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Table 3—

Professional and organizational interventions versus usual care

Author YearDesignIntervention i) intervention group c) control groupa) Number of providers b) Number of patients c) Number of practicesSettingFollow-up (months)Results
Conclusion
Patient outcomesProcess measures
Aubert (44) 1998 Sikka (45) 1999; U.S. RCT i) educational materials (detailed management algorithms); revision of professional roles (nurse case management); arrangements for follow-up; patient education c) no intervention a) ? (nurse) b) 138 c) 2 capitated group/staff model HMO 12 glyc (+) bp (0) chol (0) BMI (0) s-rep health (+) microv (+) patient + process + 
Hoskins (50) 1992, Australia RCT i) educational materials; educational outreach visits; arrangements for follow up (shared care) c1) routine care by GP c2) routine care by specialist diabetic clinic a) ? (physician+nurse) b) 206 c) ? shared care: primary care physician office and hospital; fee-for-service 12 glyc (+)within all groups bp (+)within all groups weight (+)within shared care group att pat (−)within all groups patient + I) for allthree groups thatwere compared process − withingroups 
Hurwitz (51) 1993, U.K. RCT i) educational meetings; arrangements for follow-up; changes in medical record systems c) no intervention a) ? (physicians) b) 181 c) 38 general practices and 2 hospital outpatient clinics primary care physician office; capitation and item of service 30 glyc (0) microv (0) hosp (0) glyc (+) microv (+) alb (+) att pat (+) patient 0 process + 
Marrero (53) 1995, U.S. RCT i) educational materials; a telecommunication system; skill mix changes; case management; changes in facilities and equipment; changes in medical record systems c) no intervention a) ? (nurse practitioners) b) 106 c) 1 free-standing non-academic primary care practice; variable insurance arrangements* 12 glyc (0) qual life (0) hosp (0) NA patient 0 
Naji (54) 1994, U.K. RCT i) educational materials; reminders; arrangements for follow up; changes in medical record systems c) patients received reminders for routine appointments a) ? (GPs + clinic staff involved in diabetes care) b) 274 c) 1 clinic + 3 general practices shared care: primary care physician office and hospital; capitation and item of service, and fee-for-service (specialist ambulatory care) 24 glyc (0) bp (0) BMI (0) creat (0) glyc (+) bp (+) creat (0) microv (+) att pat (+) patient 0 process + 
Nilasena (55) 1995, U.S. RCT i) educational materials; reminders; changes in medical record systems c) no intervention a) 35 b) 164 c) 2 hospital-based academic primary care clinic; federal program 6  NA compl (0)between groups,but within both groups (+) process +withinboth groups 
Rutten (59) 1990, the Netherlands RCT i) educational materials; case management c) no intervention a) ? (GPs supported by nurses) b) 149 c) 8 primary care physician office; capitation (social)+ fee-for-service (private) 12 glyc (+)# weight (0)# NA patient + 
See Tai (60) 1999, U.K. RCT i) reminders; changes in medical record system (implementation of new diabetes templates) c) usual diabetes care (usual basic template), but implementation of new asthma templates a) 17 GPs and 11 practice nurses b) 167 c) 6 primary care physician office; capitation and item of service 12 NA compl (+) process +not statistically tested, but a positive trend 
Shultz (61) 1992, U.S. RCT i) a telecommunication system; changes in facilities and equipment; changes in medical record systems c) no intervention a) ? (physicians) b) 30 c) 1 Veteran’s Administration hospital clinic; federal program 15 glyc (+) NA patient + 
Stein (62) 1974, U.S. RCT i) educational materials; revision of professional roles; patient education c) no intervention a) nurse practitioner + clinic physician(s) b) 28 c) 1 hospital-based primary care clinic; variable insurance arrangements glyc (0) weight (0) NA patient 0 
Vinicor (64) 1987 Mazzuca (65) 1988; U.S. RCT For patient outcomes (39) i1) patient education i2) physician education: educational materials; local consensus processes; audit and feedback; reminders; communication and case discussion between distant health professionals; i3) patient education + physician education c) no intervention For process measures (58) i) i2+i3 c) i1+c a) 86 residents b) 532 c) 1 hospital-based academic primary care clinic; variable insurance arrangements process measures: 11 patient: 26 glyc (+i1,i2,i3)# bp (+i1)# weight (+i1,i3)# glyc (+)# bp (0)# chol (+)# creat (0)# microv (0)# patient + process + 
Weinberger (66) 1995 Kirkman (67) 1994; U.S. RCT i) patient mediated interventions (nurses attempted to telephone patients to facilitate compliance, monitor patients’ health status, facilitate resolution of identified problems, facilitate access to primary care); arrangements for follow up; patient education c) no intervention a) ? b) 275 c) 1 Veteran’s Administration hospital clinic; federal program 12 glyc (+) chol (0) weight (0) qual life (0) NA patient + 
Boucher (46) 1987, U.K. CBA i) educational materials; educational meetings; arrangements for follow up; communication and case discussion between distant health professionals; changes in medical record systems c) no intervention a) ? (physicians, supported by nurses) b) 217 c) 3 general medicine clinic; capitation and item of service 24 glyc (+)#within att pat (+/−)no statisticalanalyses but a positivetrend patient +within process +/−nostatistical analysesbut a positive trend 
Deeb (47) 1988, U.S. CBA i) educational materials; educational meetings; educational outreach visits; clinical multidisciplinary team; patient education c) no intervention a) ? (physician+nurses) b) 1,029 were identified and their records were reviewed at baseline. Only 636 of the patients were seen during the year after the intervention c) 6 federally funded primary care centers; variable insurance arrangements 12 NA bp (0)# microv (+)# process +within 
Hartmann (48) 1995 Hartmann (49) 1995; Germany CBA i) educational materials; educational meetings; audit and feedback; changes in medical record systems c) no intervention a) 17 (physicians) b) 403 c) 17 primary care physician office; fee-for-service 12 NA glyc (0)# bp (0)# chol (+)# weight (0)# creat (+)# microv (+)# process 0(documented quarterly) process +(docu-ment ed yearly) 
Legorreta (52) 1996, U.S. CBA i) educational materials; educational meetings; clinical multidisciplinary teams; skill mix changes; arrangements for follow up; changes in medical records systems c) no intervention a) ? (physicians + nurses/physician assistant) b) Site A: 205, Site B: 195 c) ? practices affiliated with Network or Independent Practice Association (IPA) HMO 18 glyc (+)# NA patient + 
O’Connor (56) 1995, U.S. CBA i) local consensus procedures; skill mix changes; more aggressive educational outreach to patients c) no intervention a) ? (physicians + nurses) b) 267 c) 2 clinics capitated group/staff model HMO 18 glyc (+)# glyc (+)#within bothgroups, no differencebetween both groups att pat (+/−)# patient + process +within both groups, not statistically tested 
Peters (57) 1998, U.S. CBA i) educational materials; audit and feedback; revision of professional roles; arrangements for follow up; changes in medical record systems c) no intervention a) providers- ? (nurse practitioners) b) 164 c) 1 medical center vs. 1 HMO practices affiliated with Network or Independent Practice Association (IPA) HMO 36 glyc (+) chol (+)within intervgroup glyc (+) chol (+) microv (+) patient + process +not statis-tically tested 
Taplin (63) 1998, U.S. CBA i) educational materials; local consensus processes; audit and feedback; reminders; marketing (establishing a team and after that, regular team meetings to discuss and achieve clinical goals); clinical multidisciplinary team; changes in medical record systems c) no intervention a) ? (physicians supported by nurses) b)? (the number of patients that visited the practice for diabetes care is not reported separately). In total, 9,754 patients were included for studying compliance with guidelines for different areas c) 6 capitated group/staff model HMO 24 NA compl microv (0)# process 0 
Rith-Najarian (58) 1998, U.S. ITS i) educational materials; reminders; clinical multidisciplinary team a) 1 physician + 3 nurses (+nutritionist +registrar) b) 449 c) 1 Indian Health service clinic; federal program 36 microv (0) microv (0) patient 0 process 0 
Author YearDesignIntervention i) intervention group c) control groupa) Number of providers b) Number of patients c) Number of practicesSettingFollow-up (months)Results
Conclusion
Patient outcomesProcess measures
Aubert (44) 1998 Sikka (45) 1999; U.S. RCT i) educational materials (detailed management algorithms); revision of professional roles (nurse case management); arrangements for follow-up; patient education c) no intervention a) ? (nurse) b) 138 c) 2 capitated group/staff model HMO 12 glyc (+) bp (0) chol (0) BMI (0) s-rep health (+) microv (+) patient + process + 
Hoskins (50) 1992, Australia RCT i) educational materials; educational outreach visits; arrangements for follow up (shared care) c1) routine care by GP c2) routine care by specialist diabetic clinic a) ? (physician+nurse) b) 206 c) ? shared care: primary care physician office and hospital; fee-for-service 12 glyc (+)within all groups bp (+)within all groups weight (+)within shared care group att pat (−)within all groups patient + I) for allthree groups thatwere compared process − withingroups 
Hurwitz (51) 1993, U.K. RCT i) educational meetings; arrangements for follow-up; changes in medical record systems c) no intervention a) ? (physicians) b) 181 c) 38 general practices and 2 hospital outpatient clinics primary care physician office; capitation and item of service 30 glyc (0) microv (0) hosp (0) glyc (+) microv (+) alb (+) att pat (+) patient 0 process + 
Marrero (53) 1995, U.S. RCT i) educational materials; a telecommunication system; skill mix changes; case management; changes in facilities and equipment; changes in medical record systems c) no intervention a) ? (nurse practitioners) b) 106 c) 1 free-standing non-academic primary care practice; variable insurance arrangements* 12 glyc (0) qual life (0) hosp (0) NA patient 0 
Naji (54) 1994, U.K. RCT i) educational materials; reminders; arrangements for follow up; changes in medical record systems c) patients received reminders for routine appointments a) ? (GPs + clinic staff involved in diabetes care) b) 274 c) 1 clinic + 3 general practices shared care: primary care physician office and hospital; capitation and item of service, and fee-for-service (specialist ambulatory care) 24 glyc (0) bp (0) BMI (0) creat (0) glyc (+) bp (+) creat (0) microv (+) att pat (+) patient 0 process + 
Nilasena (55) 1995, U.S. RCT i) educational materials; reminders; changes in medical record systems c) no intervention a) 35 b) 164 c) 2 hospital-based academic primary care clinic; federal program 6  NA compl (0)between groups,but within both groups (+) process +withinboth groups 
Rutten (59) 1990, the Netherlands RCT i) educational materials; case management c) no intervention a) ? (GPs supported by nurses) b) 149 c) 8 primary care physician office; capitation (social)+ fee-for-service (private) 12 glyc (+)# weight (0)# NA patient + 
See Tai (60) 1999, U.K. RCT i) reminders; changes in medical record system (implementation of new diabetes templates) c) usual diabetes care (usual basic template), but implementation of new asthma templates a) 17 GPs and 11 practice nurses b) 167 c) 6 primary care physician office; capitation and item of service 12 NA compl (+) process +not statistically tested, but a positive trend 
Shultz (61) 1992, U.S. RCT i) a telecommunication system; changes in facilities and equipment; changes in medical record systems c) no intervention a) ? (physicians) b) 30 c) 1 Veteran’s Administration hospital clinic; federal program 15 glyc (+) NA patient + 
Stein (62) 1974, U.S. RCT i) educational materials; revision of professional roles; patient education c) no intervention a) nurse practitioner + clinic physician(s) b) 28 c) 1 hospital-based primary care clinic; variable insurance arrangements glyc (0) weight (0) NA patient 0 
Vinicor (64) 1987 Mazzuca (65) 1988; U.S. RCT For patient outcomes (39) i1) patient education i2) physician education: educational materials; local consensus processes; audit and feedback; reminders; communication and case discussion between distant health professionals; i3) patient education + physician education c) no intervention For process measures (58) i) i2+i3 c) i1+c a) 86 residents b) 532 c) 1 hospital-based academic primary care clinic; variable insurance arrangements process measures: 11 patient: 26 glyc (+i1,i2,i3)# bp (+i1)# weight (+i1,i3)# glyc (+)# bp (0)# chol (+)# creat (0)# microv (0)# patient + process + 
Weinberger (66) 1995 Kirkman (67) 1994; U.S. RCT i) patient mediated interventions (nurses attempted to telephone patients to facilitate compliance, monitor patients’ health status, facilitate resolution of identified problems, facilitate access to primary care); arrangements for follow up; patient education c) no intervention a) ? b) 275 c) 1 Veteran’s Administration hospital clinic; federal program 12 glyc (+) chol (0) weight (0) qual life (0) NA patient + 
Boucher (46) 1987, U.K. CBA i) educational materials; educational meetings; arrangements for follow up; communication and case discussion between distant health professionals; changes in medical record systems c) no intervention a) ? (physicians, supported by nurses) b) 217 c) 3 general medicine clinic; capitation and item of service 24 glyc (+)#within att pat (+/−)no statisticalanalyses but a positivetrend patient +within process +/−nostatistical analysesbut a positive trend 
Deeb (47) 1988, U.S. CBA i) educational materials; educational meetings; educational outreach visits; clinical multidisciplinary team; patient education c) no intervention a) ? (physician+nurses) b) 1,029 were identified and their records were reviewed at baseline. Only 636 of the patients were seen during the year after the intervention c) 6 federally funded primary care centers; variable insurance arrangements 12 NA bp (0)# microv (+)# process +within 
Hartmann (48) 1995 Hartmann (49) 1995; Germany CBA i) educational materials; educational meetings; audit and feedback; changes in medical record systems c) no intervention a) 17 (physicians) b) 403 c) 17 primary care physician office; fee-for-service 12 NA glyc (0)# bp (0)# chol (+)# weight (0)# creat (+)# microv (+)# process 0(documented quarterly) process +(docu-ment ed yearly) 
Legorreta (52) 1996, U.S. CBA i) educational materials; educational meetings; clinical multidisciplinary teams; skill mix changes; arrangements for follow up; changes in medical records systems c) no intervention a) ? (physicians + nurses/physician assistant) b) Site A: 205, Site B: 195 c) ? practices affiliated with Network or Independent Practice Association (IPA) HMO 18 glyc (+)# NA patient + 
O’Connor (56) 1995, U.S. CBA i) local consensus procedures; skill mix changes; more aggressive educational outreach to patients c) no intervention a) ? (physicians + nurses) b) 267 c) 2 clinics capitated group/staff model HMO 18 glyc (+)# glyc (+)#within bothgroups, no differencebetween both groups att pat (+/−)# patient + process +within both groups, not statistically tested 
Peters (57) 1998, U.S. CBA i) educational materials; audit and feedback; revision of professional roles; arrangements for follow up; changes in medical record systems c) no intervention a) providers- ? (nurse practitioners) b) 164 c) 1 medical center vs. 1 HMO practices affiliated with Network or Independent Practice Association (IPA) HMO 36 glyc (+) chol (+)within intervgroup glyc (+) chol (+) microv (+) patient + process +not statis-tically tested 
Taplin (63) 1998, U.S. CBA i) educational materials; local consensus processes; audit and feedback; reminders; marketing (establishing a team and after that, regular team meetings to discuss and achieve clinical goals); clinical multidisciplinary team; changes in medical record systems c) no intervention a) ? (physicians supported by nurses) b)? (the number of patients that visited the practice for diabetes care is not reported separately). In total, 9,754 patients were included for studying compliance with guidelines for different areas c) 6 capitated group/staff model HMO 24 NA compl microv (0)# process 0 
Rith-Najarian (58) 1998, U.S. ITS i) educational materials; reminders; clinical multidisciplinary team a) 1 physician + 3 nurses (+nutritionist +registrar) b) 449 c) 1 Indian Health service clinic; federal program 36 microv (0) microv (0) patient 0 process 0 
*

In the U.S., most practices, whether hospital based or not, care for patients under a variety of insurance arrangements: government (Medicare, Medicaid) or private (HMO or indemnity [fee-for-service]). ?, not reported; +, positive effect; 0, no effect; −, negative effect; +/−, effect unclear; NA, not applicable; #, possible unit of analysis error; within, differences are statistically tested within groups only, not between groups; alb, albumin; att pat, attendance patients; bp, blood pressure; comp, compliance care provider; CBA, controlled before-after study; creat, creatinine; glyc, glycemic control; HMO, health maintenance organization; hlth surv, health survey; hosp, hospitalizations; macrov, macrovascular complications; microv, microvascular complications; qual life, quality of life; RCT, randomized controlled trial.

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