An evaluation of the quality of evidence underpinning diabetes management models: a review of the literature
Deborah Schofield A B , Michelle M. Cunich B D and Lucio Naccarella CA School of Public Health, Sydney Medical School, The University of Sydney, Locked Bag 77, Camperdown, NSW, 1450, Australia. Email: deborah.schofield@ctc.usyd.edu.au
B NHMRC Clinical Trials Centre, Sydney Medical School, The University of Sydney, Locked Bag 77, Camperdown, NSW, 1450, Australia.
C The Australian Health Workforce Institute, The University of Melbourne and General Practice Victoria, Level 3, 766 Elizabeth Street, The University of Melbourne, Parkville, Vic. 3010, Australia. Email: l.naccarella@unimelb.edu.au
D Corresponding author. Email: michelle.cunich@ctc.usyd.edu.au
Australian Health Review 38(5) 495-505 https://doi.org/10.1071/AH14018
Submitted: 23 January 2014 Accepted: 1 June 2014 Published: 4 August 2014
Journal Compilation © AHHA 2014
Abstract
Objective There is a paucity of research on the quality of evidence relating to primary care workforce models. Thus, the aim of the present study was to evaluate the quality of evidence on diabetes primary care workforce models in Australia.
Methods The National Health and Medical Research Council of Australia’s (National Health and Medical Reseach Council; 2000, 2001) frameworks for evaluating scientific evidence and economic evaluations were used to assess the quality of studies involving primary care workforce models for diabetes care involving Australian adults. A search of medical databases (MEDLINE, AMED, RURAL, Australian Indigenous HealthInfoNet and The Cochrane Institute), journals for diabetes care (Diabetes Research and Clinical Practice, Diabetes Care, Diabetic Medicine, Population Health Management, Rural and Remote Health, Australian Journal of Primary Health, PLoS Medicine, Medical Journal of Australia, BMC Health Services Research, BMC Public Health, BMC Family Practice) and Commonwealth and state government health websites was undertaken to acquire Australian studies of diabetes workforce models published 2005–13. Various diabetes workforce models were examined, including ‘one-stop shops’, pharmacy care, Aboriginal services and telephone-delivered interventions. The quality of evidence was evaluated against several criteria, including relevance and replication, strength of evidence, effect size, transferability and representativeness, and value for money.
Results Of the14 studies found, four were randomised controlled trials and one was a systematic review (i.e. Level II and I (best) evidence). Only three provided a replicable protocol or detailed intervention delivery. Eleven lacked a theoretical framework. Twelve reported significant improvements in clinical (patient) outcomes, commonly HbA1c, cholesterol and blood pressure; only four reported changes in short- and long-term outcomes (e.g. quality of life). Most studies used a small or targeted population. Only two studies assessed both benefits and costs of their intervention compared with usual care and cost effectiveness.
Conclusions More rigorous studies of diabetes workforce models are needed to determine whether these interventions improve patient outcomes and, if they do, represent value for money.
What is known about the topic? Although health systems with strong primary care orientations have been associated with enhanced access, equity and population health, the primary care workforce is facing several challenges. These include a mal-distribution of resources (supply side) and health outcomes (demand side), inconsistent support for teamwork care models, and a lack of enhanced clinical inter-professional education and/or training opportunities. These challenges are exacerbated by an ageing health workforce and general population, as well as a population that has increased prevalence of chronic conditions and multi-morbidity. Although several policy directions have been advocated to address these challenges, there is a lack of high-quality evidence about which primary care workforce models are best (and which models represent better value for money than current practice) and what the health effects are for patients.
What does this paper add? This study demonstrated several strengths and weaknesses of Australian diabetes models of care studies. In particular, only five of the 14 studies assessed were designed in a way that enabled them to achieve a Level II or I rating (and hence the ‘best’ level of evidence), based on the NHMRC’s (2000, 2001) frameworks for assessing scientific evidence. The majority of studies risked the introduction of bias and thus may have incorrect conclusions. Only a few studies described clearly what the intervention and the comparator were and thus could be easily replicated. Only two studies included cost-effectiveness studies of their interventions compared with usual care.
What are the implications for practitioners? Although there has been an increase in the number of primary care workforce models implemented in Australia, there is a need for more rigorous research to assess whether these interventions are effective in producing improved health outcomes and represent better value for money than current practice. Researchers and policymakers need to make decisions based on high-quality evidence; it is not obvious what effect the evidence is having on primary care workforce reform.
Additional keywords: economic evaluation, models of care, primary care, workforce.
References
[1] Atun R. What are the advantages and disadvantages of restructuring a health care system to be more focussed on primary care services? Health Evidence Network report. Copenhagen, WHO, Regional Office for Europe; 2004. Available at: http://www.euro.who.int/documetn/e82997.pdf [verified November 2010][2] Schofield DJ, Beard J. Baby boomer doctors and nurses: demographic change and transitions to retirement. Med J Aust 2005; 183 80–3.
| 16022613PubMed |
[3] Tedesschi P. European Forum for Primary Care Position Paper: Interdisciplinary collaboration within primary care teams. Almere, The Netherlands: European Forum for Primary Care; 2009.
[4] Laurant M, Harmsen M, Faber M, Wollersheim H, Sibbald B, Grol R. Revision of professional roles and quality improvement: a review of the evidence. London: The Health Foundation; 2010; Available at: http://www.pharmacienconsultant.org/wp-content/uploads/2010/03/The_Health_Foundation-Revision_of_professional_roles_and_quality_improvement.pdf (verified March 2011).
[5] Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem solving. BMJ 1995; 310 1122–6.
| Evidence based medicine: an approach to clinical problem solving.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2M3mtFaiuw%3D%3D&md5=57e73101349a7131e12761526e1bc8feCAS | 7742682PubMed |
[6] National Health and Medical Research Council. How to compare the costs and benefits: evaluation of economic evidence. Canberra: NHMRC; 2001.
[7] National Health and Medical Research Council. How to use the evidence: assessment and application of scientific evidence. Canberra: NHMRC; 2000.
[8] Graves N, Barnett AG, Halton KA, Veerman JL, Winkler E, Owen N, Reevew MM, Marshall A, Eakin E. Cost-effectiveness of a telephone-delivered intervention for physical activity and diet. PLoS ONE 2009; 4 e7135
| Cost-effectiveness of a telephone-delivered intervention for physical activity and diet.Crossref | GoogleScholarGoogle Scholar | 19779611PubMed |
[9] Dennis SM, Zwar N, Griffiths R, Roland M, Hasan I, Davies GP, Harris M. Chronic disease management in primary care: from evidence to policy. Med J Aust 2008; 188 S53–6.
| 18429737PubMed |
[10] Clifford RM, Davis WA. Effect of a pharmaceutical care program on vascular risk factors in type 2 diabetes: The Freemantle Diabetes Study. Diabetes Care 2005; 28 771–6.
| Effect of a pharmaceutical care program on vascular risk factors in type 2 diabetes: The Freemantle Diabetes Study.Crossref | GoogleScholarGoogle Scholar | 15793171PubMed |
[11] Krass I, Armour CL, Mitchell B, Dienaar R, Hughes J, Lau P, Peterson G, Stewart K, Taylor S, Wilkinson J. The pharmacy diabetes care program: assessment of a community pharmacy diabetes service model in Australia. Diabet Med 2007; 24 677–83.
| The pharmacy diabetes care program: assessment of a community pharmacy diabetes service model in Australia.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD2sXot12rsrc%3D&md5=ddd0528b66fe1645705bf77f6c1b6e4cCAS | 17523968PubMed |
[12] Laatikainen T, Dunbar J, Chapman A, Kilkkinen A, Vartiainen E, Heistaro S, Philpot B, Absetz P, Bunker S, O’Neil A, Reddy P, Best JD, Janus ED. Prevention of type 2 diabetes in a primary health care setting: Greater Green Triangle diabetes prevention project. BMC Public Health 2007; 7 249
| Prevention of type 2 diabetes in a primary health care setting: Greater Green Triangle diabetes prevention project.Crossref | GoogleScholarGoogle Scholar | 17877832PubMed |
[13] Kilkkinen A, Heistaro S, Laatikainen T, Janus E, Chapman A, Absetz P, Dunbar J. Prevention of type 2 diabetes in a primary health care setting: interim results from the Greater Green Triangle (GGT) diabetes prevention project. Diabetes Res Clin Pract 2007; 76 460–2.
| Prevention of type 2 diabetes in a primary health care setting: interim results from the Greater Green Triangle (GGT) diabetes prevention project.Crossref | GoogleScholarGoogle Scholar | 17069921PubMed |
[14] Foster MM, Mitchell G, Haines T, Tweedy S, Cornwell P, Fleming J. Does enhanced primary care enhance primary care/ Policy-induced dilemmas for allied health professionals. Med J Aust 2008; 188 29–32.
| 18205560PubMed |
[15] Rasekaba TM, Graco M, Risteski C, Jasper A, Berlowitz DJ, Hawthorne G, Hutchinson A. Impact of a diabetes disease management program on diabetes control and patient quality of life. Popul Health Manag 2012; 15 12–9.
| Impact of a diabetes disease management program on diabetes control and patient quality of life.Crossref | GoogleScholarGoogle Scholar | 22229386PubMed |
[16] McRae IS, Butler JRG, Sibthorpe BM, Ruscoe W, Snow J, Rubiano D, Gardner KL. A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia. BMC Health Serv Res 2008; 8 205
| A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia.Crossref | GoogleScholarGoogle Scholar | 18834551PubMed |
[17] McDermott R, Segal L. Cost impact of improved primary level diabetes care in remote Australian Indigenous communities. Aust J Primary Health 2006; 12 124–30.
| Cost impact of improved primary level diabetes care in remote Australian Indigenous communities.Crossref | GoogleScholarGoogle Scholar |
[18] Shephard MD, Mazzachi BC, Shephard AK, McLaughlin KJ, Denner B, Barnes G. The impact of point of care testing on diabetes services along Victoria’s Mallee Track. Rural Remote Health 2005; 5 371
| 16026194PubMed |
[19] Li Wai Suen C, Aw H, Paul E, Wong J. Evaluation of an Australian multidisciplinary diabetes support clinic. Internet J Endocrinol 2012; 7 http://ispub.com/IJEN/7/1/13951# [verified 3 July 2014].
[20] WA Department of Health. Diabetes model of care. Perth, WA: Health Networks Branch, Department of Health; 2008. Available at: http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/Diabetes_Model_of_Care.pdf [verified April 2013].
[21] Shephard MD. Cultural and clinical effectiveness of the ‘QAAMS’ point of care testing model for diabetes management in Australian diabetes medical services. Clin Biochem Rev 2006; 27 161–70.
| 17268584PubMed |
[22] Battersby MW, Ah Kit J, Prideaux C, Harvey PW, Collins J, Mills PD. Implementing the Flinders model of self-management support with Aboriginal people who have diabetes: findings from a pilot study. Aust J Primary Health 2008; 14 66–74.
| Implementing the Flinders model of self-management support with Aboriginal people who have diabetes: findings from a pilot study.Crossref | GoogleScholarGoogle Scholar |
[23] Roxon N. Early pilot of diabetes coordinated care to being in 2011 [media release]. 12 November 2010. Available at: http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr10-nr-nr169.htm [verified September 2011].
[24] Commonwealth of Australia. Diabetes care project. 2012. Available at: http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/factsheet-gp-02 [verified April 2013].
[25] Lavis JN, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health policymaking (STP). Health Res Policy Systems 2009; 7 I1
| SUPPORT Tools for evidence-informed health policymaking (STP).Crossref | GoogleScholarGoogle Scholar |
