CCDC study reveals multi-pronged diabetes care improves patient outcomes in India, Pakistan

A new study by Centre for Chronic Disease Control, India (CCDC) on cardiovascular risk reduction in South Asia has demonstrated significant long-term benefits of a multi-faceted quality improvement (QI) strategy, comprising of task sharing, and clinical decision support software (CDSS) with electronic health records, in managing type-2 diabetes in India and Pakistan.

The study, published in the prestigious journal PLOS Medicine, highlights the sustained impact of QI interventions on diabetes care and associated complications over a median follow-up period of 6.5 years.

The burden of diabetes
Diabetes control remains a global challenge, leading to severe complications such as heart disease, stroke, blindness or visual impairment, and kidney and nerve damage. LMICs are often faced with challenges such as inadequate infrastructure and trained healthcare staff with digital literacy. In that respect, the study's findings are crucial for integrating care models sustainably and identifying relevant organizational barriers.

Previous studies from high-income countries showed improvements in diabetes care, but their long-term impact on vascular complications and mortality was unclear. This study aimed to address the critical gap in data regarding the long-term effectiveness of QI strategies and their impacts on vascular complications in LMICs.

Professor Nikhil Tandon, Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, and senior author of the study explained the relevance of these findings in the context of national efforts to combat non-communicable diseases (NCDs). He said, "The National Programme for NCDs [NP-NCDs] operationalized by the Government of India has already a functional portal which provides an electronic health record functionality. Integrating the CDSS in this portal will provide significant incremental benefit to the impact of the National Programme, and bolster governmental efforts to battle the scourge of NCDs including diabetes and hypertension."

Speaking about the findings, Prof. (Dr) Dorairaj Prabhakaran, Executive Director, CCDC, and one of the study authors, said, "Through the trial, we've demonstrated that a sustained quality improvement strategy can significantly enhance diabetes care and reduce complications in South Asia. For every 13 patients treated with this strategy, one major adverse cardiovascular event like heart attacks or strokes- or a microvascular event -like eye disease or decline in kidney function- was prevented, showcasing its profound impact on patient outcomes."

Professor MK Ali, William H. Foege Distinguished Professor of Global Health, Emory University and one of the key authors of this article, said, "This study is an exemplar of trans-national collaboration for benefits of both, the global south and global north."

Study Design and Findings
The randomized clinical trial included 1,146 patients with poorly controlled type 2 diabetes across ten outpatient diabetes clinics from January 2011 through September 2019. Participants were randomized to receive either the QI strategy, which involved trained non-physician care coordinators and a clinical decision support software (CDSS) integrated into the electronic health record form, for physicians, or the usual care.

Some of the key findings from the study include:

• At 6.5 years, patients in the QI strategy group were nearly twice as likely to achieve and maintain target levels for HbA1c (<7%), systolic blood pressure (<130mmHg), and LDL-cholesterol (<100mg/dl), compared to the usual care group.
  
• The incidence of first microvascular complications, such as diabetic eye disease, decline in kidney function, and nerve pain was notably 32% lower in the QI group.
  
• There was a significant 28% reduction in the combined occurrence of microvascular and macrovascular events in the QI group.

Importantly, these benefits were sustained only in clinics that continued the QI strategy for 6.5 years. With diabetes accounting for one in seven deaths in South Asia, the study provides unique insights into the sustainability of QI strategies in achieving diabetes care goals in low- and middle-income (LMICs) and the effects of these improvements on reducing vascular complications and diabetes-related deaths.