Diabetes Management: Team-Based Care for Patients with Type 2 Diabetes
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends team-based care to control type 2 diabetes. Evidence shows team-based care improves patients’ blood glucose (measured using A1c levels), blood pressure, and lipid levels. Interventions also increase the proportion of patients who reach target blood glucose, blood pressure, and lipid levels.
The full CPSTF Finding and Rationale Statement and supporting documents for Diabetes Management: Team-Based Care for Patients with Type 2 Diabetes are available in The Community Guide Collection on CDC Stacks.
Intervention
Team-based care to improve diabetes control is a health systems-level, organizational intervention that assigns a multidisciplinary team to help patients manage their diabetes. Each team includes the patient, the patient’s primary care provider (not necessarily a physician), and one or more other health professionals.
Teams work together to help patients:
- Get appropriate medical tests and examinations (e.g., blood glucose level, blood pressure, lipid level, weight, eye and foot examinations)
- Use medications to manage and control risk factors (e.g., blood glucose level, blood pressure, lipid level)
- Self-manage their health care and adhere to treatment
- Make healthy behavior and lifestyle choices (e.g., improved diet, increased physical activity, cessation of smoking)
- Improve their quality of life and prevent diabetes-related complications
About The Systematic Review
The CPSTF recommendation is based on evidence from a systematic review of 35 studies (search period 1960 October 2015) that evaluated the impact of team-based care on blood glucose, blood pressure, and lipids. The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes prevention and control.
Study Characteristics
Interventions were implemented in the following settings:
- The United States (25 studies), Canada (3 studies), the United Kingdom (2 studies), Hong Kong (1 study), the Netherlands (1 study), Switzerland (1 study), Taiwan (1 study), and United Arab Emirates (1 study)
- Clinics (22 studies), hospitals (5 studies), pharmacies (4 studies), or Veterans Affairs facilities (4 studies)
- Urban (22 studies), suburban (1 study), rural (1 study), or mixed settings (8 studies)
Study participants had the following demographic characteristics:
- Mean age of 58.4 years (31 studies)
- 52.2% female (34 studies)
Intervention characteristics:
- Services delivered: education component (33 studies), continuing education/counseling component (32 studies), regular testing and monitoring (29 studies), medication modification (24 studies), patient goal setting and creation of an action plan (16 studies)
- Intervention duration ranged from less than 6 months to more than 3 years
- In addition to the patient and primary care provider, teams added one member (23 studies), two members (9 studies), or three or more members (3 studies)
- Teams added a nurse (20 studies), pharmacist (14 studies), or other type of healthcare provider (12 studies)
Summary of Results
Compared with usual care, team-based care improved health outcomes:
Blood glucose
- A1c levels decreased by a mean of 0.5% (25 studies)
Blood pressure
- Systolic blood pressure decreased by a mean of 5.5mmHg (18 studies)
- Diastolic blood pressure decreased by a mean of 3.2mmHg (17 studies)
Lipids
- High-density level (HDL) cholesterol increased by a mean of 0.7mg/dL (9 studies)
- Low-density level (LDL) cholesterol decreased by a mean of 8.0mg/dL (14 studies)
- Total cholesterol level decreased by a mean 7.4mg/dL (12 studies)
- Triglycerides levels decreased by a mean of 13.3mg/dL (7 studies)
Compared with usual care, team-based care increased the proportion of patients reaching target blood glucose, blood pressure, and lipid levels:
- The proportion of patients who reached an A1c level below 7.0% increased by a median of 15.1 percentage points (7 studies)
- The proportion of patients who reached a blood pressure below 130/80mmHg increased by a median of 15.0 percentage points (10 studies)
- The proportion of patients who reached an LDL level below 130mg/dL increased by a median of 16.7 percentage points (5 studies)
Team Composition
- Greater reductions in patients’ blood glucose levels were reported when pharmacists (13 studies) rather than nurses (19 studies) were added to the team
- The addition of either a pharmacist or nurse led to improved blood glucose levels
Summary of Economic Evidence
A systematic review of economic evidence has not been conducted.
Applicability
Based on results for interventions in different settings and populations, findings should be applicable to the following:
- High income countries
- Urban environments
- Clinics, hospitals, pharmacies, or Veterans Affairs facilities
- Adults and older adults who have type 2 diabetes with or without diabetes-related complications or high risk for developing complications
- Women and men
- All examined racial and ethnic groups
- People with different socioeconomic statuses (SES)
- Patients with health insurance
Evidence Gaps
- What are intervention effects on diabetes-related complications and healthcare use?
- How effective are interventions with the following populations?
- People with type 1 diabetes
- Younger people with diabetes
- Uninsured people with diabetes
- People with diabetes living in rural settings
- How do team composition and operation influence intervention outcomes?
- What services (e.g. education, counseling, goal setting, medication modification) are provided by team members?
- How do team members communicate? Do teams use electronic records or meetings or other means of communication?
- Do programs provide protocols to delineate the team roles and responsibilities?
- Who is the team lead? The primary care provider, or the team member providing the majority of services?
- Who would be the most effective primary contact for patients? The primary care provider, the team member providing the majority of services, or someone else?
Implementation Considerations and Resources
- Teams that use explicit communication are likely to see more favorable outcomes.
- When possible, it is best when teams deliver services through a combination of face-to-face and remote (email, telephone) communications.
- Team-based care works best when changes to patient medication can be suggested by all team members and approved by primary care providers.
- Pharmacists and nurses are strong additions to patient-provider teams.
- Program challenges may include limited resources or lack of knowledge on how to transition to patient-centered care or form an effective multidisciplinary team.
- Evidence from this review and the Community Guide review of team-based care to improve blood pressure control suggests that team-based care may be a platform to successfully treat other chronic conditions or patients with multiple chronic conditions.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.