Organization of Diabetes Care

Abstract

Key Messages•Diabetes care should be organized around the person living with diabetes who is practising self-management and is supported by a proactive, interprofessional team with specific training in diabetes.•Diabetes care should be delivered using as many elements as possible of the chronic care model.•The following strategies have the best evidence for improved outcomes and should be used: promotion of self-management, including self-management support and education; interprofessional team-based care with expansion of professional roles, in cooperation with the collaborating physician, to include monitoring or medication adjustment and disease (case) management, including patient education, coaching, treatment adjustment, monitoring and care coordination.•Diabetes care should be structured, evidence based and supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback. •Diabetes care should be organized around the person living with diabetes who is practising self-management and is supported by a proactive, interprofessional team with specific training in diabetes.•Diabetes care should be delivered using as many elements as possible of the chronic care model.•The following strategies have the best evidence for improved outcomes and should be used: promotion of self-management, including self-management support and education; interprofessional team-based care with expansion of professional roles, in cooperation with the collaborating physician, to include monitoring or medication adjustment and disease (case) management, including patient education, coaching, treatment adjustment, monitoring and care coordination.•Diabetes care should be structured, evidence based and supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback. Helpful Hints Box: Organization of CareRecognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes.Register: Develop a registry for all of your patients with diabetes.Resource: Support self-management through the use of interprofessional teams which could include the primary care provider, diabetes educator, dietitian, nurse, pharmacist and other specialists.Relay: Facilitate information sharing between the person with diabetes and the team for coordinated care and timely management changes.Recall: Develop a system to remind your patients and caregivers of timely review and reassessment. Recognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes. Register: Develop a registry for all of your patients with diabetes. Resource: Support self-management through the use of interprofessional teams which could include the primary care provider, diabetes educator, dietitian, nurse, pharmacist and other specialists. Relay: Facilitate information sharing between the person with diabetes and the team for coordinated care and timely management changes. Recall: Develop a system to remind your patients and caregivers of timely review and reassessment. In Canada, there is a care gap between the clinical goals outlined in evidence-based guidelines for diabetes management and real-life clinical practice (1Harris S.B. Ekoé J.-M. Zdanowicz Y. et al.Glycemic control and morbidity in the Canadian primary care setting (results of the Diabetes in Canada Evaluation Study).Diabetes Res Clin Pract. 2005; 70: 90-97Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar, 2Braga M. Casanova A. Teoh H. et al.Treatment gaps in the management of cardiovascular risk factors in patients with type 2 diabetes in Canada.Can J Cardiol. 2010; 26: 297-302Abstract Full Text PDF PubMed Scopus (69) Google Scholar). Since almost 80% of the care of people with diabetes takes place in the primary care setting, there has been a shift toward delivering diabetes care in the primary care setting using the chronic care model (CCM) (3Jaakkimainen L. Shah B. Kopp A. Sources of physician care for people with diabetes.in: Diabetes in Ontario: An ICES Practice Atlas. 6. Institute for Clinical Evaluative Sciences, Toronto, ON2003: 161-192Google Scholar, 4Jaana M. Pare G. Home telemonitoring of patients with diabetes: a systematic assessment of observed effects.J Eval Clin Pract. 2007; 13: 242-253Crossref PubMed Scopus (130) Google Scholar, 5Borgermans L. Goderis G. Van Den Broeke C. et al.Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project.BMC Health Serv Res. 2009; 9: 179Crossref PubMed Scopus (44) Google Scholar). The CCM is an organizational approach as well as a quality improvement (QI) strategy in caring for people with chronic diseases, the elements of which are evidence based. These elements facilitate planning and coordination among providers while helping patients play an informed role in managing their own care (6Coleman K. Austin B. Brach C. Wagner E.H. Evidence on the chronic care model in the new millennium.Health Affairs. 2009; 28: 75-85Crossref Scopus (1076) Google Scholar). Previous recommendations in this chapter, in 2008, focused on the daily commitment of the individual with diabetes to self-management, with the support of the interprofessional diabetes healthcare team. Although these are still critical elements of diabetes care, increasing evidence suggests that the CCM, which includes elements beyond the patient and healthcare provider, provides a framework for the optimal care of persons with diabetes (6Coleman K. Austin B. Brach C. Wagner E.H. Evidence on the chronic care model in the new millennium.Health Affairs. 2009; 28: 75-85Crossref Scopus (1076) Google Scholar, 7Wagner E.H. Austin B.T. Von Korff M. Organizing care for patients with chronic illness.Milbank Q. 1996; 74: 511-544Crossref PubMed Scopus (2143) Google Scholar, 8Renders C.M. Valk G.D. Griffin S. et al.Interventions to improve the management of diabetes mellitus in primary care, outpatient, and community settings.Cochrane Database Syst Rev. 2001; 1: CD001481PubMed Google Scholar). This chapter has been revised to reflect the importance of the CCM design, delivery and organization of diabetes care. Despite the use of new terminology (Table 1), many of the previous recommendations have remained the same but have been reorganized to fall under specific components of the CCM and broadened to include elements such as the health system and the community (9Barr V.J. Robinson S. Marin-Link B. Underhill L. et al.The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model.Hosp Q. 2003; 7: 73-80PubMed Google Scholar). This is intended to assist the readers in increasing their understanding and use of the CCM framework in their daily practice.Table 1Definition of terms 9Barr V.J. Robinson S. Marin-Link B. Underhill L. et al.The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model.Hosp Q. 2003; 7: 73-80PubMed Google Scholar, 10Shojania K.G. Ranjii S.R. McDonald K.M. et al.Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.JAMA. 2006; 296: 427-440Crossref PubMed Scopus (568) Google Scholar, 11Improving Chronic Illness Care. Available at: http://www.improvingchroniccare.org/index.php?p=ACIC_Survey&s=35. Accessed February 24, 2013.Google Scholar, 12Tricco A.C. Ivers N.M. Grimshaw J.M. et al.Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.Lancet. 2012; : 12-21PubMed Google ScholarTerminology Chronic care model (CCM)The CCM is an organizational approach to caring for people with chronic diseases as well as a quality improvement strategy, the elements of which are evidence based. These elements facilitate planning and coordination among providers while helping patients play an informed role in managing their own care. This model has evolved from the original Wagner CCM (1999) to the expanded care model 9Barr V.J. Robinson S. Marin-Link B. Underhill L. et al.The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model.Hosp Q. 2003; 7: 73-80PubMed Google Scholar. Elements of CCM1)Delivery systems designs2)Self-management support3)Decision support4)Clinical information5)The community6)Health systems Primary careFirst contact and ongoing healthcare: family physicians, general practitioners and nurse practitioners Shared careJoint participation of primary care physicians and specialty care physicians in the planned delivery of care, informed by an enhanced information exchange over and above routine discharge and referral noticesCan also refer to the sharing of responsibility for care between the patient and provider or teamQuality Improvement Strategies Audit and feedbackSummary of provider or group performance on clinical or process indicators delivered to clinicians to increase awareness of performance Clinical information systemsThe part of an information system that helps organize patient and population data to facilitate efficient and effective care.May provide timely reminders for providers and patients, identify relevant subpopulations for proactive care, facilitate individual patient care planning, and share information with patients and providers to coordinate care or monitor performance of practice team and care system. Clinician remindersPaper-based or electronic system to prompt healthcare professionals to recall patient-specific information (e.g. A1C) or do a specific task (e.g. foot exam) CollaborationA collaborative intervention is a method used to help healthcare organizations apply continuous quality improvement techniques and affect organizational change. Continuous quality improvementTechniques for examining and measuring clinical processes, designing interventions, testing their impacts and then assessing the need for further improvement Decision supportIntegration of evidence-based guidelines into the flow of clinical practice Disease (case) managementA structured, multifaceted intervention that supports the practitioner/patient relationship and plan of care; emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategiesMay include education, coaching, treatment adjustment, monitoring and care coordination, often by a nurse, pharmacist or dietitian Facilitated relay of information to clinicianClinical information collected from patients and sent to clinicians, other than the existing medical record (e.g. pharmacist sending SMBG results) Patient registryA list of patients sharing a common characteristic, such as a diabetes registryMay be paper based but increasingly is electronic, ranging from a simple spreadsheet to one embedded in an electronic health record Patient remindersAny effort to remind patients about upcoming appointments or aspects of self-care (e.g. glucose monitoring) Self-management education (SME)A systematic intervention that involves active patient participation in self-monitoring (physiological processes) and/or decision making (managing) (see Self-Management Education chapter, p. S26) Self-management supportIn addition to SME strategies that enhance patients’ ability to manage their condition, including internal and community resources, such as disease management with patient reminders, monitoring and linage to self-management support/interest groups Team changesChanges to the structure of a primary healthcare team, such as:•Adding a team member or shared care, such as a physician, nurse specialist or pharmacist•Using an interdisciplinary team in primary routine management•Expansion of professional role (e.g. nurse or pharmacist has a more active role in monitoring or adjusting medications)Other Terms Lay leaderTrained and accredited non-healthcare professional delivering a program that adopts a philosophy of self-management rather than the medical model TelehealthDelivery of health-related services and information via telecommunications technologyA1C, glycated hemoglobin; SMBG, self-monitoring of blood glucose. Open table in a new tab A1C, glycated hemoglobin; SMBG, self-monitoring of blood glucose. In many ways, diabetes care has been the prototype for the CCM (Figure 1). Developed in the late 1990s, this model aims to transform the care of patients with chronic illnesses from acute and reactive to proactive, planned and population based. This model has been adopted by many countries as well as several provinces in Canada (13Health Canada Council. Progress Report 2011: Health care renewal in Canada. May 2011. Available at: http://www.healthcouncilcanada.ca/tree/2.45-2011Progress_ENG.pdf. Accessed February 24, 2013.Google Scholar). Early studies showed that the following interventions improved care in the chronically ill: educating and supporting the patient, team-based care, increasing the healthcare provider’s skills and use of registry-based information systems (7Wagner E.H. Austin B.T. Von Korff M. Organizing care for patients with chronic illness.Milbank Q. 1996; 74: 511-544Crossref PubMed Scopus (2143) Google Scholar, 8Renders C.M. Valk G.D. Griffin S. et al.Interventions to improve the management of diabetes mellitus in primary care, outpatient, and community settings.Cochrane Database Syst Rev. 2001; 1: CD001481PubMed Google Scholar, 10Shojania K.G. Ranjii S.R. McDonald K.M. et al.Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.JAMA. 2006; 296: 427-440Crossref PubMed Scopus (568) Google Scholar). The current CCM has expanded on this evidence to include the following 6 elements that work together to strengthen the provider-patient relationship and improve health outcomes: 1) delivery systems design, 2) self-management support, 3) decision support, 4) clinical information systems, 5) the community, and 6) health systems. A recent systematic review found that primary care practices were able to successfully implement the CCM (6Coleman K. Austin B. Brach C. Wagner E.H. Evidence on the chronic care model in the new millennium.Health Affairs. 2009; 28: 75-85Crossref Scopus (1076) Google Scholar). Furthermore, incorporating most or all of the CCM elements has been associated with improved quality of care and disease outcomes in patients with various chronic illnesses, including diabetes (6Coleman K. Austin B. Brach C. Wagner E.H. Evidence on the chronic care model in the new millennium.Health Affairs. 2009; 28: 75-85Crossref Scopus (1076) Google Scholar, 8Renders C.M. Valk G.D. Griffin S. et al.Interventions to improve the management of diabetes mellitus in primary care, outpatient, and community settings.Cochrane Database Syst Rev. 2001; 1: CD001481PubMed Google Scholar, 10Shojania K.G. Ranjii S.R. McDonald K.M. et al.Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.JAMA. 2006; 296: 427-440Crossref PubMed Scopus (568) Google Scholar, 14Minkman M. Kees A. Robbert H. Performance improvement based on integrated quality management models: what evidence do we have? A systematic literature review.Int J Qual Health Care. 2007; 19: 90-104Crossref PubMed Scopus (101) Google Scholar, 15Piatt G.A. Orchard T.J. Emerson S. et al.Translating the chronic care model into the community.Diabetes Care. 2006; 29: 811-817Crossref PubMed Scopus (206) Google Scholar, 16Gabbay R.A. Bailit M.H. Mauger D.T. et al.Multipayer patient-centered medical home implementation guided by the chronic care model.Jt Comm J Qual Patient Saf. 2011; 37: 265-273PubMed Scopus (83) Google Scholar). A recent systematic review and meta-analysis of QI strategies on the management of diabetes concluded that interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving care. Although some of the improvements were modest, it may be that, when the QI components are used together, there is a synergistic effect as noted in the above studies (12Tricco A.C. Ivers N.M. Grimshaw J.M. et al.Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.Lancet. 2012; : 12-21PubMed Google Scholar). Initial analyses of CCM interventions for improving diabetes care suggested that a multifaceted intervention was the key to QI (8Renders C.M. Valk G.D. Griffin S. et al.Interventions to improve the management of diabetes mellitus in primary care, outpatient, and community settings.Cochrane Database Syst Rev. 2001; 1: CD001481PubMed Google Scholar, 15Piatt G.A. Orchard T.J. Emerson S. et al.Translating the chronic care model into the community.Diabetes Care. 2006; 29: 811-817Crossref PubMed Scopus (206) Google Scholar, 17Bodenheimer T. Wagner E.H. Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2.JAMA. 2002; 288: 1909-1914Crossref PubMed Scopus (1635) Google Scholar). Organizations that provided diabetes care in accordance with the CCM provided better quality care than did organizations that were less likely to use elements of this model (18Fleming B. Silver A. Ocepek-Welikson K. et al.The relationship between organizational systems and clinical quality in diabetes care.Am J Manag Care. 2004; 10: 934-944PubMed Google Scholar). Furthermore, the degree to which care delivered in a primary care setting conforms to the CCM has been shown to be an important predictor of the 10-year risk of coronary heart disease (CHD) in patients with type 2 diabetes (19Parchman M.L. Zeber J.E. Romero R.R. et al.Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: a STARNet study.Med Care. 2007; 45: 1129-1134Crossref PubMed Scopus (61) Google Scholar). Initially, it appeared as if only process outcomes, such as behaviours of patients and caregivers, are improved with the CCM; however, with longer-term use of the model in clinical practice, improvements in clinical outcomes also are noted, such as reductions in glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C) levels (20Chin M.H. Drum M.L. Guillen M. et al.Improving and sustaining diabetes care in community health centers with the health disparities collaboratives.Med Care. 2007; 45: 1135-1143Crossref PubMed Scopus (106) Google Scholar). A large, 2-arm, cluster-randomized, QI trial, using all 6 dimensions of the CCM, found significant improvements in A1C and LDL-C and an increase in the use of statins and antiplatelet therapy among patients with diabetes (5Borgermans L. Goderis G. Van Den Broeke C. et al.Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project.BMC Health Serv Res. 2009; 9: 179Crossref PubMed Scopus (44) Google Scholar). A recent meta-analysis of randomized controlled trials (RCTs) assessing the effectiveness of disease management programs for improving glycemic control found significant reductions in A1C with programs that included the fundamental elements of the CCM (21Pimouguet C. Le G.M. Thiebaut R. et al.Effectiveness of disease-management programs for improving diabetes care: a meta-analysis.CMAJ. 2011; 183: e115-e127Crossref PubMed Scopus (165) Google Scholar). Other trials found that use of the CCM improved cardiovascular (CV) risk factors in patients with diabetes (19Parchman M.L. Zeber J.E. Romero R.R. et al.Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: a STARNet study.Med Care. 2007; 45: 1129-1134Crossref PubMed Scopus (61) Google Scholar, 22Vargas R.B. Mangione C.M. Asch S. et al.Can a chronic care model collaborative reduce heart disease risk in patients with diabetes.J Gen Intern Med. 2007; 22: 215-222Crossref PubMed Scopus (82) Google Scholar). One large-scale analysis of a nationwide disease management program using the CCM and based in primary care reduced overall mortality as well as drug and hospital costs (23Stock S. Drabik A. Buscher G. et al.German diabetes management programs improve quality of care and curb costs.Health Affairs. 2010; 29: 2197-2205Crossref PubMed Scopus (100) Google Scholar). The Assessment of Chronic Illness Care (ACIC) is a practical assessment as well as a research tool. It can help teams strategically involve themselves in a structured way to assess and identify gaps to develop into a more robust CCM (11Improving Chronic Illness Care. Available at: http://www.improvingchroniccare.org/index.php?p=ACIC_Survey&s=35. Accessed February 24, 2013.Google Scholar). Current evidence continues to support the importance of a multi- and interprofessional team with specific training in diabetes within the primary care setting (10Shojania K.G. Ranjii S.R. McDonald K.M. et al.Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.JAMA. 2006; 296: 427-440Crossref PubMed Scopus (568) Google Scholar, 12Tricco A.C. Ivers N.M. Grimshaw J.M. et al.Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.Lancet. 2012; : 12-21PubMed Google Scholar, 21Pimouguet C. Le G.M. Thiebaut R. et al.Effectiveness of disease-management programs for improving diabetes care: a meta-analysis.CMAJ. 2011; 183: e115-e127Crossref PubMed Scopus (165) Google Scholar). The team should work collaboratively with the primary care provider who, in turn, should be supported by a diabetes specialist. Specialist support may be direct or indirect through shared care, an interdisciplinary team member or educational support (5Borgermans L. Goderis G. Van Den Broeke C. et al.Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project.BMC Health Serv Res. 2009; 9: 179Crossref PubMed Scopus (44) Google Scholar, 12Tricco A.C. Ivers N.M. Grimshaw J.M. et al.Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.Lancet. 2012; : 12-21PubMed Google Scholar). In adults with type 2 diabetes, this care model has been associated with improvements in A1C, blood pressure (BP), lipids and care processes compared to care that is delivered by a specialist or primary care physician alone (5Borgermans L. Goderis G. Van Den Broeke C. et al.Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project.BMC Health Serv Res. 2009; 9: 179Crossref PubMed Scopus (44) Google Scholar, 24vanBruggen R. Gorter K. Stolk R. et al.Clinical inertia in general practice: widespread and related to the outcome of diabetes care.Fam Pract. 2009; 26: 428-436Crossref PubMed Scopus (73) Google Scholar, 25Davidson M.B. Blanco-Castellanos M. Duran P. Integrating nurse-directed diabetes management into a primary care setting.Am J Manag Care. 2010; 16: 652-656PubMed Google Scholar, 26Saxena S. Misra T. Car J. et al.Systematic review of primary healthcare interventions to improve diabetes outcomes in minority ethnic groups.J Ambul Care Manage. 2007; 30: 218-230Crossref PubMed Scopus (29) Google Scholar, 27Willens D. Cripps R. Wilson A. et al.Interdisciplinary team care for diabetic patients by primary care physicians, advanced practice nurses and clinical Pharmacists.Clin Diabetes. 2011; 29: 60-68Crossref Scopus (60) Google Scholar). A reduction in preventable, diabetes-related emergency room visits also has been noted when the team includes a specifically trained nurse who follows detailed treatment algorithms for diabetes care (25Davidson M.B. Blanco-Castellanos M. Duran P. Integrating nurse-directed diabetes management into a primary care setting.Am J Manag Care. 2010; 16: 652-656PubMed Google Scholar). In Canada, observational data from primary care networks, whose approach is to improve access and coordinate care, suggest that patients who are part of these interdisciplinary teams have better outcomes and fewer hospital visits than patients who are not (28Manns B.J. Tonelli M. Zhang J. et al.Enrolment in primary care networks: impact on outcomes and processes of care for patients with diabetes.CMAJ. 2012; 184: e144-e152Crossref PubMed Scopus (59) Google Scholar). Team membership may be extensive and should include various disciplines. Those disciplines associated with improved diabetes outcomes include nurses, nurse practitioners, dietitians, pharmacists and providers of psychological support. Nurses have always been, and continue to be, core members of the team. A systematic review (26Saxena S. Misra T. Car J. et al.Systematic review of primary healthcare interventions to improve diabetes outcomes in minority ethnic groups.J Ambul Care Manage. 2007; 30: 218-230Crossref PubMed Scopus (29) Google Scholar) and recent meta-analysis (29Welch G. Garb J. Zagarins S. et al.Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis.Diabetes Res Clin Pract. 2010; 88: 1-6Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar) found that case management led by specialist nurses or dietitians improved both glycemic control and CV risk factors. Another study found improved BP outcomes with nurse-led interventions vs. usual care, particularly when nurses followed algorithms and were able to prescribe (30Clark C.E. Smith L.F.P. Taylor R.S. et al.Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis.Diabet Med. 2011; 28: 250-261PubMed Google Scholar). In addition, a large RCT found that nurse-led, guideline-based, collaborative care management was associated with improvements in A1C, lipids, BP and depression in patients with depression and type 2 diabetes and/or CHD (31Katon W.J. Collaborative care for patients with depression and chronic disease.N Engl J Med. 2010; 363: 2611-2620Crossref PubMed Scopus (1139) Google Scholar). Practices with nurse practitioners also were found to have better diabetes process outcomes than those with physicians alone or those employing only physician assistants (32Ohman-Strickland P.A. Orzano A.J. Hudson S.V. et al.Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants.Ann Fam Med. 2008; 6: 14-22Crossref PubMed Scopus (91) Google Scholar). Small-group or individualized nutrition counselling by a registered dietitian with expertise in diabetes management is another important element of team-based care. A variety of individual and community healthcare support systems, particularly psychological support, can also improve glycemic control (33Ismail K. Winkley K. Rabe-Hesketh S. Systemic review and meta-analysis of randomized controlled trial of psychological interventions to improve glycaemic control in patients with type 2 diabetes.Lancet. 2004; 363: 1589-1597Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar). Recent meta-analyses involving people with both type 1 and type 2 diabetes showed a significant 0.76% drop in A1C (34Collins C. Limone B.L. Scholle J.M. et al.Effect of pharmacist interventions on glycemic control in diabetes.Diabetes Res Clin Pract. 2011; 92: 145-152Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar) as well as improved adherence and quality of life (QOL) and reductions in adverse drug reactions and LDL-C with collaborative pharmacist intervention (35Chisholm-Burns M.A. Kim Lee J. Spivey C.A. et al.U.S. pharmacists’ effect as team members on patient care: systematic review and meta-analyses.Med Care. 2010; 48: 923-933Crossref PubMed Scopus (591) Google Scholar). A Canadian randomized trial that added a pharmacist to primary care teams showed a significant reduction in BP for people with type 2 diabetes (36Simpson S.H. Majumdar S.R. Tsuyuki R.T. et al.Effect of adding pharmacists to primary care teams on blood pressure control in patients with type 2 diabetes: a randomized controlled trial (ISRCTN97121854).Diabetes Care. 2010; (Available at:) (Accessed February 24, 2013)http://care.diabetesjournals.org/content/early/2010/10/05/dc10-1294.full.pdf+htmlPubMed Google Scholar). Therefore, pharmacists can play a key role in diabetes management, beyond that of dispensing medications. Flexibility in the operation of the team is important. Team changes, such as adding a team member, active participation of professionals from more than one discipline and role expansion, have been associated with improved clinical outcomes (10Shojania K.G. Ranjii S.R. McDonald K.M. et al.Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.JAMA. 2006; 296: 427-440Crossref PubMed Scopus (568) Google Scholar, 12Tricco A.C. Ivers N.M. Grimshaw J.M. et al.Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.Lancet. 2012; : 12-21PubMed Google Scholar, 21Pimouguet C. Le G.M. Thiebaut R. et al.Effectiveness of disease-management programs for improving diabetes care: a meta-analysis.CMAJ. 2011; 183: e115-e127Crossref PubMed Scopus (165) Google Scholar). The greatest body o