Diabetes Management: Team-Based Care for Patients with Type 2 Diabetes
Summary of CPSTF Finding
Teams work together to help patients
- Get appropriate medical tests and examinations (e.g., blood glucose level, blood pressure, lipid level, weight, eye and foot examinations)
- Use medications to manage and control risk factors (e.g., blood glucose level, blood pressure, lipid level)
- Self-manage their health care and adhere to treatment
- Make healthy behavior and lifestyle choices (e.g., improved diet, increased physical activity, cessation of smoking)
- Improve their quality of life and prevent diabetes-related complications
CPSTF Finding and Rationale Statement
About The Systematic Review
The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes prevention and control.
Summary of Results
Compared with usual care, team-based care improved health outcomes:
- Blood glucose
- A1c levels decreased by a mean of 0.5% (25 studies)
- Blood pressure
- Systolic blood pressure decreased by a mean of 5.5mmHg (18 studies)
- Diastolic blood pressure decreased by a mean of 3.2mmHg (17 studies)
- High-density level (HDL) cholesterol increased by a mean of 0.7mg/dL (9 studies)
- Low-density level (LDL) cholesterol decreased by a mean of 8.0mg/dL (14 studies)
- Total cholesterol level decreased by a mean 7.4mg/dL (12 studies)
- Triglycerides levels decreased by a mean of 13.3mg/dL (7 studies)
Compared with usual care, team-based care increased the proportion of patients reaching target blood glucose, blood pressure, and lipid levels. Target health outcomes are benchmarks that, when reached, show significant health benefits for the patient.
- Blood glucose
- The proportion of patients who reached an A1c level below 7.0% increased by a median of 15.1 percentage points (7 studies).
- The proportion of patients who reached an A1c level below 7.5% increased by a median of 18.0 percentage points (1 study).
- Blood pressure
- The proportion of patients who reached a blood pressure below 130/80mmHg increased by a median of 15.0 percentage points (10 studies).
- The proportion of patients who reached a systolic blood pressure below 130mmHg increased by a median of 4.4 percentage points (3 studies).
- The proportion of patients who reached a diastolic blood pressure below 80mmHg decreased by a median of 1.0 percentage point (3 studies).
- The proportion of patients who reached an HDL level above 35mg/dL decreased by a median of 3.2 percentage points (1 study).
- The proportion of patients who reached an HDL level above 40mg/dL increased by a median of 0.6 percentage points (1 study).
- The proportion of patients who reached above 43mg/dL for males or above 50mg/dL for females increased by a median of 2.0 percentage points (1 study).
- The proportion of patients who reached an LDL level below 130mg/dL increased by a median of 16.7 percentage points (5 studies).
- The proportion of patients who reached a total cholesterol level below 200mg/dL increased by a of median 14.0 percentage points (1 study).
- Greater reductions in patients’ blood glucose levels were reported when pharmacists (13 studies) rather than nurses (19 studies) were added to the team.
- The addition of either a pharmacist or nurse led to improved blood glucose levels.
Changing patient medications
- Programs that allowed team members to make suggestions for medication changes with primary care provider approval (4 studies) led to greater reductions in diastolic blood pressure than did programs that only allowed primary care providers to make medication changes (11 studies).
Communicating between team members
- Studies with explicit communication (15 studies) showed more favorable blood pressure outcomes than studies with implicit communication (4 studies).
- Explicit communication team members actively share information during team meetings or other formal channels
- Implicit communication team members share information passively through notes in patient records or status updates in doctors’ folders
Accessing patient medical records
- Studies that allowed all team members to access patients’ medical records (21 studies) showed more favorable reductions in blood glucose when compared to studies that did not (3 studies).
Delivery of Care
Patients experienced greater reductions in blood glucose levels when care services were delivered both in-person and remotely (10 studies), rather than just in-person (12 studies) or remotely (3 studies).
Summary of Economic Evidence
- High income countries
- Urban environments
- Clinics, hospitals, pharmacies, or Veterans Affairs facilities
- Adults and older adults who have type 2 diabetes with or without diabetes-related complications or high risk for developing complications
- Women and men
- All examined racial and ethnic groups
- People with different socioeconomic statuses (SES)
- Patients with health insurance
Based on results for interventions with different characteristics, findings should be applicable to interventions that formed the teams by adding:
- One, two, or more team members to the patient and primary care provider relationship,
- A nurse or pharmacist, and
- Members by hiring new people or expanding the roles of existing staff.
- What are intervention effects on diabetes-related complications and healthcare use?
- How effective are interventions with the following populations?
- People with type 1 diabetes
- Younger people with diabetes
- Uninsured people with diabetes
- People with diabetes living in rural settings
- How do team composition and operation influence intervention outcomes?
- What services (e.g. education, counseling, goal setting, medication modification) are provided by team members?
- How do team members communicate? Do teams use electronic records or meetings or other means of communication?
- Do programs provide protocols to delineate the team roles and responsibilities?
- Who is the team lead? The primary care provider, or the team member providing the majority of services?
- Who would be the most effective primary contact for patients? The primary care provider, the team member providing the majority of services, or someone else?
- The United States (25 studies), Canada (3 studies), the United Kingdom (2 studies), Hong Kong (1 study), the Netherlands (1 study), Switzerland (1 study), Taiwan (1 study), and United Arab Emirates (1 study)
- Clinics (22 studies), hospitals (5 studies), pharmacies (4 studies), or Veterans Affairs facilities (4 studies)
- Urban (22 studies), suburban (1 study), rural (1 study), or mixed settings (urban/ suburban/ rural; 8 studies); Three studies did not provide this information.
Study participants had the following demographic characteristics:
- Mean age of 58.4 years (31 studies)
- 52.2% female (34 studies)
- Type 2 diabetes (25 studies), type 1 or type 2 diabetes (3 studies), or unreported diabetes type (7 studies)
- Low-income or underserved population (7 studies); too few studies reported on socioeconomic status, and the metrics were too various to be summarized
- Median of 51.3% had less than high school education (8 studies)
- Race/ Ethnicity (20 studies):
- White (median 61.5%; 15 studies)
- African Americans (median 16.5%; 12 studies)
- Hispanic/Latino (median 19.2%; 8 studies)
- Asian American (median 2.9%; 3 studies)
- American Indian/Alaskan Native (median 2.9%; 3 studies)
- Other (median 3.8%; 5 studies).
- Five studies targeted specific races or ethnicities, including African American (3 studies), Samoan (1 study), and Hispanic (1 study) populations.
- Services delivered
- Education component (33 studies)
- Continuing education/counseling component (32 studies)
- Regular testing and monitoring (29 studies)
- Medication modification (24 studies)
- Patient goal setting and creation of an action plan to achieve those goals (16 studies)
- Intervention duration ranged from less than 6 months to more than 3 years.
- Team composition and operation
- In addition to the patient and primary care provider, teams added one member (23 studies), two members (9 studies), or three or more members (3 studies).
- Teams added a nurse (20 studies), pharmacist (14 studies), or other type of healthcare provider (12 studies).
- Studies added team members by hiring new people (22 studies) or expanding the roles of existing staff (6 studies).
Levengood TW, Peng Y, Xiong KZ, et al. Team-based care to improve diabetes management: a Community Guide meta-analysis. American Journal of Preventive Medicine. 2019;57(1):e17-26.
Community Preventive Services Task Force. Team-based care to improve type 2 diabetes management: recommendation of the Community Preventive Services Task Force. American Journal of Preventive Medicine. 2019;57(1):e27-9.
When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.
Summary Evidence Table
Al Mazroui NR, Kamal MM, Ghabash NM, Yacout TA, Kole PL, McElnay JC. Influence of pharmaceutical care on health outcomes in patients with Type 2 diabetes mellitus. British Journal of Clinical Pharmacology 2009;67(5):547-57.
Aubert RE, Herman WH, Waters J, Moore W, Sutton D, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Annals of Internal Medicine 1998;129(8):605-12.
Bellary S, O’Hare JP, Raymond NT, Gumber A, Mughal S, et al. Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial. Lancet 2008;371(9626):1769-76.
Chan CW, Siu SC, Wong CK, Lee VW. A pharmacist care program: positive impact on cardiac risk in patients with type 2 diabetes. Journal of Cardiovascular Pharmacology and Therapeutics 2012;17(1):57-64.
Choe HM, Mitrovich S, Dubay D, Hayward RA, Krein SL, Vijan S. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. American Journal of Managed Care 2005;11(4):253-60.
Crowley MJ, Powers BJ, Olsen MK, Grubber JM, Koropchak C, et al. The Cholesterol, Hypertension, And Glucose Education (CHANGE) study: results from a randomized controlled trial in African Americans with diabetes. American Heart Journal 2013;166(1):179-86.
DePue JD, Dunsiger S, Seiden AD, Blume J, Rosen RK, et al. Nurse-community health worker team improves diabetes care in American Samoa: results of a randomized controlled trial. Diabetes Care 2013;36(7):1947-53.
Doucette WR, Witry MJ, Farris KB, McDonough RP. Community pharmacist-provided extended diabetes care. Annals of Pharmacotherapy 2009;43(5):882-9.
Frei A, Senn O, Chmiel C, Reissner J, Held U, Rosemann T. Implementation of the chronic care model in small medical practices improves cardiovascular risk but not glycemic control. Diabetes Care 2014;37(4):1039-47.
Gabbay RA, Lendel I, Saleem TM, Shaeffer G, Adelman AM, et al. Nurse case management improves blood pressure, emotional distress and diabetes complication screening. Diabetes Research and Clinical Practice 2006;71(1):28-35.
Gary TL, Batts-Turner M, Yeh HC, Hill-Briggs F, Bone LR, et al. The effects of a nurse case manager and a community health worker team on diabetic control, emergency department visits, and hospitalizations among urban African Americans with type 2 diabetes mellitus: a randomized controlled trial. Archives of Internal Medicine 2009;169(19):1788-94.
Gary TL, Bone LR, Hill MN, Levine DM, McGuire M, et al. Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Preventive Medicine 2003;37(1):23-32.
Groeneveld Y, Petri H, Hermans J, Springer M. An assessment of structured care assistance in the management of patients with type 2 diabetes in general practice. Scandinavian Journal of Primary Health Care 2001;19(1):25-30.
Hargraves JL, Ferguson WJ, Lemay CA, Pernice J. Community health workers assisting patients with diabetes in self-management. Journal of Ambulatory Care Management 2012;35(1):15-26.
Hiss RG, Armbruster BA, Gillard ML, McClure LA. Nurse care manager collaboration with community-based physicians providing diabetes care: a randomized controlled trial. Diabetes Educator 2007;33(3):493-502.
Huang MC, Hsu CC, Wang HS, Shin SJ. Prospective randomized controlled trial to evaluate effectiveness of registered dietitian-led diabetes management on glycemic and diet control in a primary care setting in Taiwan. Diabetes Care 2010;33(2):233-9.
Jameson JP, Baty PJ. Pharmacist collaborative management of poorly controlled diabetes mellitus: a randomized controlled trial. American Journal of Managed Care 2010;16(4):250-5.
Kraemer DF, Kradjan WA, Bianco TM, Low JA. A randomized study to assess the impact of pharmacist counseling of employer-based health plan beneficiaries with diabetes: the EMPOWER study. Journal of Pharmacy Practice 2012;25(2):169-79.
Krein SL, Klamerus ML, Vijan S, Lee JL, Fitzgerald JT, et al. Case management for patients with poorly controlled diabetes: a randomized trial. American Journal of Medicine 2004;116(11):732-9.
Litaker D, Mion L, Planavsky L, Kippes C, Mehta N, Frolkis J. Physician – nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care. Journal of Interprofessional Care 2003;17(3):223-7.
McLean DL, McAlister FA, Johnson JA, King KM, Makowsky MJ, et al. A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN). Archives of Internal Medicine 2008;168(21):2355-61.
The California Medi-Cal Type 2 Diabetes Study Group. Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study. Diabetes Care 2004;27(1):95-103.
Odegard PS, Goo A, Hummel J, Williams KL, Gray SL. Caring for poorly controlled diabetes mellitus: a randomized pharmacist intervention. Annals of Pharmacotherapy 2005;39(3):433-40.
O’Hare JP, Raymond NT, Mughal S, Dodd L, Hanif W, et al. Evaluation of delivery of enhanced diabetes care to patients of South Asian ethnicity: the United Kingdom Asian Diabetes Study (UKADS). Diabetic Medicine 2004;21(12):1357-65.
Pape GA, Hunt JS, Butler KL, Siemienczuk J, LeBlanc BH, et al. Team-based care approach to cholesterol management in diabetes mellitus: two-year cluster randomized controlled trial. Archives of Internal Medicine 2011;171(16):1480-6.
Piette JD, Weinberger M, Kraemer FB, McPhee SJ. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: a randomized controlled trial. Diabetes Care 2001;24(2):202-8.
Planas LG, Crosby KM, Farmer KC, Harrison DL. Evaluation of a diabetes management program using selected HEDIS measures. Journal of the American Pharmacists Association 2012;52(6):e130-8.
Rothman RL, Malone R, Bryant B, Shintani AK, Crigler B, et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. American Journal of Medicine 2005;118(3):276-84.
Scott DM, Boyd ST, Stephan M, Augustine SC, Reardon TP. Outcomes of pharmacist-managed diabetes care services in a community health center. American Journal of Health-System Pharmacy 2006;63(21):2116-22.
Sczupak CA, Conrad WF. Relationship between patient-oriented pharmaceutical services and therapeutic outcomes of ambulatory patients with diabetes mellitus. American Journal of Hospital Pharmacy 1977;34(11):1238-42.
Simpson SH, Majumdar SR, Tsuyuki RT, Lewanczuk RZ, Spooner R, Johnson JA. Effect of adding pharmacists to primary care teams on blood pressure control in patients with type 2 diabetes: a randomized controlled trial. Diabetes Care 2011;34(1):20-6.
Taylor CB, Miller NH, Reilly KR, Greenwalk G, Cunning D, et al. Evaluation of a nurse-care management system to improve outcomes in patients with complicated diabetes. Diabetes Care 2003;26(4):1058-63.
Taylor KI, Oberle KM, Crutcher RA, Norton PG. Promoting health in type 2 diabetes: nurse-physician collaboration in primary care. Biological Research for Nursing 2005;6(3):207-15.
Weinberger M, Kirkman MS, Samsa GP, Shortliffe EA, Landsman PB, et al. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. Journal of General Internal Medicine 1995;10(2):59-66.
Welch G, Allen NA, Zagarins SE, Stamp KD, Bursell SE, Kedziora RJ. Comprehensive diabetes management program for poorly controlled Hispanic type 2 patients at a community health center. Diabetes Educator 2011;37(5):680-8.
- Agency for Healthcare Research and Quality: Creating Teams and Team-based Care.
- American Medical Association: Strengthen Team Cohesion and Engagement. This webpage provides step-by-step tools on creating a strong team culture.
- Interprofessional Education Collaborative. This website provides educational materials to promote interprofessional learnings for enhanced team-based care.
- The Primary Care Team Guide: Building a Primary Care Team. This free online learning tool guides people on establishing an effective team for team-based care.
The following are search terms used for the Medline search; similar search terms were used for the search through the EPOC database.
- Search Disease Management [mh] OR Patient Care Planning [mh] OR Patient-Centered Care [mh] OR Primary Health Care [mh] OR Progressive Patient Care [mh] OR Critical Pathways [mh] OR Delivery of Health Care, Integrated [mh] OR Health Services Accessibility [mh] OR Managed Care Programs [mh] OR Product Line Management [mh] OR Patient Care Team [mh] OR Patient-Centered Care [mh] OR Behavior Control [mh] OR Counseling [mh] OR Health Promotion [mh] OR Patient Compliance [mh] OR After-Hours Care [mh] OR ((coordination [ti] OR coordinated [ti] OR Multifactorial [ti] OR Multi-factorial [ti] OR Multicomponent [ti] OR Multi-component [ti] OR multidisciplinary [ti] OR multi-disciplinary [ti] OR interdisciplinary [ti] OR inter-disciplinary [ti] OR integrated [ti] OR community-based [ti] OR organized [ti]) AND (care [ti] OR approach [ti] OR intervention [ti] OR strategy [ti] OR strategies [ti] OR management [ti] OR managing [ti] OR center* [ti] OR clinic*[ti])) OR Organization and Administration [mh] OR “Disease Management” [ti] OR “case management” [ti]
- Search Total Quality Management [mh] OR Quality control [mh] OR TQM [ti] OR CQI [ti] OR (quality [ti] AND (continuous [ti] OR total [ti]) AND (management [ti] OR improvement [ti]))
- Search Education, Continuing [mh] OR (Education [ti] AND Continuing [ti] AND (medical [ti] OR professional* [ti] OR nursing [ti] OR physician* [ti] OR nurse* [ti])) OR (outreach [ti] AND (visit*[ti] OR educational [ti]) OR (academic [ti] AND detailing [ti]))
- Search Diffusion of Innovation [mh] OR (Diffusion [ti] AND (Innovation [ti] OR technology [ti]))
- Search Medical audit [mh] OR ((Audit [ti] OR feedback [ti] OR compliance [ti] OR adherence [ti] OR training [ti]) AND (improvement* [ti] OR improving [ti] OR improves [ti] OR improve [ti] OR guideline* [ti] OR practice* [ti] OR medical [ti] OR provider* [ti] OR physician* [ti] OR nurse* [ti] OR clinician* [ti] OR practice guidelines [mh] OR academic [ti] OR visit* [ti])) OR Reminder Systems [mh] OR Reminder* [ti] OR ((financial [ti] OR economic [ti] OR physician* [ti] OR patient*) AND incentive* [ti]) OR Reimbursement Mechanisms [mh] OR “pay for performance” [tw] OR “pay-for-performance” [tw]
- Search Medical Informatics [mh] OR computer [ti] OR (decision [ti] AND support [ti]) OR Telemedicine[mh] OR Telemedicine [ti] OR telecommunication* [ti] OR Internet [mh] OR web [ti] OR modem [ti] OR telephone* [ti] OR telephone [mh] OR hospital information systems [mh] OR decision support systems, clinical [mh] OR drug therapy, computer-assisted [mh] OR Clinical Pharmacy Information Systems [mh] OR Medical Records Systems, Computerized [mh] OR (decision [ti] AND support [ti]) OR ((computerized [ti] OR computerised [ti] OR computer [ti] OR computer-based [ti]) AND (order* [ti] OR entry [ti]))
- Search #1 or #2 or #3 or #4 or #5 or #6
- Search N Engl J Med [ta] OR JAMA [ta] OR Ann Intern Med [ta] OR Am J Med [ta] OR Arch Intern Med [ta] OR J Gen Intern Med [ta] OR BMJ [ta] OR Lancet [ta] OR CMAJ [ta] OR Clin Invest Med [ta] OR Arch Fam Med [ta] OR J Fam Pract [ta] OR Fam Pract [ta] OR Ann Med [ta] OR Br J Gen Pract [ta] OR J Intern Med [ta] OR Med J Aust [ta] OR South Med J [ta] OR West J Med [ta] OR Aust N Z J Med [ta] OR Med Care [ta] OR Health Serv Res [ta] OR Inquiry [ta] OR Milbank Q [ta] OR “Health Aff (Millwood)” [ta] OR Health Care Financ Rev [ta] OR Med Care Res Rev [ta] OR eff clin pract [ta] OR eval health prof [ta] OR Jt Comm J Qual Improv [ta] OR Qual Saf Health Care [ta] OR Int J Qual Health Care [ta] OR Qual Health Care [ta] OR Qual Health Res [ta] OR Rep Med Guidel Outcomes Res [ta] OR Am J Manag Care [ta] OR Am J Med Qual [ta] OR J Contin Educ Health Prof [ta] OR Prev Med [ta] OR Am J Prev Med [ta] OR Patient Educ Couns [ta] OR Ann Behav Med [ta] OR Diabetes Educ [ta] OR Endocrinology [ta] OR J Clin Endocrinol Metab [ta] OR Diabet Med [ta] OR Diabetes Care [ta] OR Diabetes Res Clin Pract [ta] OR Exp Clin Endocrinol Diabetes [ta] OR J Pediatr Endocrinol Metab [ta]
- Search ((meta-analysis [pt] OR meta-analysis [tw] OR metaanalysis [tw]) OR ((review [pt] OR guideline [pt] OR consensus [ti] OR guideline* [ti] OR literature [ti] OR overview [ti] OR review [ti] OR Decision Support Techniques [mh]) AND ((Cochrane [tw] OR Medline [tw] OR CINAHL [tw] OR (National [tw] AND Library [tw])) OR (handsearch* [tw] OR search* [tw] OR searching [tw]) AND (hand [tw] OR manual [tw] OR electronic [tw] OR bibliographi* [tw] OR database* OR (Cochrane [tw] OR Medline [tw] OR CINAHL [tw] OR (National [tw] AND Library [tw]))))) OR ((synthesis [ti] OR overview [ti] OR review [ti] OR survey [ti]) AND (systematic [ti] OR critical [ti] OR methodologic [ti] OR quantitative [ti] OR qualitative [ti] OR literature [ti] OR evidence [ti] OR evidence-based [ti]))) BUTNOT (case report [mh] OR case* [ti] OR report [ti] OR editorial [pt] OR comment [pt] OR letter [pt])
- Search Randomised [ti] OR Randomized [ti] OR Controlled [ti] OR intervention [ti] OR evaluation [ti] OR impact [ti] OR effectiveness [ti] OR Evaluation [ti] OR Studies [ti] OR study [ti] Comparative [ti] OR Feasibility [ti] OR Program [ti] OR Design [ti] OR Clinical Trial [pt] OR Randomized Controlled Trial [pt] OR Epidemiologic Studies [mh] OR Evaluation Studies [mh] OR Comparative Study [mh] OR Feasibility Studies [mh] OR Intervention Studies [mh] OR Program Evaluation [mh] OR Epidemiologic Research Design [mh]
- Search # 8 or #9 or #10
- Search #7 and #11
- Search (Diabetes Mellitus [mh] OR diabetes [ti] OR diabetic [ti] OR glycemic [ti] OR glycaemic [ti] OR sugar* [ti])
- Search #12 and #13
- Search #14 BUT NOT (editorial [pt] OR comment [pt] OR letter [pt])
- Search Limits: Humans, English
- Search #15 AND #16
Considerations for Implementation
- Teams that use explicit communication are likely to see more favorable outcomes.
- When possible, it is best when teams deliver services through a combination of face-to-face and remote (email, telephone) communications.
- Team-based care works best when changes to patient medication can be suggested by all team members and approved by primary care providers.
Pharmacists and nurses are strong additions to patient-provider teams.
Program challenges may include limited resources or lack of knowledge on how to transition to patient-centered care or form an effective multidisciplinary team. A list of resources to help implement team-based care is available in the Additional Materials section.
Evidence from this review and the Community Guide review of team-based care to improve blood pressure control suggests that team-based care may be a platform to successfully treat other chronic conditions or patients with multiple chronic conditions.
Healthy People 2030
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.