Effectiveness of the EMPOWER-PAR Intervention on Primary Care Providers’ Adherence to Clinical Practice Guideline on the Management of Type 2 Diabetes Mellitus: A Pragmatic Cluster Randomised Controlled Trial

  • Maryam Hannah Daud Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Selangor, Malaysia
  • Anis Safura Ramli Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Selangor, Malaysia
  • Suraya Abdul-Razak Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Selangor, Malaysia
  • Jamaiyah Haniff Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Selangor, Malaysia
  • Tg Mohd Ikhwan Tg Abu Bakar Sidik Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Selangor, Malaysia
  • Nur Khairul Bariyyah Mohd Hatta Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Selangor, Malaysia
  • Sarimah Mahmood Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
  • Sharmila Lakshmanan Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA, Selangor, Malaysia
Keywords: Adherence, Clinical practice guideline, Primary care providers, Type 2 diabetes mellitus

Abstract

AIM: The objective of this study was to evaluate the effectiveness of the EMPOWER- participatory action research (PAR) intervention, a multifaceted strategy based on the chronic care model (CCM) on primary care providers (PCP)’ adherence to type 2 diabetes mellitus (T2DM) clinical practice guideline (CPG) in the Malaysian primary care setting.

METHODS: This was a pragmatic cluster randomized controlled trial –PAR conducted in ten public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. The outcome measure was the absolute change in the proportion of PCP’s adherence to T2DM CPG captured using the “Indicators of Care Pro forma,” based on the recommendation by the Malaysian CPG on the Management of T2DM. Data were collected from the patients’ medical records, at baseline and at 1-year follow-up; and were analyzed using mixed method model.

RESULTS: A total of 888 patients were recruited at baseline; 471 were in the intervention and 417 were in the control group. There was no significant demographic difference between the two groups at baseline except for ethnicity. At 1-year, 455 (96.6%) and 406 (97.3%) patients in the intervention and control groups completed the study, respectively. There were significant improvements in the absolute change in the proportion of PCPs’ adherence to T2DM CPG in the intervention group compared to the control group at 1-year follow-up in several indicators of care. These included the recording of BMI (0.6% vs. −1.8%, p<0.001); performing foot examination (2.4% vs. 0.6%, p<0.001); performing funduscopy/fundus photography (1.5% vs. 0.3%, p<0.001); monitoring renal profile (0.9% vs. −0.6%, p=0.001); measuring urine protein (1.2% vs. 0.6%, p<0.001), and giving lifestyle modification and self-management advice (1.2% vs. −0.3%, p<0.001) in the intervention versus control groups, respectively.

CONCLUSION: The EMPOWER-PAR intervention has been proven to be effective in improving the PCPs’ adherence to T2DM CPG in several indicators of care. Findings from this study provided objective evidence of the effectiveness of multifaceted intervention based on the CCM in the Malaysian public primary care setting.

TRIAL REGISTRATION: Registered with: ClinicalTrials.gov: NCT01545401. Date of registration: 1st March 2012.

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References

Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-53. https://doi. org/10.2337/diacare.27.5.1047 PMid:15111519

Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014;103(2):137-49. https://doi.org/10.1016/j. diabres.2013.11.002 PMid:24630390

Nanditha A, Ma RC, Ramachandran A, Snehalatha C, Chan JC, Chia KS, et al. Diabetes in asia and the pacific: Implications for the global epidemic. Diabetes Care. 2016;39(3):472-85. https:// doi.org/10.2337/dc15-1536 PMid:26908931

National Health and Morbidity Survey. Non-communicable Diseases, Risk Factors and other Health Problems. Vol. 2. National Health and Morbidity Survey; 2015. p. 1-315.

Feisul IM, Azmi S, Rizal AM, Zanariah H, Nik Mahir NJ, Fatanah I, et al. What are the direct medical costs of managing Type 2 diabetes mellitus in Malaysia? Med J Malaysia. 2017;72(5):271-7. PMid:29197881

Mafauzy M, Hussein Z, Chan SP. The status of diabetes control in Malaysia: Results of diabcare 2008. Med J Malaysia. 2011;66(3):175-81. PMid:22111435

International Diabetes Federation. IDF Diabetes Atlas. 7th ed. Brussels: International Diabetes Federation; 2015. Available from: http://www.diabetesatlas.org. [Last accessed 2019 Feb 15].

Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: A systematic analysis for the global burden of disease study 2010. Lancet. 2012;380(9859):2197-223. https://doi.org/10.1016/ s0140-6736(12)61690-0 PMid:23245608

Seidu S, Khunti K. Non-adherence to diabetes guidelines in primary care – the enemy of evidence-based practice. Diabetes Res Clin Pract. 2012;95(3):301-2. https://doi.org/10.1016/j. diabres.2012.01.015 PMid:22293930

Oh SW, Lee HJ, Chin HJ, Hwang JI. Adherence to clinical practice guidelines and outcomes in diabetic patients. Int J Qual Health Care. 2011;23(4):413-9. PMid:21705772

Barth JH, Misra S, Aakre KM, Langlois MR, Watine J, Twomey PJ, et al. Why are clinical practice guidelines not followed? Clin Chem Lab Med. 2016;54(7):1133-9. https://doi. org/10.1515/cclm-2015-0871 PMid:26650076

Chew BH, Shariff-Ghazali S, Lee PY, Cheong AT, Mastura I, Haniff J, et al. Type 2 diabetes mellitus patient profiles, diseases control and complications at four public health facilities a cross-sectional study based on the adult diabetes control and management (ADCM) registry 2009. Med J Malaysia. 2013;68(5):397-404. https://doi.org/10.1186/1475-2840-11-54 PMid:24632869

Mastura I, Chew BH, Lee PY, Cheong AT, Sazlina SG, Jamaiyah H, et al. Control and treatment profiles of 70,889 adult Type 2 diabetes mellitus patients in Malaysia a cross sectional survey in 2009. Int J Collab Res Intern Med Public Health. 2011;3(1):97-113.

Sazlina SG, Zailinawati AH, Zaiton A, Ong I. A clinical audit on diabetes care in two urban public primary care clinics in Malaysia. Malays J Med Health Sci. 2010;6(1):101-9.

Ramli AS, Taher SW. Managing chronic diseases in the Malaysian primary health care a need for change. Malays Fam Phys. 2008;3(1):7-13.

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775-9. https://doi.org/10.1001/jama.288.14.1775 PMid:12365965

Rothman AA, Wagner EH. Chronic illness management: What is the role of primary care? Ann Intern Med. 2003;138(3):256-61. https://doi.org/10.7326/0003-4819-138-3-200302040-00034 PMid:12558376

Hussein Z, Taher SW, Singh HK, Swee WC. Diabetes care in Malaysia: Problems, new models, and solutions. Ann Glob Health. 2015;81(6):851-62. https://doi.org/10.1016/j. aogh.2015.12.016 PMid:27108152

Bongaerts BW, Mussig K, Wens J, Lang C, Schwarz P, Roden M, et al. Effectiveness of chronic care models for the management of Type 2 diabetes mellitus in Europe: A systematic review and meta-analysis. BMJ Open. 2017;7(3):e013076. https://doi. org/10.1136/bmjopen-2016-013076 PMid:28320788

Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: A systematic review. Prev Chronic Dis. 2013;10:26. https://doi. org/10.5888/pcd10.120180 PMid:23428085

Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, et al. Use of chronic care model elements is associated with higher-quality care for diabetes. Ann Fam Med. 2007;5(1):14-20. https://doi.org/10.1370/afm.610 PMid:17261860

Barletta V, Profili F, Gini R, Grilli L, Rampichini C, Matarrese D, et al. Impact of chronic care model on diabetes care in tuscany: A controlled before-after study. Eur J Public Health. 2017;27(1):8- 13. https://doi.org/10.1093/eurpub/ckw189 PMid:28177456

Ku GM, Kegels G. Implementing elements of a context-adapted chronic care model to improve first-line diabetes care: Effects on assessment of chronic illness care and glycaemic control among people with diabetes enrolled to the first-line diabetes care (FiLDCare) project in the Northern Philippines. Prim Health Care Res Dev. 2015;16(5):481-91. https://doi.org/10.1017/s1463423614000553 PMid:25600305

Ramli AS, Selvarajah S, Daud MH, Haniff J, Abdul-Razak S, Tg-Abu-Bakar-Sidik TM, et al. Effectiveness of the EMPOWER-PAR intervention in improving clinical outcomes of Type 2 diabetes mellitus in primary care: A pragmatic cluster randomised controlled trial. BMC Fam Pract. 2016;17(1):157. https://doi.org/10.1186/s12875-016-0557-1 PMid:27842495

Ramli AS, Lakshmanan S, Haniff J, Selvarajah S, Tong SF, Bujang MA, et al. Study protocol of EMPOWER Participatory Action Research (EMPOWER-PAR): A pragmatic cluster randomised controlled trial of multifaceted chronic disease management strategies to improve diabetes and hypertension outcomes in primary care. BMC Fam Pract. 2014;15(1):151. https://doi.org/10.1186/1471-2296-15-151 PMid:25218689

Ministry of Health. Clinical Practice Guideline on Management of Type 2 Diabetes Mellitus. 5th ed. Malaysia: Ministry of Health; 2015. Available from: http://www.moh.gov.my/moh/ resources/Penerbitan/CPG/Endocrine/3a.pdf. [Last accessed on 2019 Feb 18].

Rushforth B, McCrorie C, Glidewell L, Midgley E, Foy R. Barriers to effective management of Type 2 diabetes in primary care: Qualitative systematic review. Br J Gen Pract. 2016;66(643):114- 27. https://doi.org/10.3399/bjgp16x683509 PMid:26823263

van Bruggen R, Gorter KJ, Stolk RP, Verhoeven RP, Rutten GE. Implementation of locally adapted guidelines on Type 2 diabetes. Fam Pract. 2008;25(1):430-7. https://doi.org/10.1093/ fampra/cmn045 PMid:18718886

Bertoni AG, Bonds DE, Chen H, Hogan P, Crago L, Rosenberger E, et al. Impact of a multifaceted intervention on cholesterol management in primary care practices. Arch Intern Med. 2009;169(7):678-86. https://doi.org/10.1001/ archinternmed.2009.44 PMid:19364997

Putnam LR, Levy SM, Sajid M, Dubuisson DA, Rogers NB, Kao LS, et al. Multifaceted interventions improve adherence to the surgical checklist. Surgery. 2014;156(2):336-44. https://doi. org/10.1016/j.surg.2014.03.032 PMid:24947646

Godwin M, Ruhland L, Casson I, MacDonald S, Delva D, Birtwhistle R, et al. Pragmatic controlled clinical trials in primary care: The struggle between external and internal validity. BMC Med Res Methodol. 2003;3(1):28. https://doi. org/10.1186/1471-2288-3-28 PMid:14690550

Samoutis GA, Soteriades ES, Stoffers HE, Philalithis A, Delicha EM, Lionis C. A pilot quality improvement intervention in patients with diabetes and hypertension in primary care settings of Cyprus. Fam Pract. 2010;27(3):263-70. https://doi. org/10.1093/fampra/cmq009 PMid:20348163

Zgibor JC, Rao H, Wesche-Thobaben J, Gallagher N, McWillinms J, Korytkozuski MT. Improving the quality of diabetes care in primary care practice. J Healthc Qual. 2004;26(4):14-21. https://doi.org/10.1111/j.1945-1474.2004.tb00502.x PMid:15352340

Jeffery RA, To MJ, Hayduk-Costa G, Cameron A, Taylor C, Van Zoost C, et al. Interventions to improve adherence to cardiovascular disease guidelines: A systematic review. BMC Fam Pract. 2015;16(1):147. https://doi.org/10.1186/ s12875-015-0341-7 PMid:26494597

English M, Nzinga J, Mbindyo P, Ayieko P, Irimu G, Mbaabu L. Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals--interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies. Implement Sci. 2011;6(1):124. https://doi.org/10.1186/1748-5908-6-124 PMid:22132875

Satman I, Imamoglu S, Yilmaz C, Admire Study Group. A patient-based study on the adherence of physicians to guidelines for the management of Type 2 diabetes in Turkey. Diabetes Res Clin Pract. 2012;98(1):75- 82. https://doi.org/10.1016/j.diabres.2012.05.003 PMid:22652276

Farquhar CM, Kofa EW, Slutsky JR. Clinicians’ attitudes to clinical practice guidelines: A systematic review. Med J Aust. 2002;177(9):502-6. https://doi.org/10.5694/j.1326-5377.2002. tb04920.x PMid:12405894

Lesho EP, Myers CP, Ott M, Winslow C, Brown JE. Do clinical practice guidelines improve processes or outcomes in primary care? Mil Med. 2005;170(3):234-46. https://doi.org/10.7205/ milmed.170.3.243 PMid:15828703

Published
2020-05-30
How to Cite
1.
Daud MH, Ramli AS, Abdul-Razak S, Haniff J, Tg Abu Bakar Sidik TMI, Mohd Hatta NKB, Mahmood S, Lakshmanan S. Effectiveness of the EMPOWER-PAR Intervention on Primary Care Providers’ Adherence to Clinical Practice Guideline on the Management of Type 2 Diabetes Mellitus: A Pragmatic Cluster Randomised Controlled Trial. Open Access Maced J Med Sci [Internet]. 2020May30 [cited 2020Oct.31];8(B):470-9. Available from: https://www.id-press.eu/mjms/article/view/3764