Monday, December 27, 2010

The Lessons from 41 Randomized Clinical Trials of Disease Management for Diabetes Mellitus

Which is a better gauge of culinary skill? Using only the finest ingredients to concoct the consummate feast? Or, being able to dress up whatever's laying around in the fridge to make everyone full and satisfied?

The latter has always been favored Disease Management Care Blog when it comes to both cooking and research. It likes taking leftover bits of data and assembling them into a coherent meal after the fact. But that doesn't mean there isn't a role for prospectively staring out with randomized controlled clinical trials (RCTs) to make a repast from the ground up. Now that's tasty!

Case in point is this feast of a study that was published online by the CMAJ. Using the Care Continuum Alliance's definition of "disease management," the authors scoured the published scientific literature for only the finest RCT ingredients and found 41 articles. When the data were baked in a "random effects model," the mean absolute difference in blood glucose control between the intervention and control groups, as determined by the A1c, was 0.51%. Patients with poorer control of their diabetes (having an A1c greater than 8%) appeared to benefit the most. Programs 1) that allowed their nurses to "start or modify treatment with or without prior approval from the physician" and 2) with patient contract at least once a month were also statistically associated with better control. If there were adverse events (like hypoglycemia), they were more likely to occur in the control groups.

The Disease Management Care Blog didn't know that there were so many RCTs how well disease management works. A mean drop in A1c of 0.51 is also both statistically and clinically significant. What is particularly savory are the operational implications of the research: glycemic control is more likely if disease management coaches 1) operate at the "top of their license," 2) contact the patient at least once a month and 3) are reserved for patients at greater risk - not every patient needs to be or should be called by the nurses and, when they do get involved, patients are NOT put at risk.

Here's the reference for your quoting pleasure:

Pimouguet C, Le Goff M, ThiƩbaut R, Dartigues JF, Helmer C: Effectiveness of disease-management programs for improving diabetes care: a meta-analysis. CMAJ 2010. DOI:10.1503/cmaj.091786

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