Quality improvement strategies at primary care level to reduce inequalities in diabetes care: an equity-oriented systematic review

BACKGROUND

There is evidence that disparities exist in diabetes prevalence, access to diabetes care, diabetes-related complications, and the quality of diabetes care. A wide range of interventions has been implemented and evaluated to improve diabetes care. We aimed to review trials of quality improvement (QI) interventions aimed to reduce health inequities among people with diabetes in primary care and to explore the extent to which experimental studies addressed and reported equity issues.

METHODS

Pubmed, EMBASE, CINAHL, and the Cochrane Library were searched to identify randomized controlled studies published between January 2005 and May 2016. We adopted the PROGRESS Plus framework, as a tool to explore differential effects of QI interventions across sociodemographic and economic factors.

RESULTS

From 1903 references fifty-eight randomized trials met the inclusion criteria (with 17.786 participants), mostly carried out in USA. The methodological quality was good for all studies. Almost all studies reported the age, gender/sex and race distribution of study participants. The majority of trials additionally used at least one further PROGRESS-Plus factor at baseline, with education being the most commonly used, followed by income (55%). Large variation was observed between these studies for type of interventions, target populations, and outcomes evaluated. Few studies examined differential intervention effects by PROGRESS-plus factors. Existing evidence suggests that some QI intervention delivered in primary care can improve diabetes-related health outcomes in social disadvantaged population subgroups such as ethnic minorities. However, we found very few studies comparing health outcomes between population subgroups and reporting differential effect estimates of QI interventions.

CONCLUSIONS

This review provides evidence that QI interventions for people with diabetes is feasible to implement and highly acceptable. However, more research is needed to understand their effective components as well as the adoption of an equity-oriented approach in conducting primary studies. Moreover, a wider variety of socio-economic characteristics such as social capital, place of residence, occupation, education, and religion should be addressed.

Key issues in emergency department management of COVID-19: proposals for improving care for patients in Latin America

The incidence of the coronavirus disease 2019 (COVID-19) in Latin America and Spain and its impact particularly on hospital emergency departments have been great, sustained, and unpredictable. Unfortunately, this situation will continue in the medium term, regardless of the diverse concepts and definitions used to identify cases or hypotheses about the role of staff. In the context of the worldwide pandemic, a multinational group of experts from the Latin American Working Group to Improve Care for Patients With Infection (GT-LATINFURG) has drafted various opinion papers for use by emergency care systems in the member countries. The GT-LATINFURG is comprised of representatives from the 13 scientific associations affiliated with the Latin American Federation for Emergency Medicine (FLAME). Experts from the Spanish Society of Emergency Medicine (SEMES) also participated. The present consensus statement offers protocols and recommendations to facilitate the work of hospital emergency departments with regard to key issues the group identified, namely, the need for reorganization, triage, and routine test availability. Additional issues discussed include biomarkers; clinical, laboratory, radiologic, and microbiologic criteria for identifying patients with COVID-19; and risk and prognostic factors for mortality that emergency staff can use to quickly detect severe cases in our settings.