Key messages

- Quality improvement programmes can improve diabetes care, especially when multiple strategies are used in combination.

- Strategies used in these programmes that lead to the largest improvements in key outcomes in people with diabetes are: case management, team changes, patient education and promotion of self-management.

Why is improving diabetes care important?

Diabetes, a disorder of how sugar is managed by the body, can lead to complications such as heart disease and blindness. If people with diabetes get the best possible treatment, their risk for these and other diabetes-related complications will be lowered. Unfortunately, many people with diabetes do not get the best possible treatment. 

What are quality improvement strategies?

Quality improvement programmes using different strategies help healthcare professionals improve care. We examined 12 common types of quality improvement strategies. 

- Four strategies were directed at healthcare professionals: audit and feedback, clinician education, clinician reminders and financial incentives.

- Three strategies were directed at people living with diabetes: patient education, patient reminders and promotion of self-management. 

- Five strategies involved healthcare organisations: case management, team changes, electronic patient registry, facilitated relay of clinical information and continuous quality improvement.

What did we want to find out?

We wanted to find out which strategies worked best to improve:

- blood sugar control (measured using a test called glycated haemoglobin or HbA1c);

- blood pressure;

- low-density lipoprotein cholesterol (LDL-C).

Lower levels on these tests are associated with lower rates of complications such as heart attacks.

We also assessed whether quality improvement strategies improved rates of screening for eye damage (also known as retinopathy) and loss of sensation in the foot (also known as neuropathy). Routine screening for these issues in people living with diabetes is recommended to prevent blindness or amputation, respectively. 

What did we do? 
We searched for randomised trials including adults living with diabetes managed in outpatient settings, which evaluated at least one quality improvement strategy. Although we were interested in strategies directed at people living with diabetes, patient strategies needed to be tested in combination with strategies directed at healthcare organisations or professionals for the study to be included. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods, size and other considerations. 

What did we find? 

We found 553 studies that involved 412,161 people with diabetes up to the year 2019. Studies took place in countries around the world with most being conducted in the USA (231) and in medical settings. 

Most studies (367) involved people with type 2 diabetes. Half of the study participants were female. The average age of participants was 57 years. Most studies lasted 12 months. 

Studies usually used multiple quality improvement strategies together. Most commonly, studies featured three quality improvement strategies.

Main results 

Overall, case management, team changes, patient education and promotion of self-management appeared to be the most effective quality improvement strategies for diabetes care.

When considering three-strategy combinations (the median number of quality improvement strategies in multicomponent interventions), the combination of clinician education, promotion of self-management and patient reminders may lead to the most improvement in blood sugar control in people who begin with lower HbA1c. Whereas the combination of case management, patient education and electronic patient registries may lead to the largest improvement in blood sugar control for people who begin with higher HbA1c. 

For blood pressure, people who have lower systolic blood pressure may see the most improvement with the combination of patient education, team changes and promotion of self-management. People who have higher systolic blood pressure may improve the most with the combination of case management, team changes and promotion of self-management. 

For cholesterol, we found that team changes, patient education and case management may lead to the most improvement in people who already have lower low-density lipoprotein levels. For those who have higher levels of low-density lipoprotein, team changes, case management and clinician reminders may lead to the largest improvement.

Patient education, patient reminders and team changes may lead to an increase in retinopathy screening rates. Patient education, team changes and audit and feedback, financial incentives and continuous quality improvement strategies combined may lead to an increase in foot screening rates.

What does this mean?

Clinics can improve their diabetes care by engaging in quality improvement programmes (especially those including case management, team changes, patient education and patient self-management).

What are the limitations of the evidence?

Many studies did not provide information on everything we were interested in. Most focused on blood sugar control and few studies reported screening rates. We included studies in this review that had important flaws in the way they were conducted, which limits how confident we can be in our findings.

How up-to-date is this evidence?

The evidence for this review is up-to-date to June 2019, and we have further searched for and screened studies up to September 2021. We are currently working on a living systematic review that will be updated with new evidence at least once a year.