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Educational toolkit did not improve quality of care or outcomes for patients with diabetes


An educational toolkit designed to improve care of patients with diabetes was not effective, Baiju R Shah and colleagues (University of Toronto) found in a cluster randomized trial conducted in 2009-2011. During 10 months of follow-up, patients of Canadian family physicians who had been cluster-randomized to receive the toolkit did not receive improved care and their outcomes did not differ compared with patients of physicians who did not receive the toolkit. All 933,789 people aged ≥40 years with diagnosed diabetes in Ontario, Canada, were studied using population-level administrative databases and evaluated for the primary outcome in the administrative data study, death or non-fatal myocardial infarction. This composite outcome occurred in 11,736 (2.5%) patients in the intervention group and 11,536 (2.5%) in the control group (p = 0.77). Additional clinical outcome data was collected from a random sample of 1,592 high risk patients. The primary outcome in this clinical data study was use of a statin; this occurred in 700 (88.1%) patients in the intervention group and 725 (90.1%) in the control group (p = 0.26). Other secondary outcomes, including other clinical events, were also not improved by the intervention. In a few cases the educational toolkit was actually associated with slightly worse process-of-care outcomes. A limitation was that a very high proportion of the high risk patients in the clinical study group were already prescribed statins. The authors conclude, "The results of this study highlight the need for a rigorous and scientifically based approach to the development, dissemination, and evaluation of quality improvement interventions."


Funding: The study was funded by an operating grant from the Canadian Institutes for Health Research (CIHR) and the Heart and Stroke Foundation of Canada. BRS receives salary support from the CIHR, and previously received support from the Canadian Diabetes Association. The Institute for Clinical Evaluative Sciences (ICES) is a non-profit research institute funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this study are those of the authors and are independent from the funding sources. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. No endorsement by ICES or the MOHLTC is intended or should be inferred.

Competing Interests: BRS was a member of the Guideline Dissemination and Implementation Committee and the National Research Council of the Canadian Diabetes Association (CDA) at the time of the study. OB was a member of the Executive of the Clinical and Scientific Section and the Guideline Dissemination and Implementation Committee of the CDA at the time of the study. CHYY is currently Chair of the Guideline Dissemination and Implementation Committee of the CDA. MMM has served as an Advisory Board member for the following pharmaceutical companies: Astra Zeneca, Bristol-Myers Squibb, Eli Lilly and Company, Glaxo Smith Kline, Hoffman La Roche, Novartis, Novo Nordisk, and Pfizer. JAP has served as both a guest academic editor and a reviewer for PLOS Medicine.

Citation: Shah BR, Bhattacharyya O, Yu CHY, Mamdani MM, Parsons JA, et al. (2014) Effect of an Educational Toolkit on Quality of Care: A Pragmatic Cluster Randomized Trial. PLoS Med 11(2): e1001588. doi:10.1371/journal.pmed.1001588



Baiju Shah
Insitute for Clinical Evaluative Sciences
+1 416-480-4706

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