Mean blood glucose was only used as an efficacy outcome in one study (Raskin et al. We specifically acknowledge the writing contributions of John Downs, MD, Rodney Hayward, MD, Curtis Hobbs, MD, Jacqueline Pugh, MD, and Ruth Weinstock, MD, PhD. Regarding Subgroup analyses, exploratory analysis seems to suggest differences in effect sizes for the primary outcome when analyzing by subgroup; however, subgroup analyses should only be viewed as exploratory or hypothesis-generating. Recent guidelines by cardiology and diabetes organizations recommend divergent approaches to managing hyperglycemia in patients with type 2 diabetes. Devries et al. Intervention: Monitoring must be combined with a coordinated management and feedback system based on transmitted data. The ADA Clinical Practice Recommendations state that there are no clinical trial data available for the effects of glycemic control in patients with advanced complications and in the elderly (≥65 years of age) and acknowledge that less stringent goals may be appropriate for individuals with limited life expectancy (11). The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology. The database search identified 286 relevant citations published between 1996 and August 2008. On July 22, 2008 the government of Ontario announced an investment of $741 million in new funding over four years for a comprehensive Diabetes Strategy. Interviewees noted that physicians in private practice generally do not have a sufficient number of nurses or other support staff to assist them in carrying out standards of care. Current methods for assessing strength of evidence prioritize the contributions of randomized controlled trials (RCTs). Based upon these considerations, the VA/DoD Guideline recommends a stringent glycemic control target (HbA1c <7.0%) for patients with a life expectancy >15 years who have no, or only minimal, microvascular complications. To evaluate this factor, the VA/DoD Guidelines relied on previous estimates from Markov model computer simulations where absolute risk reduction of end-stage microvascular complications was using age of diabetes onset as a surrogate for life expectancy (8,9). Lastly, trials often included blood glucose home telemonitoring adjunctive to other telemedicine components and thus the incremental value of adding home telemonitoring remains unclear. Based on moderate quality evidence, specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinically significant reduction in HbA1c of 1.0% compared with usual care. Upon examination, two studies were subsequently excluded from the meta-analysis due to small sample size and missing data (Berthe et al. The Medical Advisory Secretariat conducts systematic reviews of scientific evidence and consultations with experts in the health care services community to produce the Ontario Health Technology Assessment Series. All healthcare costs used in the model were based on direct costs as it was not possible to measure productivity costs or other patient costs from the data available. There is conflicting evidence regarding both mild and severe hypoglycemic events in this population when using CSII pumps as compared to MDI. Meta-analysis of seven trials identified a moderate but significant reduction in HbA1c levels (~0.5% reduction) in favour blood glucose home telemonitoring compared to usual care for adults with type 2 diabetes). For severe hypoglycemic events, Hoogma et al. Of the 638 abstracts reviewed, 12 studies met the inclusion criteria, one of which was a meta-analysis. Based on moderate quality evidence, behavioural interventions as defined by the 2007 Self-management mapping guide (Government of Victoria, Australia) produce a moderate reduction in HbA1c levels in patients with type 2 diabetes compared with usual care. There is insufficient evidence to evaluate the incremental clinical efficacy of home telemonitoring for type 2 diabetes above other home telemedicine initiatives. E-mail. The Medical Advisory Secretariat is part of the Ontario Ministry of Health and Long-Term Care. There are, however, still risks associated with the use of CSII pumps. Both of these surgical options can be performed either as open surgery or laparoscopically. Reasons included the following: physicians do not hire additional staff because they do not place a high priority on diabetes education a… Observational studies come above case reports. Address correspondence and reprint requests to Leonard M. Pogach, MD, Medical Service (111), 385 Tremont St., East Orange, NJ 07019. diet, behaviour modification, increased physical activity, and drugs therapy) but who have not lost weight permanently. This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry’s newly released Diabetes … Included were English articles that conducted comparisons between CSII and MDI with the outcome of Quality Adjusted Life Years (QALY) in an adult population with type 1 diabetes. It also incorporates, when available, Ontario data, and information provided by experts and applicants to the Medical Advisory Secretariat to inform the analysis. Despite the homogeneity in the aims of the interventions, there was substantial clinical heterogeneity in other intervention characteristics such as duration, intensity, setting, mode of delivery (group vs. individual), interventionist, and outcomes of interest. To account for event-related dependencies, the model makes use of time-varying risk factors (e.g. In studies where no baseline data was reported, the final values were used. The group developing each module critically reviewed relevant literature for scientific merit, clinical relevance, and applicability to the federal health care system. This perspective briefly summarizes the growing evidence for a public health ‘effectiveness hierarchy’, and examines the policy implications for future preventive health strategies. Of these, five studies focused on care provided by at least a nurse, dietician, and physician (primary care and/or specialist) model of care (Model 1; see Table ES 1), while three studies focused on care provided by at least a pharmacist and primary care physician (Model 2; see Table ES 2). Using structured evidence reviews that were independently prepared, a module was developed for each of eight areas of diabetes care: screening, glycemic control, hypertension, lipids, nephropathy, retinopathy screening, foot risk screening, and diabetes education/self-monitoring. Studies with a control group other than usual care. In June 2008, the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project, an evidence-based review of the literature surrounding strategies for successful management and treatment of diabetes. Studies varied considerably on characteristics of design, population, and intervention/control. Evidence-based analyses have been prepared for each of these five areas: insulin pumps, behavioural interventions, bariatric surgery, home telemonitoring, and community based care.
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