Improving risk factor management for patients with poorly controlled type 2 diabetes: a systematic review of non-pharmaceutical interventions in primary care and community settings Murphy ME 1, Galvin R 2, Fahey T 1, Boland F 1, Byrne M 3, Smith SM 1 1/ HRB Centre for Primary Care Research, Royal College of Surgeons, Ireland 2/ Department of Physiotherapy, University of Limerick3/ Department of Psychology, NUI, Galway Poorly-controlled type 2 diabetes mellitus (T2DM) is associated with higher morbidity, higher mortality, worse quality of life and substantial economic burden (1). Four large randomised controlled trials (RCTs) from North America and the UK have investigated the effects of intensive management of hyperglycaemic and cardiac risk factors on mortality, but uncertainty remains regarding intensive glycaemic management on all patients with T2DM (2-4). Systematic reviews have examined interventions designed to support the delivery of diabetes care in the community to improve glycaemic and cardiovascular risk factor control- however none have specifically examined their effects on populations with poor T2DM control (5). It is uncertain what the effect interventions in poorly-controlled T2DM populations in primary care would have. Figure 1: Effects of longer-follow up (≥ 10 months) interventions on HbA1c SBP effect size Overall SBP improved in the 24 interventions that reported this outcome (MD SBP – 4.5 (- 5.06, -3.94)), but had high heterogeneity. Meta-regression showed that organisational interventions were more likely to reduce SBP compared to patient-centred interventions (β-Coefficient -3.7, p = 0.006). Introduction To assess the effectiveness of healthcare professional-led interventions, targeting poorly-controlled T2DM and seeking to improve glycaemic control and cardiovascular risk in primary care and community settings. A systematic review was undertaken. Only studies of interventions in populations with poor T2DM control were included. Poor control was defined as a HbA1c over 68 mmol/ mol (7.5%). Primary outcomes were HbA1c, systolic blood pressure (SBP) and lipids. Secondary outcomes included patient reported outcome measures and health care utilisation. Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis was performed using a random effects model (Revman software). Meta-regression were undertaken to explore the effects of interventions and to examine the impact of different study characteristics on HbA1c and BP. Aims Methods Results (continued) 1.HRB-funded SPHeRE Programme 1.HRB Centre for Primary Care Research Conclusion Acknowledgements Characteristics of studies included 15,130 studies were screened. 38 studies met the eligibility criteria, all were were RCTs, encompassing 45 interventions in total, comprising 8,907 patients. The predominant intervention-types were patient-directed (47%) and organisational (47%), with one financial and one professional intervention. The mean HbA1c across all studies was 9.5%. Predominant risk of bias 22 studies (58%) had a low-risk of bias. 12 studies (32%) had an unclear-risk of bias. 4 studies (10%) had a high-risk of bias. HbA1c effect size 17 studies had a short follow up (≤10 months) and interventions showed a favourable effect overall compared to controls (MD – 0.27 (-0.43, -0.10)).  Patient-directed interventions or interventions on those with baseline HbA1c over 9.5% showed the greatest benefit. 20 studies had a longer follow-up (≥ 12 months) and interventions showed a more favourable effect overall compared to controls (MD (-0.61, -0.16)) but had high heterogeneity (see Figure 1).  Organisational interventions or interventions on those with baseline HbA1c over 9.5% showed the greatest benefit. Meta-regression indicated that North American interventions showed a greater reduction in HbA1c (β-Coefficient -0.4, p 0.015) compared to European interventions. Predominant intervention type did not effect HbA1c. Results 1.Stratton et al. BMJ Patel et al. N Engl J Med Duckworth et al. N Engl J Med Hayward et al. N Engl J Med Seitz et al. Diabetes Obes Metab References Main findings and implications This is the first systematic review to look at interventions specifically targeting poorly- controlled patients with T2DM in community settings. The results suggest that non-pharmaceutical interventions improve HbA1c and SBP, with studies on those with the poorest control (≥ 9.5%) and those with a longer follow up possessing a stronger effect size. Organisational-predominant interventions appear to maintain the strongest effects on glycaemic control and should be the focus for policy makers, as a prudent strategy for future chronic disease management interventions. Strengths and limitations There is no specific definition for ‘poor control’ of T2DM in the literature, but by including all studies with a HbA1c ≥7.5%, we captured the full range of poor control of glycaemia. As we only included studies with poor control, regression towards the mean is a possibility; however since all included studies were RCTs, with usual care as the control group, this should negate this effect. Future research Future experimental research should:  Target patients with the poorest control of T2DM  Incorporate organisational elements  Focus more on professional interventions which are understudied  Consider targeting intensification of medications and medication adherence, through decision support.