How to Implement Evidence Into Practice to Improve Diabetes Care : Response to Ilag et al. Free

In their article, Ilag et al. (1) used the Annual Diabetes Assessment Program (ADAP) as a model to improve the standard of care for patients with type 2 diabetes. Despite established guidelines for type 2 diabetes, the majority of patients in the U.S. do not reach these goals (2). Various approaches have been used, including disease management programs, physician education, nurse case management, and use of information systems to translate evidence-based recommendations into clinical practice (3).

Diabetes translation research should be conducted as an effectiveness trial, rather than an efficacy trial with loose eligibility criteria, in order to produce a heterogeneous population to enhance external validity of the intervention. Ilag et al. used comparatively strict and subjective eligibility criteria, since 284 of 584 patients were considered eligible. The study population in this trial was mainly composed of Caucasian Americans. Hispanic Americans have a higher prevalence rate of diabetes and its complications (4). The Hispanic population should be oversampled in these trials.

There was a high drop-out rate in their study group, as only 83 of 173 (48%) subjects who were enrolled returned for the year-2 visit compared with 71 of 111 (64%) in the control group. Because compliance to treatment is the major challenge faced in diabetes management, intent-to-treat analysis should be included along with protocol analysis in diabetes translation research trials.

The authors did not mention the costs and resources of implementation of this model. Certified diabetes educators (CDEs) were used for implementation of the ADAP. It was not described how many CDEs were used in relation to a certain number of patients. The use of CDEs for implementation of guidelines questions the reproducibility of this model on a mass scale due to the lack of easy availability of CDEs.

I agree with the authors’ comments that lack of integration of ADAP providers in the practice and lack of continuous communication (once-a-year visit only) with both patients and physicians resulted in lower enthusiasm in providers and lack of impact on intermediate outcomes. The combined effects of a program like the ADAP, generating guideline-driven recommendations and consistent follow-up by nurse case managers, with management algorithms may prove more effective.