Academic journal article Australian Health Review

An Evaluation of the Quality of Evidence Underpinning Diabetes Management Models: A Review of the Literature

Academic journal article Australian Health Review

An Evaluation of the Quality of Evidence Underpinning Diabetes Management Models: A Review of the Literature

Article excerpt


Although health systems with strong primary care orientations have been associated with improved access, equity and population health,1 the primary care workforce is currently facing significant challenges. These include a mal-distribution of resources (supply-side) and health outcomes (demand-side), inconsistent support for teamwork care models and a lack of enhanced clinical inter-professional education and/or training opportunities. These challenges are exacerbated by an ageing health workforce and an ageing general population that has increased prevalence of chronic conditions and multi-morbidity.2

Novel health workforce models have been advanced as a way forward to address these challenges, and growing patient and wider health system demands through new roles (e.g. nurse practitioners), support roles (e.g. allied health assistants) which may substitute for current forms of service delivery, or enhanced roles (e.g. diabetes nurses). Approaches to improve the retention of primary healthcare workers through organisational policies, increase the efficiency of the current skills mix, or improve productivity through linking pay to performance have also been advanced. Although several policy directions have been advocated, there is a lack of evidence about which primary care workforce models are best and what the health effects are for patients.3,4

The lack of evidence to support these new directions in primary care is surprising, since it is widely acknowledged in medicine (and public health) that evidence-based medicine is essential to reduce the introduction of ineffective and expensive medical treatments.5

In this paper, we draw on the National Health and Medical Research Council (NHMRC: 2000, 2001) frameworks for assessing the quality of scientific evidence (and economic evaluations)6'7 to evaluate the quality of evidence on primary care workforce models for diabetes care.

The NHMRC's6,7 frameworks for evaluating the quality of scientific evidence with examples from primary care workforce models

To make a decision about whether to introduce a new care model it is important to be familiar with the quality of the evidence surrounding that model. In particular, whether the care model (intervention) is likely to achieve the aims of the intended model and whether it represents value for money.6

A set of criteria established by the NHMRC (2000, 2001) to assess medical and public health research is used in this paper to appraise diabetes primary care workforce models.6,7 These criteria are summarised in Table 1. The first is whether the study states clearly what health outcomes may be achieved by the particular intervention, and whether these outcomes have been measured in appropriate units. For example, whether the new primary care model was intended to improve health outcomes or save money but produce no worse health outcomes (non-inferiority). Additionally, the study needs to have a reasonable hypothesis and scientific explanation with evidence (and perhaps a theoretical model) underpinning it, information that can be used to explain why the desired effect is expected from the model.

The design of studies can vary markedly. The highest quality of evidence, as classified by the NHMRC, comes from systematic reviews of randomised controlled trials (RCTs; Level I). Systematic reviews determine whether a treatment effect can be replicated and, by pooling the results of RCTs, provides a best estimate of the magnitude of the effect.7 The second level of evidence comes from a well-designed RCT, which has the strength of minimising bias (Level II). Pseudo RCTs, comparative studies, case control studies or cohort studies have the potential to introduce bias and are ranked as Level III. Case series (pre- and post-test studies) suffer from problems related to the lack of randomisation (e.g. non-comparability of control and treatment groups, different outcome measures for the two groups) and are ranked as Level IV. …

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