Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

Abstract

Background Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs. Methods and findings We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was −0.46% (95% CI −0.60% to −0.31%, I2 87.8%, p < 0.001) overall, −0.37% (95% CI −0.64% to −0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, −0.87% (−1.20% to −0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and −0.27% (−0.50% to −0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes. Conclusions In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

Analyzing the Implementation of Policies and Guidelines for the Prevention and Management of Type 2 Diabetes at Primary Health Care Level in Nepal

“…Studies have shown that delivery of diabetes care through strong PHC has resulted in lower health costs, better health outcomes, higher satisfaction of people with diabetes, fewer hospitalization rate, and greater socioeconomic equity (32)(33)(34)(35). While the prevalence of diabetes and its impact on health and overall quality of life is high in Nepal, low institutional capacity of primary health care center, inadequate human resources for health, lack of resources/funding and priority for diabetes and other NCDs and poor intersectoral coordination are some key challenges to implementing programs for prevention and control of diabetes.…”

Lifestyle Interventions to Improve Glycemic Control in Adults with Type 2 Diabetes Living in Low-and-Middle Income Countries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs)

“…When compared to a control group, these reviews, exploring self-management education [ 11 ] in the Asian Western Pacific region, diet/exercise modification [ 12 ] in a Southeast Asian population and a combination of both (primarily in high-income countries) [ 54 ], reported a significant reduction in HbA1c and BMI from the baseline in the lifestyle intervention groups. Specifically with regard to LMICs, a very recent review exploring health system interventions for adults with T2DM with similar cohort selection criteria to ours found diabetes multicomponent self-management education interventions to be successful at improving glycemic control [ 55 ].…”

“…Our findings showed that programs delivered by HCPs in a clinical environment were more effective in reducing HbA1c than those delivered by peer educators at home or in a community setting. Previous reviews have reported on the differences between interventions that are delivered by one healthcare professional versus a multidisciplinary team [ 11 , 55 ], showing a team approach to be more effective. A very recent review exploring the effectiveness of peer- and community health worker-led self-management education programs in LMICs showed inconsistent improvements in clinical, behavior and psychological outcomes [ 58 ].…”

Cost-Effectiveness of Conbercept vs. Ranibizumab for Age-Related Macular Degeneration, Diabetic Macular Edema, and Pathological Myopia: Population-Based Cohort Study and Markov Model

“…About one-third of diabetic patients develop DR and about one-third of patients with DR develop DME ( 58 ). Until now, diabetes mellitus (DM) remains a major health burden, with ~80% occurring in low- and middle-income countries ( 59 , 60 ). The number of DM in China is expected to increase to 142.7 million by 2035 ( 61 ).…”