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Impact of a comprehensive guideline dissemination strategy on diabetes diagnostic test rates: an interrupted time series


Background — Diabetes Canada launched a comprehensive Dissemination and Implementation (D&I) strategy to optimize uptake of their 2013 Clinical Practice Guidelines; the strategy involved continuing professional development courses, webinars, an interactive website, applications for mobile devices, point-of-care decision support tools, and media awareness campaigns. It included a focus on promoting HbA1c as the recommended diagnostic test for diabetes.

Objective — To determine the impact of Diabetes Canada’s 2013 D&I strategy on physician test-ordering behavior, specifically HbA1c testing, for the diagnosis of diabetes, using provincial healthcare administrative data.

Design — Population-based interrupted time series.

Setting — Ontario, Canada.

Participants — Ontario residents aged 40–79 not previously diagnosed with diabetes.

Measurements — For each quarter between January 2005 and December 2014, we conducted an interrupted time series analysis on the first-order difference of the proportion of patients receiving HbA1c tests per quarter with an autoregressive integrated moving average model with the intervention step occurring in quarter 2 of 2013. Subgroup analyses by rurality, physician graduation year, and practice size were also conducted.

Results — There were 32 quarters pre-intervention and 6 post-intervention; average sample size per quarter was 5,298,686 individuals. Pre-intervention, the quarter-to-quarter growth was 1.51 HbA1c tests per quarter per 1000 people. Post-intervention, the quarter-to-quarter growth increased by 8.45 tests per 1000 people (p < 0.005). Growth of HbA1c ordering differed significantly by region, years since physician graduation, and practice size.

Limitations — Incomplete data collection, inadequate stratification, and other unidentified confounders.

Conclusion — The D&I strategy resulted in a significant increase in the growth of HbA1c tests. The successful uptake of this recommendation may be due to its simplicity; guideline developers should consider this when drafting recommendations. Furthermore, differential uptake by user groups suggests that future strategies should include targeted barrier analysis and interventions to these groups.



Nichols J, Shah BR, Pequeno  P, Gall Casey C, Yu CH. J Gen Intern Med. 2020; 35(9):2662-7. Epub 2020 Mar 10.

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