Improving Diabetes Care in Rural Areas: A Systematic Review and Meta-Analysis of Quality Improvement Interventions in OECD Countries

<div><p>Background and Aims</p><p>Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.</p> <p>Methods</p><p>We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.</p> <p>Results</p><p>Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).</p> <p>Conclusions</p><p>This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.</p> </div

Effectiveness of quality Improvement interventions, by type of target.

<p>Effectiveness of quality Improvement interventions, by type of target.</p

Summary of evidence search and selection.

<p>* Information regarding the sources is available on Table S2.</p

Taxonomy of quality improvement strategies (adapted from Shojania et al. [25] and Tricco et al [24]).

<p>Taxonomy of quality improvement strategies (adapted from Shojania et al. [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0084464#B25" target="_blank">25</a>] and Tricco et al [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0084464#B24" target="_blank">24</a>]).</p

Methodological quality of included studies (n = 18).

<p>Methodological quality of included studies (n = 18).</p

Meta-analysis: proportion of mental health-related ED attendances due to specific conditions.

<p>Meta-analysis: proportion of mental health-related ED attendances due to specific conditions.</p