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

• Published in: PLoS medicine 2020-11, Vol.17 (11), p.e1003434-e1003434
• Main Authors: Flood, David, Hane, Jessica, Dunn, Matthew, Brown, Sarah Jane, Wagenaar, Bradley H, Rogers, Elizabeth A, Heisler, Michele, Rohloff, Peter, Chopra, Vineet
• Format: Article
• Language: English
• Subjects: Adult; Asia; Bias; Bibliographic data bases; Biology and life sciences; Care and treatment; Community Health Planning - economics; Cost analysis; Design; Developing countries; Developing Countries - statistics & numerical data; Diabetes; Diabetes mellitus (non-insulin dependent); Diabetes Mellitus, Type 2 - epidemiology; Earth Sciences; Glucose; Government Programs - statistics & numerical data; Health aspects; Health care reform; Health Education - economics; Health Education - statistics & numerical data; Health services; Hemoglobin; Humans; Intervention; Librarians; Medical Assistance - statistics & numerical data; Medicine and Health Sciences; Meta-analysis; Methods; Mortality; Physical Sciences; Professionals; Quality of Life; Research and Analysis Methods; Social Sciences; Systematic review; Type 2 diabetes; Workers
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1003434

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. 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 q