials had low risk of bias on all risk of bias domains assessed . The duration of the intervention ranged from three days to 12.5 years . The number of participants in the included trials ranged from 20 to 11,140 . There were no statistically significant differences between targeting intensive versus conventional glycaemic control for all-cause mortality ( RR 1.00 , 95 % CI 0.92 to 1.08 ; 34,325 participants , 24 trials ) or cardiovascular mortality ( RR 1.06 , 95 % CI 0.94 to 1.21 ; 34,177 participants , 22 trials ) . Trial sequential analysis showed that a 10 % relative risk reduction could be refuted for all-cause mortality . Targeting intensive glycaemic control did not show a statistically significant effect on the risks of macrovascular complications as a composite outcome in the r and om-effects model , but decreased the risks in the fixed-effect model ( r and om RR 0.91 , 95 % CI 0.82 to 1.02 ; and fixed RR 0.93 , 95 % CI 0.87 to 0.99 ; P = 0.02 ; 32,846 participants , 14 trials ) . Targeting intensive versus conventional glycaemic control seemed to reduce the risks of non-fatal myocardial infa rct ion ( RR 0.87 , 95 % CI 0.77 to 0.98 ; P = 0.02 ; 30,417 participants , 14 trials ) , amputation of a lower extremity ( RR 0.65 , 95 % CI 0.45 to 0.94 ; P = 0.02 ; 11,200 participants , 11 trials ) , as well as the risk of developing a composite outcome of microvascular diseases ( RR 0.88 , 95 % CI 0.82 to 0.95 ; P = 0.0008 ; 25,927 participants , 6 trials ) , nephropathy ( RR 0.75 , 95 % CI 0.59 to 0.95 ; P = 0.02 ; 28,096 participants , 11 trials ) , retinopathy ( RR 0.79 , 95 % CI 0.68 to 0.92 ; P = 0.002 ; 10,300 participants , 9 trials ) , and the risk of retinal photocoagulation ( RR 0.77 , 95 % CI 0.61 to 0.97 ; P = 0.03 ; 11,212 participants , 8 trials ) . No statistically significant effect of targeting intensive glucose control could be shown on non-fatal stroke , cardiac revascularization , or peripheral revascularization . Trial sequential analyses did not confirm a reduction of the risk of non-fatal myocardial infa rct ion but confirmed a 10 % relative risk reduction in favour of intensive glycaemic control on the composite outcome of microvascular diseases . For the remaining microvascular outcomes , trial sequential analyses could not establish firm evidence for a 10 % relative risk reduction . Targeting intensive glycaemic control significantly increased the risk of mild hypoglycaemia , but substantial heterogeneity was present ; severe hypoglycaemia ( RR 2.18 , 95 % CI 1.53 to 3.11 ; 28,794 participants , 12 trials ) ; and serious adverse events ( RR 1.06 , 95 % CI 1.02 to 1.10 ; P = 0.007 ; 24,280 participants , 11 trials ) . Trial sequential analysis for a 10 % relative risk increase showed firm evidence for mild hypoglycaemia and serious adverse events and a 30 % relative risk increase for severe hypoglycaemia when targeting intensive versus conventional glycaemic control . Overall health-related quality of life , as well as the mental and the physical components of health-related quality of life did not show any statistical significant differences . Authors ' conclusions Although we have been able to exp and the number of participants by 16 % in this up date , we still find paucity of data on outcomes and the bias risk of the trials was mostly considered high . Targeting intensive glycaemic control compared with conventional glycaemic control did not show significant differences for all-cause mortality and cardiovascular mortality . Targeting intensive glycaemic control seemed to reduce the risk of microvascular complications , if we disregard the risks of bias , but increases the risk of hypoglycaemia and serious adverse events BACKGROUND Type 1 diabetes ( T1D ) in children and young people is increasing worldwide with a particular increase in children under the age of 5 years . Fewer than one in six children and young people achieve glycosylated fraction of haemoglobin ( HbA1c ) values in the range identified as providing best future outcomes . There is an urgent need for clinic-based pragmatic , feasible and effective interventions that improve both glycaemic control and quality of life ( QoL ) . The intervention offers both structured education , to ensure young people know what they need to know , and a delivery model design ed to motivate self-management . OBJECTIVE To assess the feasibility of providing a clinic-based structured educational group programme incorporating psychological approaches to improve long-term glycaemic control , QoL and psychosocial functioning in a diverse range of young people . DESIGN The study was a pragmatic , cluster r and omised control trial with integral process and economic evaluation . SETTING Twenty-eight paediatric diabetes services across London , south-east Engl and and the Midl and s. R AND OMISATION Minimised by clinic size , age ( paediatric or adolescent ) and specialisation ( district general hospital clinic or teaching hospital/tertiary clinic ) . ALLOCATION Half of the sites were r and omised to the intervention arm and half to the control arm . Allocation was concealed until after clinics had consented and the first participant was recruited . Where possible , families were blind to allocation until recruitment finished . PARTICIPANTS Forty-three health-care practitioners ( 14 teams ) were trained in the intervention . The study recruited 362 children aged 8 - 16 years , diagnosed with T1D for > 12 months , with a mean 12-month HbA1c level of ≥ 8.5 % . INTERVENTION Two 1-day workshops taught intervention delivery . A detailed manual and re sources were provided . The intervention consists of four group education sessions led by a paediatric diabetes specialist nurse with another team member . OUTCOMES The primary outcome was glycaemic control , assessed at the individual level using venous HbA1c values , measured at baseline , 12 and 24 months . Secondary outcomes were directly and indirectly related to diabetes management , including hypoglycaemic episodes , hospital admissions , diabetes regimen , knowledge , skills and responsibility for diabetes management , intervention compliance , clinic utilisation , emotional and behavioural adjustment , and general and diabetes-specific QoL. PROCESS EVALUATION Question naires , semistructured interviews , informal discussion following observation sessions , fieldwork notes and case note review were used to collect qualitative and quantitative data from key stakeholder groups at specific time points in the trial . STATISTICAL ANALYSES Primary and secondary analyses were intention-to-treat comparisons of outcomes at 12 and 24 months , using analysis of covariance with a r and om effect for clinic . Prespecified subgroup analyses based on age , gender , initial HbA1c value and socioeconomic status were estimated from models that included an interaction term . The economic analysis compared long-term costs and predicted quality -adjusted life-years ( QALYs ) . RESULTS The intervention did not improve HbA1c at 12 months [ intervention effect 0.11 ; 95 % confidence interval ( CI ) -0.28 to 0.50 ; p = 0.584 ] or 24 months ( intervention effect 0.03 ; 95 % CI -0.36 to 0.41 ; p = 0.891 ) . A total of 298/362 patients ( 82.3 % ) provided blood sample s at 12-month follow-up , and 284/362 ( 78.5 % ) provided blood sample s at 24-month follow-up . Follow-up question naires were completed by 307 patients ( 85.3 % ) at 12 months and by 295 patients ( 81.5 % ) at 24 months . Intervention group parents at 12 months ( 95 % CI 0.74 ; 0.03 to 1.52 ) and young people at 24 months ( 0.85 ; 95 % CI 0.03 to 1.61 ) had higher scores on the diabetes family responsibility question naire . Young people reported reduced happiness with body weight at 12 months ( -0.56 ; 95 % CI -1.03 to -0.06 ) . Only 68 % of groups were run . Of the 180 families recruited , 96 ( 53 % ) attended at least one module . Reasons for low uptake included difficulties organising groups , and work and school commitments . Young people with higher HbA1c levels were less likely to attend . Parents and young people who attended groups described improved family relationships , improved knowledge and underst and ing , greater confidence and increased motivation to manage diabetes . Twenty-four months after the intervention , nearly half of the young people reported that the groups had made them want to try harder and that they had carried on trying . A high- quality , complex , pragmatic trial of structured education can be delivered alongside st and ard care in NHS diabetes clinics . Health-care providers benefited from behaviour change skill training and can deliver pragmatic aspects of a National Institute for Health and Care Excellence (NICE)-compliant structured education programme after relatively brief training . The process evaluation provides insight into aspects of the model , and highlights strengths and aspects that may have contributed to the failure to influence primary and secondary outcomes . Current NHS practice dominates CASCADE ( Child and Adolescent Structured Competencies Approach to Diabetes Education ) in that it achieves the same number of QALYs at a lower cost . The mean cost of providing the intervention was £ 5098 per site or £ 683 per child . Members of paediatric diabetes services trained to deliver the CASCADE structured education package using behaviour change techniques did not improve glycaemic control in patients compared with control subjects 1 and 2 years after the intervention . The training workshops for practitioners were well evaluated ; however , more intensive training was needed . The intervention cost £ 683 per patient but was not cost-effective because it did not improve metabolic control . CONCLUSIONS A high- quality , complex , pragmatic trial of structured education can be successfully conducted alongside st and ard care in NHS diabetes clinics . Pragmatic components of a NICE-compliant structured education programme can be successfully delivered following a relatively brief 2-day training while paediatric health-care professionals benefit from training in behaviour change skills . The study provides invaluable information on barriers and opportunities regarding future , similar interventions . A low dropout rate and good attendance for the subgroup that attended the intervention suggests there might be improved uptake if offered to young people with lower HbA1c . Testing whether this approach can be more successful with a robust ongoing supervisory element should be a target of further research . TRIAL REGISTRATION Current Controlled Trials IS RCT N52537669 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 18 , No. 20 . See the NIHR Journals Library website for further project information Background Chronic diseases represent a major challenge for health care and social services . A number of people with chronic diseases require more services due to characteristics that increase their vulnerability . Given the burden of increasingly vulnerable patients on primary care , a pragmatic intervention in four Family Medicine Groups ( primary care practice s in Quebec , Canada ) has been proposed for individuals with chronic diseases ( diabetes , cardiovascular diseases , respiratory diseases , musculoskeletal diseases and /or chronic pain ) who are frequent users of hospital services . The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program . The goals of this study are to : ( 1 ) analyze the implementation of the intervention in the participating practice s in order to determine how the various context s have influenced the implementation and the observed effects ; ( 2 ) evaluate the proximal ( self-efficacy , self-management , health habits , activation and psychological distress ) and intermediate ( empowerment , quality of life and health care use ) effects of the intervention on patients ; ( 3 ) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention . Methods / Design The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders ( Family Medicine Group and health centre management , Family Medicine Group practitioners , patients and their families , health centre or community partners ) . The data will be obtained through individual and group interviews , project documentation review s and by documenting the intervention . Evaluation of the effects on patients will be based on a pragmatic r and omized before-after experimental design with a delayed intervention control group ( six months ) . Economic analysis will include cost-effectiveness and cost-benefit analysis . Discussion The integration of a case management intervention delivered by nurses and self-management group support into primary care practice s has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care . Decision-makers , managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practice s in the region and elsewhere . Trial Registration
Educational interventions did not seem to have a positive impact on HbA1c , systolic blood pressure or lipid profiles .
The use of telemedicine , clinician reminders and feedback showed mixed results but there was a level of consistency in improvement in HbA1c when multifaceted interventions on multidisciplinary teams were implemented .
Targeting general or family physicians was largely ineffective in improving the cardiovascular risk factors considered , except when using a computer application on insulin h and ling of type 2 diabetes or customised simulated cases with feedbacks .
Similarly , interventions targeting nurses did not improve outcomes compared to st and ard care .
Multifaceted professional interventions were more effective than single interventions targeting single primary or community care professionals in improving glycaemic control
OBJECTIVE To review the interventions targeting primary care or community based professionals on glycaemic and cardiovascular risk factor control in people with diabetes .