Strategies for Improving the Acquisition and Integration of Evidence Into Diabetes Care

Overview of common types of evidence

Unfortunately, not all evidence is created equal. The amount of reading time required to keep up with best practices can be reduced by knowing the types and quality of the research articles available and how to evaluate the strength or quality of the research findings or evidence base used to develop practice recommendations.⁵ Figure 1 highlights definitions and examples of key types of evidence.⁶ At the base of the pyramid are individual studies, and these form the evidence base for the layers above, including syntheses (e.g., systematic reviews), synopses (e.g., evidence base libraries), and summaries (Table 1). Examples of individual studies include case series and reports, case-control studies, cohort studies, and randomized, controlled trials (RCTs).

Useful resources for finding evidence

The information listed below describes useful resources for finding evidence pertaining to diabetes care. Descriptions of the different types of resources are followed by suggested strategies for using these resources to stay informed.

Evaluation or grading of evidence. Many resources are available to assist in the evaluation or grading of the evidence from different types of studies, such as the Cochrane Systematic Reviews of Interventions, which describes the process of preparing and maintaining systematic reviews on the effects of health care interventions;⁷ the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which uses a tiered approach to grading the quality of evidence in a study for a particular outcome;⁸ and the Strength of Recommendation Taxonomy (SORT), which rates and grades individual studies for patient- and disease-oriented evidence.⁹

Several standards, such as type of study and level of rigor in study methodology, have been adopted across types of systems, and many organizations have used this as the basis for the development of their own guidelines for evaluating the relevant research evidence base to develop clinical guidelines. As an example of evidence grading for studies relevant to diabetes education, the recent Guidelines for the Practice of Diabetes Education¹⁰ were based on review and grading of evidence relating to diabetes self-management education and training (DSME/T). This endeavor used the approach of the American Association of Clinical Endocrinologists,¹¹ which is based on generally accepted evaluations of standards for evidence-based medicine. The guidelines describe the criteria for rating levels of evidence and the process of grading the evidence related to each of the domains of DSME/T.¹⁰

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Figure 1.

The 5 S's evidence pyramid. Reproduced with permission from and based on Ref. ⁶.

RCTs, multicenter trials with rigorous methodology, and large meta-analyses with quality ratings are generally considered to provide the strongest sources of evidence.^11,12 Examples of landmark RCTs that have informed diabetes prevention and care practice include the Diabetes Control and Complications Trial (DCCT),^13,14 the U.K. Prospective Diabetes Study (UKPDS),^15,16 and the Diabetes Prevention Program (DPP).^17,18 Examples of others underway include the Action for Health in Diabetes (LookAHEAD)¹⁹ and Action to Control Cardiovascular Risk in Diabetes (ACCORD)²⁰ trials. Diabetes care providers across disciplines are encouraged to review methodologies and treatment protocols of these RCTs to help guide their specific practices.

Strategies for using evaluations or graded evidence. As an example of using RCT data to inform practice, providers might want to review landmark trials to learn optimal approaches to setting individualized goals for blood glucose control and cardiovascular risk reduction for high-risk patients who are living with type 2 diabetes. Given familiarity with earlier research, providers might be interested in updates on the costs and benefits of pursuing tight control. An examination of the evidence would reveal three recent major RCTs that could provide helpful guidance.

The ACCORD trial²⁰, the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial^21,22, and the Veterans Affairs Diabetes Trial (VADT)^23,24 all were large, well-controlled, long-term RCTs that compared the effects of intensive versus standard glycemic control on cardiovascular outcomes in adults with type 2 diabetes. The results, overall, did not show significant reduction in cardiovascular disease (CVD) outcomes with intensive glycemic control. However, the evidence did indicate that some individuals and subgroups (with fewer health problems and lower risks for hypoglycemia) showed benefits. Familiarity with these studies could assist providers in making informed decisions regarding goal-setting based on individual patient characteristics.

Medical society, medical school, and health care quality organization summaries and standards. Health professionals generally turn to experts for help in navigating the huge volume of ever-emerging evidence and for guidance about which evidence to incorporate, relying especially on medical specialty societies, medical schools, and health care quality organizations, such as the National Quality Forum and the Agency for Healthcare Research and Quality (AHRQ). In addition, panels of clinical experts are used to sort through current research and work with established guidelines to assess whether interventions (e.g., drugs or behaviors) are considered effective enough to be declared evidence-based. These recognized groups can serve as valuable resources for synopses and summaries to help guide practice. In particular, it has been suggested that systematic reviews (syntheses), meta-analyses (syntheses) of RCTs, and evidence-based practice guidelines (summaries) are considered to provide the strongest level of evidence to inform clinical practice decisions.¹² Therefore, it is crucial to keep current on any published syntheses, synopses, or summaries related to practice.

Strategies for using summaries and standards. There have been recent meta-analyses on a variety of important topics related to diabetes care, such as efficacy of pharmacist-based interventions,²⁵ self-management programs for older adults,²⁶ and the impact of depression on patient adherence.²⁷ The annually updated American Diabetes Association (ADA) Standards of Medical Care in Diabetes, published each January, is an excellent example of evidence-based practice guidelines.²⁸ The 2010 Standards review the recent ADVANCE, ACCORD, and VADT trials mentioned above in the context of the practice guidelines.²⁸

Systematic reviews. Systematic reviews are commonly used to synthesize evidence for specific areas of care or patient populations. These structured literature reviews objectively and systematically search, identify, and summarize the available evidence that addresses a specific clinical question, paying particular attention to methodological quality.²⁹ With this approach, the relevant literature is critically appraised, and the data are extracted and synthesized to formulate findings from the identified evidence base.

Strategies for using systematic review evidence. As an example, a series of systematic reviews in diabetes education addressed specific self-care behaviors, including healthy eating, physical activity, self-monitoring, medication-taking, problem solving, healthy coping, and reducing risks.³⁰ These reviews identified, evaluated, and synthesized published studies in an explicit and systematic manner, thereby helping readers become familiar with the process used by researchers to conduct the systematic reviews and to independently assess the results.

Computerized support systems. Health care systems may provide computerized decision support approaches, such as electronic medical records, to guide optimal and evidence-based patient care.

Strategies for using computerized support systems. Computerized decision support systems have been found to increase accuracy in patient diagnosis and care.³¹ However, a review of relevant studies indicates that this approach has not yet been widely adopted.³¹

Using Evidence to Inform Clinical Care

The approaches described above illustrate the underpinnings of evidence-based methods of evaluating research. Diabetes care can be well informed by using these strategies. As history has shown, evidence and data do not immediately translate into evidence-based practice. For example, it has been estimated that there is a 17-year lag, on average, in translation of scientific findings into everyday clinical practice.³²

Fortunately, numerous resources have been developed to help busy professionals reduce the time they need to keep informed about the latest research evidence affecting practice. These resources synthesize and critically evaluate the available research literature to support evidence-based best practices. Examples of such resources include the Cochrane Database of Systematic Reviews (Cochrane Reviews)³³ and the American College of Physicians (ACP) Physicians' Information and Education Resource (PIER), which provides evidence-based guidance on clinical topics.³⁴ Many institutions subscribe to resources such as Up to Date, which provides evidence-based, peer-reviewed topic reviews that may be accessed by computer or mobile device.³⁵

Organizations may offer resources for providers both across and within disciplines. The American Dietetic Association provides the Evidence Analysis Library (EAL), a searchable database, for its members. Members of the American Association of Diabetes Educators (AADE) can also access this resource. EAL allows users to identify and access resources for a specific condition (e.g., diabetic neuropathy), intervention type (e.g., structured physical activity), and outcome (e.g., A1C, cholesterol, or blood pressure). Users are then able to identify recommended treatment or intervention options determined to be effective.

The AADE members' Web site provides links to several organizational initiatives and publications that address diabetes education research findings and strategies on how to translate them into practice.³⁶

The Centers for Disease Control and Prevention (CDC) Division of Diabetes Translation provides access to the CDC Community Guide as an additional resource. This guide synthesizes and makes recommendations about a variety of diabetes-related topics.³⁷ Specific resources related to DSME/T include Task Force on Community Preventive Services Recommendations and Findings Related to Case Management Interventions to Improve Glycemic Control; Disease Management Programs; and Self-Management Education in Community Gathering Places. Related guide topics include Promoting Physical Activity, Obesity Prevention, and Worksite Health Promotion. An overview of resources that diabetes care providers may use to obtain data and recommendations based on evidence-based reviews is provided in Table 2.

Using multiple resources to locate pertinent evidence may provide convergent and complementary information. The following case studies illustrate the use of these resources to find evidence to support practice recommendations.

Case study 1

A primary care provider consults with a diabetes care provider about a 65-year-old male patient with type 2 diabetes and peripheral neuropathy who has expressed interest in beginning a weight-training program at his gym. The primary care provider has inquired about the utility and safety of this plan.

Resources consulted. The diabetes care and primary care providers could examine the 2010 ADA Standards of Medical Care in Diabetes²⁸ for information about the effectiveness of resistance exercise training in older men with type 2 diabetes. The Standards cite several well-designed RCTs focusing on older men with type 2 diabetes. These trials indicate that resistance training has the same or an even greater impact on A1C as aerobic activity and has an additive benefit to aerobic exercise in this population.

An additional examination of the Cochrane Reviews (see Table 1) may be helpful, especially because this resource permits searching and browsing by topic. In this case, a review on exercise for people with peripheral neuropathy is available. The review is based on studies with heterogeneous samples of adults with peripheral neuropathy, including those with diabetes. Although review of study designs and findings in this area does not result in adequate evidence to evaluate the effect of exercise on disability in people living with peripheral neuropathy, it does suggest that strength training moderately improves muscle strength in adults with peripheral neuropathy.

Outcome. The clinician could use information gleaned from these reviews to provide guidance to the patient based on current best-practice evidence. Based on the available empirical data, the primary care provider could advise the patient that resistance training offers numerous benefits and approve the participation in weight training.

Case study 2

A diabetes educator is working with a 50-year-old man with type 2 diabetes and CVD. He has requested information about optimal nutrition, and the educator would like to provide him with current, evidence-based recommendations.

Resources consulted. A search of diabetes and CVD on the EAL Web site (see Table 1) reveals that a systematic literature review addresses the question, What is the evidence supporting specific nutrition interventions in the treatment of CVD in people with diabetes?

Outcome. From this review, the educator learns that well-controlled studies indicate good strength of evidence that Mediterranean diets and reduced-sodium diets positively affect endothelial function, blood pressure, and lipids in adults with CVD and diabetes. This search and the information it yields informs the educator's recommendations for optimal, evidence-based dietary recommendations.

Case study 3

An interdisciplinary diabetes care team has discussed approaches to CVD and diabetes risk factor reduction, including health behavior change for diet and diabetes management. The behavioral medicine team member suggests cognitive behavioral therapy (CBT) strategies for intervention in outpatient and clinic settings. Some team members have heard of this approach for treating depression and would like information about the studies that have been done with health behavior change.

Resources consulted. Team members access EAL. They find a systematic review examining CBT approaches to health- and food-related behavior change to reduce diabetes and CVD risk factors, promote weight loss, and support diabetes management.

Outcome. The review the team located summarized and graded studies of short-term CBT (of 6 months' duration), intermediate duration CBT (of 6–13 months' duration), and long-term CBT (of > 12 months' duration). The review indicated good supporting evidence that CBT provides benefits for dietary behavior change such as decreased fat and sodium intake and increased consumption of fruit and vegetables. In addition, it included strong evidence supporting intensive intermediate and long-term CBT aimed at diabetes prevention or onset delay (e.g., as used in the DPP) or improvement in hypertension and other CVD risk factors. The team found that program materials based on CBT use in the DPP are available online (see Table 1). Knowledge of such evidence guided the team in their decision-making regarding the use of this approach and in their subsequent program planning.

Summary: Implications of Evidence-Based Research for Diabetes Practice

To make informed decisions, diabetes care providers are encouraged to follow four guidelines: 1) become familiar with the types of evidence available, 2) know where to find the best sources of evidence to inform practice, 3) keep current on landmark RCTs in the field, and 4) use the evidence available by applying it in daily clinical decision-making.

It is also important to note that other factors influence the diffusion and adoption of evidence-based innovations into clinical practice. Bradley et al.³⁸ identified the following factors as necessary in hastening the adoption of research into evidence-based practice:

1. Strong support of senior management at the adopting organization is essential. Administrative support in a key position to make management changes (senior management) is necessary to implement clinical improvements. Therefore, having an administrative champion is crucial to support the adoption of new evidence-based approaches.

2. Effective clinical leadership in adopter organizations speeds up adoption. Involving clinical leaders (e.g., nurse managers or a respected peer) who are credible to clinicians and understand organizational dynamics (e.g., cultural norms, organizational decision-making patterns, and established treatment protocols) can help in championing the adoption of new evidence-based research findings into practice.

3. Data to support start-up, implementation, and ongoing evaluation of evidence-based initiatives must be credible and persuasive. Adopting evidence-based research findings into practice makes good sense not only from a clinical perspective, but also from a business perspective. Improvements in the delivery of clinical care based on evidence-based research helps to improve overall quality. Administrators can see the added value of evidence-based innovations that can help the organization fulfill its strategic business goals. Diabetes care providers can access numerous resources and publications that address the large evidence base demonstrating the cost-effectiveness of implementing interventions from the DPP³⁹ and the DCCT.⁴⁰ Full publications lists and links for each landmark trial are available from the Web sites shown in references ³⁹ and ⁴⁰.

In conclusion, by using the available resources described in this article, administrators, clinical leaders, and diabetes care providers can actively and effectively examine the evidence for themselves. This can better position diabetes care providers to make informed decisions for providing patient education and care based on the best available practices.