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Quality Improvement Strategies for Type 2 Diabetes—Reply

Quality Improvement Strategies for Type 2 Diabetes—Reply In Reply: We appreciate these clarifications from authors of the primary studies included in our analysis. Dr Krein and colleagues clarify that case managers in one1 of their 2 trials1,2 did not make medication changes without approval from primary care physicians. Repeating the random-effects meta-analysis shown in Figure 3 of our article after reclassifying the trial by Krein et al1 increased the pooled reduction in HbA1c levels for the trials in which case managers could make independent medication changes from 0.96% (95% confidence interval, 0.52%-1.41%) to 1.09% (95% confidence interval, 0.71%-1.47%). This relatively small change is because this study contributed only 16% weight to the estimate associated with trials in which case managers could make independent medication changes. Drs Pignone and DeWalt also bring attention to a misclassification on our part. On reviewing their study3 again, we agree that it could have been coded as including team changes and involving an electronic patient registry. The 2 reviewers who abstracted this trial debated both of these specific classifications. We did not classify all case management interventions as also involving team changes, because that would have diluted the meaning of team changes and prevented discrimination between the effects of these 2 common strategies. Therefore, we did not count the mere presence of a case manager as a “new team member.” Trials that involved case management had to meet at least 1 other criterion for “team changes” to be coded as such. Nonetheless, some classifications were still difficult, and we appreciate their clarification of the intervention. As we noted in the Comment section of our article, judgments about the complex interventions evaluated in the included trials were often difficult and descriptions of interventions were typically brief, as is often the case in the quality improvement literature.4 However, the classifications were made without regard to the direction or magnitude of the interventions' effects. Thus, for any given quality improvement strategy, misclassification would be expected to dampen the true effect. Therefore, the pooled estimates we obtained for the 2 strategies with significant incremental effects on glycemic control, ie, case management and team changes, are unlikely to represent overestimates. As we discussed in our article, the findings of smaller effects for other quality improvement strategies should be interpreted with caution. Back to top Article Information Financial Disclosures: None reported. References 1. Krein SL, Klamerus ML, Vijan S. et al. Case management for patients with poorly controlled diabetes: a randomized trial. Am J Med. 2004;116:732-73915144909Google ScholarCrossref 2. Choe HM, Mitrovich S, Dubay D, Hayward RA, Krein SL, Vijan S. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005;11:253-26015839185Google Scholar 3. Rothman RL, Malone R, Bryant B. et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am J Med. 2005;118:276-28415745726Google ScholarCrossref 4. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood). 2005;24:138-15015647225Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Quality Improvement Strategies for Type 2 Diabetes—Reply

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References (4)

Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.296.22.2681-a
Publisher site
See Article on Publisher Site

Abstract

In Reply: We appreciate these clarifications from authors of the primary studies included in our analysis. Dr Krein and colleagues clarify that case managers in one1 of their 2 trials1,2 did not make medication changes without approval from primary care physicians. Repeating the random-effects meta-analysis shown in Figure 3 of our article after reclassifying the trial by Krein et al1 increased the pooled reduction in HbA1c levels for the trials in which case managers could make independent medication changes from 0.96% (95% confidence interval, 0.52%-1.41%) to 1.09% (95% confidence interval, 0.71%-1.47%). This relatively small change is because this study contributed only 16% weight to the estimate associated with trials in which case managers could make independent medication changes. Drs Pignone and DeWalt also bring attention to a misclassification on our part. On reviewing their study3 again, we agree that it could have been coded as including team changes and involving an electronic patient registry. The 2 reviewers who abstracted this trial debated both of these specific classifications. We did not classify all case management interventions as also involving team changes, because that would have diluted the meaning of team changes and prevented discrimination between the effects of these 2 common strategies. Therefore, we did not count the mere presence of a case manager as a “new team member.” Trials that involved case management had to meet at least 1 other criterion for “team changes” to be coded as such. Nonetheless, some classifications were still difficult, and we appreciate their clarification of the intervention. As we noted in the Comment section of our article, judgments about the complex interventions evaluated in the included trials were often difficult and descriptions of interventions were typically brief, as is often the case in the quality improvement literature.4 However, the classifications were made without regard to the direction or magnitude of the interventions' effects. Thus, for any given quality improvement strategy, misclassification would be expected to dampen the true effect. Therefore, the pooled estimates we obtained for the 2 strategies with significant incremental effects on glycemic control, ie, case management and team changes, are unlikely to represent overestimates. As we discussed in our article, the findings of smaller effects for other quality improvement strategies should be interpreted with caution. Back to top Article Information Financial Disclosures: None reported. References 1. Krein SL, Klamerus ML, Vijan S. et al. Case management for patients with poorly controlled diabetes: a randomized trial. Am J Med. 2004;116:732-73915144909Google ScholarCrossref 2. Choe HM, Mitrovich S, Dubay D, Hayward RA, Krein SL, Vijan S. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005;11:253-26015839185Google Scholar 3. Rothman RL, Malone R, Bryant B. et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am J Med. 2005;118:276-28415745726Google ScholarCrossref 4. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood). 2005;24:138-15015647225Google ScholarCrossref

Journal

JAMA – American Medical Association

Published: Dec 13, 2006

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