Figure 1
PRISMA flowchart diagram for studies selection (based on four-phase PRISMA flowchart diagram).
Table 1
Characteristics of included studies in the systematic review (n = 16).
| AUTHOR (YEAR), COUNTRY | STUDY POPULATION | STUDY TYPE | SAMPLE SIZE | AGE | DURATION OF STUDY | CARE PROVIDERS INVOLVED | INTERVENTION BY CARE PROVIDERS | OUTCOME MEASURES |
|---|---|---|---|---|---|---|---|---|
| Anthony W Russell (2019), Australia | Individuals with type 2 diabetes | A non-inferiority randomised controlled trial | Intervention group (n = 234) Control group (n = 71) | Age (years)- mean (SD) Intervention group 55.8 (11.3), Control group 55.4 (12.1) | 33 months (2012–2015) | Two GPs with a special interest (GPwSIs), an endocrinologist and a diabetes nurse educator (DNE) | The single endocrinologist supervised and co-consulted with GPwSIs. The DNE was skilled in case co-ordination and worked independently between clinics. Duration of diabetes (years), mean (SD) Control group- 9.5 (7.8) Intervention group- 10.2 (8.1) | HbA1c, Blood Pressure, Cholesterol, BMI |
| N.Basudev (2015), United Kingdom | Individuals with type 2 diabetes | Prospective randomised controlled trial | Intervention group (n = 79) Control group (n = 88) | Age (years)- mean (SD) Intervention group 60.5(12.3), Control group 63(9) | 12 months | Diabetes specialist nurses, a Diabetologist and a GP with special interest in diabetes | Integrated working between primary care and specialist diabetes teams were based on a ‘virtual clinic’ (professional-to-professional consultations- specialist to generalist- the patient is absent). Duration of diabetes (years), mean (SD) Control- 9.4(5.2) Intervention- 10.7(6.8) | HbA1c, Blood Pressure, Cholesterol, BMI, weight, eGFR |
| Andrew Wilson (2014), United Kingdom | Individuals with type 2 diabetes | Cluster-randomised trial | Intervention group (n = 644), Control group (n = 636) | Not stated | 18 months | Consultant, General practitioner with Special Interest, Diabetes specialist nurse | Patients were reviewed and managed in the ICCD by a specialist nurse and a diabetologist with a goal of improving diabetes and cardiovascular risk factor and are then referred back to practice. Duration of diabetes was not reported. | HbA1c, Blood Pressure, Cholesterol |
| Diabetes Care Project (2015), Australia | Individuals with type 1 and type 2 diabetes | Cluster randomized controlled trial | Intervention group 1 (n = 2449), intervention group 2 (n = 2339) and Control group (n = 1845) | Not stated | 18 months | General Practitioners, dietitians, pharmacists, practice nurses, endocrinologists, mental health workers, podiatrists, exercise physiologists | In Group 1 and Group 2 interventions, a collaboration between GPs and specialists undertook reviews of patient cases together. Following major changes were tested across the two groups: Integrated information platform, continuous quality improvement processes, flexible funding based on risk stratification, quality improvement support payments (QISP), funding for care facilitation. Duration of diabetes was equal to or more than 12 months’ duration. | HbA1c, Blood Pressure, Cholesterol, Serum Creatinine, GFR, ACR, weight, BMI. |
| Shamasunder Acharya (2019), Australia | Individuals with type 2 diabetes | Pre and Post study | n = 344 | Age (years)- mean (SD) 63.2 ± 11.5 | 6 months | GP, Practice Nurse, Diabetes Educator and Endocrinologist. | Case-conference style consultations of 40-minute duration with 10 patients per day were conducted in the general practice with their own GP, Practice nurse, a visiting diabetes educator and an endocrinologist. Preparatory work included organising podiatry and eye review, up-to-date pathology. Diabetes duration (years) was- 9 (5 – 15) | HbA1c, Blood Pressure, Cholesterol, BMI, Weight, eGFR, Urine ACR |
| Gideon Meyerowitz-Katz (2018), Australia | Individuals with type 2 diabetes | Longitudinal pre-post single cohort design | n = 41 | Age (years)- mean (SD) 56.46 (14.60) | 3 years | Diabetologist, Registrar, Resident, and Nurse Educator. | Patient visits consisted of a joint patient consultation and multi-disciplinary case conference. The management plan was reviewed together and agreed between all participants and a report and treatment plan is generated. GPs were provided with a telephone support line for remote support for their decision-making. Duration of diabetes was not reported. | HbA1c, Blood Pressure, Cholesterol, Weight, eGFR, |
| Nicholas A Zwar (2007), Australia | Individuals with type 2 diabetes | Retrospective before and after study | n = 230 | Age (years)- mean (SD) 61.2(11.4) | 12 months | GP, Podiatrist, Diabetes Educator, Dietician, Endocrinologist, Ophthalmologist, Optometrist. | Multidisciplinary care for patients with diabetes was by at least two care providers other than the GP and at least one of these was diabetes related (e.g. Podiatrist, Diabetes Educator, Dietician, Endocrinologist, Ophthalmologist, Optometrist). Diabetes duration (years), mean (SD) was 6.7(6.1) | HbA1c, Blood Pressure, Cholesterol, Weight, |
| Heidemarie Abrahamian (2002), Austria | Individuals with type 2 diabetes | Prospective interventional study | n = 136 | Mean (SD) age (years) at baseline (n = 154) – 69.2 (11.1). Patients completing the study (n = 136) Mean (SD) age (years) 69.1 (11.0) | 12 months | Diabetes Specialist and four General Practitioners | Patients in whom the goals of treatment were not achieved or patients who developed acute complications were introduced by the GPs to the specialist via videoconferencing. The teleconsultations were not intended to exceed 15 min per patient. Diabetes duration (years), mean (SD) was 11.6 (10.7). | HbA1c, Blood Pressure, Cholesterol |
| Rosarie Atkinson (2015), United Kingdom | Type 1 –7 (8%) Type 2- 106 (92%) | A prospective clinical audit | n = 73 | Mean (SD) age (years) 59.15(14.57) Age groups 0–29 years- 2 (2%) 30–49 years- 34 (30%) 50–69 years- 44 (39%) 70 years and above- 33 (29%) | 6 months | Diabetes Specialist nurses, a Diabetologist and a General Practitioner with special interest in diabetes | The components of the diabetes virtual clinic (DVC) were: systematic case identification; a virtual clinic in which cases (n = 15 to 20) were jointly discussed by the GP and DVC teams- to determine clinical and therapeutic needs, self-management needs and the most appropriate care provider; formulation of a management plan; a face-to-face appointment with the most appropriate member of the clinical team to develop an agreed care plan. Duration of diabetes was not reported. | HbA1c, Blood Pressure, Cholesterol, BMI, eGFR, Albumin creatinine ratio |
| Timothy M E Davis (2021), Australia | Individuals with type 2 diabetes | Single-arm intervention study | n = 113 | Mean (SD) age (years) 59.3±12.2 | 27 months | An upskilled GP, diabetes nurse educator and endocrinologist. | Each DCCC participant was assessed by an upskilled GP and a management plan was developed in consultation with an endocrinologist who also reviewed the participant if appropriate. The management plan was then discussed with the patient and the DCCC DNE, and communicated to the participant’s usual GP. Diabetes duration (years) was-10 [45678910111213141516] | HbA1c, Blood Pressure, Cholesterol, BMI |
| Helen Hollern (2011), United Kingdom | Individuals with Type 1 and Type 2 diabetes | Pre and Post study | n = 521 | Not stated | 6 months | Diabetes specialist nurses, specialist podiatrist, specialist dietitian, care technicians, consultant diabetologist, PA/admin support. | GP practice staff and specialist team met in a virtual clinic to discuss individuals and made suggestions to possible changes in treatment or lifestyle. One or more members of the specialist team attended each virtual clinic. Duration of diabetes was not reported. | HbA1c, Weight |
| Umesh Dashora (2011), United Kingdom | Individuals with type 2 diabetes | Pre and Post study | n = 15 | Mean (SD) age (years) 49.5 (22.0) | 6 months | GP, the consultant and the diabetes specialist nurse. | Individuals were jointly seen by the GP, the consultant and the DSN together. Participants were able to discuss their diabetes control with the doctors and have their treatment adjusted. They were referred to other services as required. Duration of diabetes was not reported. | HbA1c |
| Reetu Zarora (2021), Australia | Individuals with type 2 diabetes | Pre and Post study | n = 178 | Mean (SD) age (years) 65±11 | 2.5 years | Endocrinologist, Dietitian, Credentialed diabetes educator, and Podiatrist | A monthly specialist clinic led by an endocrinologist supported by a dietitian and credentialed diabetes educator in the local community health centre involved face-to-face clinical review of patients with Type 2 diabetes requiring specialist advice and weekly dietetic, diabetes educator, group education and foot-screening clinic. Diabetes duration (years) was- 19 (11.0–24.0) | HbA1c, Blood Pressure, Cholesterol, BMI, Weight, eGFR, |
| Gillian Katz (1998), United States | Individuals with Type 1 and Type 2 diabetes | Pre and Post study | n = 36 | Mean (±SD) 54.6 ± 11.2 years. | 12 months | Diabetologist, a bicultural certified diabetes nurse-educator, and a nutritionist, | Referral were made by the primary care physicians. A complete assessment of diabetes knowledge and self-care skills was undertaken by the diabetes nurse-educator and the dietitian provided nutritional counselling. Each patient had a consultation with the diabetologist; a complete medical history was elicited, and a physical examination was performed. Diabetes duration (years), mean (SD) was 11.2(9.9). | HbA1c |
| Claire Jackson (2010), Australia | Individuals with type 2 diabetes | Pre and Post study with control arm | Intervention group (n = 99) and Usual care group (n = 67) | Not stated | 12 months | Endocrinologist, advanced skilled GPs known as ‘clinical fellows’, a credentialed diabetes educator and a podiatrist. | All patients were first assessed by a clinical fellow who examines the patient, interprets the retinal photographs and pathology results, and drafts a management plan and patient priorities. The plan is discussed with the attending endocrinologist, who then co-consults with the patient and clinical fellow together to finalise the approach. Duration of diabetes was not reported. | HbA1c |
| Anthony W. Russell (2013), Australia | Individuals with type 2 diabetes | Prospective open controlled trial | Intervention group (n = 127), Usual care group (n = 121) | Age (years)- mean (SD) Intervention group- 59.4(13.4) years, Usual group- 62.9(11.6) | 12 months | GP Clinical Fellows, a GP training registrar, an endocrinologist, diabetes educator, dietician, psychologist and podiatrist. | At the initial visit, patients underwent a 45-min comprehensive screening and then attended the ICDMS multidisciplinary clinic. The GP Clinical Fellow briefly consulted the endocrinologist to review the management plan and then both co-consulted with the patient to finalise the management approach. Duration of diabetes (years), mean (SD)- Control group 13.7 (10.2), Intervention group 12.8 (9.7) | HbA1c, Blood Pressure, Cholesterol, BMI, eGFR, Serum creatinine |
[i] M- Mean, ICCD- Intermediate care clinics for diabetes, GP- General Practitioner, GPwSIs- General Practitioners with a special interest, ACR- Albumin Creatinine Ratio, DCCC- Diabetes Complex Collaborative Care project, DSN- Diabetes Specialist Nurse, ICDMS- Inala Chronic Disease Management Service, DNE- Diabetes Nurse Educator.
Figure 2
Forest plots for randomised controlled trials clinical outcomes.
The results are expressed in WMD – weighted mean difference with 95% confidence intervals.
Figure 3
Forest plots for pre-post studies clinical outcomes.
The results are expressed in WMD – weighted mean difference with 95% confidence intervals.
Table 2
Pooled analysis of studies across RCTs in the intervention group.
| CLINICAL VARIABLE | NUMBER OF STUDIES | MEAN DIFFERENCE | 95% CONFIDENCE INTERVAL | HETEROGENEITY (I2) |
|---|---|---|---|---|
| HbA1c (%) | 4 | –0.10 | –0.15 to –0.05 | 0% |
| SBP (mmHg) | 4 | –0.99 | –3.50 to 1.15 | 72.3% |
| DBP (mmHg) | 4 | –0.34 | –1.37 to 0.69 | 45.9% |
| Total cholesterol (mmol/L) | 4 | –0.03 | –0.13 to 0.08 | 48% |
Table 3
Pooled analysis of pre-post studies.
| CLINICAL VARIABLE | NUMBER OF STUDIES | MEAN DIFFERENCE | 95% CONFIDENCE INTERVAL | HETEROGENEITY (I2) |
|---|---|---|---|---|
| HbA1c (%) | 10 | –0.77 | –1.12 to –0.42 | 79.6% |
| SBP (mmHg) | 6 | –3.30 | –5.16 to –1.44 | 42.2% |
| DBP (mmHg) | 5 | –3.61 | –4.82 to –2.39 | 38.3% |
| Total cholesterol (mmol/L) | 7 | –0.33 | –0.52 to –0.14 | 77.4% |
| Weight (kg) | 5 | –2.53 | –3.86 to –1.19 | 27.2% |
| Low-density lipoprotein (mmol/L) | 4 | 0.19 | –0.90 to 1.27 | 99.1% |