Assessing the influence of health systems on Type 2 Diabetes Mellitus awareness, treatment, adherence, and control: A systematic review

Background
Type 2 Diabetes Mellitus (T2DM) is reported to affect one in 11 adults worldwide, with over 80% of T2DM patients residing in low-to-middle-income countries. Health systems play an integral role in responding to this increasing global prevalence, and are key to ensuring effective diabetes management. We conducted a systematic review to examine the health system-level factors influencing T2DM awareness, treatment, adherence, and control.
Methods and findings
A protocol for this study was published on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016048185). Studies included in this review reported the effects of health systems factors, interventions, policies, or programmes on T2DM control, awareness, treatment, and adherence. The following databases were searched on 22 February 2017: Medline, Embase, Global health, LILACS, Africa-Wide, IMSEAR, IMEMR, and WPRIM. There were no restrictions on date, language, or study designs. Two reviewers independently screened studies for eligibility, extracted the data, and screened for risk of bias. Thereafter, we performed a narrative synthesis. A meta-analysis was not conducted due to methodological heterogeneity across different aspects of included studies. 93 studies were included for qualitative synthesis; 7 were conducted in LMICs. Through this review, we found two key health system barriers to effective T2DM care and management: financial constraints faced by the patient and limited access to health services and medication. We also found three health system factors that facilitate effective T2DM care and management: the use of innovative care models, increased pharmacist involvement in care delivery, and education programmes led by healthcare professionals.
Conclusions
This review points to the importance of reducing, or possibly eliminating, out-of-pocket costs for diabetes medication and self-monitoring supplies. It also points to the potential of adopting more innovative and integrated models of care, and the value of task-sharing of care with pharmacists. More studies which identify the effect of health system arrangements on various outcomes, particularly awareness, are needed.

研究背景
2型糖尿病（Type 2 Diabetes Mellitus, T2DM）据报道影响全球每11名成年人中就有1名患病，其中超80%的2型糖尿病患者生活在中低收入国家。医疗体系在应对这一日益攀升的全球患病率方面发挥着不可或缺的作用，亦是保障糖尿病有效管理的核心关键。本研究开展了一项系统综述，旨在探讨影响2型糖尿病知晓率、治疗、依从性及血糖控制的医疗体系层面相关因素。

研究方法与结果
本研究的方案已发表于系统综述国际前瞻性注册平台PROSPERO（PROSPERO 2016: CRD42016048185）。本次综述纳入的研究均探讨了医疗体系相关因素、干预措施、政策或项目对2型糖尿病（T2DM）控制、知晓、治疗及依从性的影响。2017年2月22日，我们检索了以下数据库：Medline、Embase、Global health、LILACS、Africa-Wide、IMSEAR、IMEMR及WPRIM。检索未对发表日期、语言及研究设计设置任何限制。由两名评价员独立筛选符合纳入标准的研究、提取数据并评估偏倚风险。随后，我们开展了叙述性合成。由于纳入研究在多个维度存在方法学异质性，故未进行Meta分析。共计93项研究被纳入定性合成，其中7项研究在中低收入国家（low-to-middle-income countries, LMIC）开展。
通过本次综述，我们明确了两大阻碍2型糖尿病有效诊疗与管理的核心医疗体系障碍：患者面临的经济负担以及医疗服务与药物可及性不足。同时也识别出三大可促进2型糖尿病有效诊疗与管理的医疗体系相关因素：采用创新型诊疗模式、提升药师在诊疗服务中的参与度，以及由医护人员主导的健康教育项目。

研究结论
本综述凸显了降低乃至取消糖尿病药物与自我监测耗材自付费用的重要性。同时也证实了采用更具创新性与整合性的诊疗模式的潜力，以及与药师共享诊疗任务的实践价值。未来仍需开展更多研究，以明确医疗体系安排对各类结局指标（尤其是疾病知晓情况）的影响。