Cluster randomised controlled trial of a theory-based multiple behaviour change intervention aimed at healthcare professionals to improve their management of Type 2 diabetes in primary care

Justin Presseau, Joan Mackintosh, Gillian Hawthorne, Jill J. Francis, Marie Johnston, Jeremy M. Grimshaw, Nick Steen, Tom Coulthard, Heather Brown, Eileen Kaner, Marko Elovainio, Falko F. Sniehotta

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Background: National diabetes audits in the UK show room for improvement in the quality of care delivered to people with Type 2 diabetes in primary care. Systematic reviews of quality improvement interventions show that such approaches can be effective but there is wide variability between trials and little understanding concerning what explains this variability. A national cohort study of primary care across 99 UK practices identified modifiable predictors of healthcare professionals’ prescribing, advising and foot examination.

Our objective was to evaluate the effectiveness of an implementation intervention to improve six guideline-recommended health professional behaviours in managing Type 2 diabetes in primary care: prescribing for blood pressure and glycaemic control, providing physical activity and nutrition advice, providing updated diabetes education and foot examination.

Methods: Two-armed cluster randomised trial involving 44 general practices. Primary outcomes (at 12 months follow-up): from electronic medical records, proportion of patients receiving additional prescriptions for blood pressure and insulin initiation for glycaemic control, and having a foot examination; from a patient survey of random sample of 100 patients per practice, reported receipt of updated diabetes education, and physical activity and nutrition advice and education.

Results: The implementation intervention did not lead to statistically significant improvement on any of the six clinical behaviours. 1,138,105 prescriptions were assessed. Intervention (29% to 37% patients) and control arms (31% to 35%) increased insulin initiation relative to baseline but were not statistically significantly different at follow-up (IRR: 1.18, 95%CI 0.95-1.48). Intervention (45% to 53%) and control practices (45% to 50%) increased blood pressure prescription from baseline to follow-up, but were not statistically significantly different at follow-up (IRR: 1.05, 95%CI 0.96 to 1.16). Intervention (75% to 78%) and control practices (74% to 79%) increased foot examination relative to baseline; control practices increased statistically significantly more (OR: 0.84, 95%CI 0.75-0.94). Fewer patients in intervention (33%) than control practices (40%) reported receiving updated diabetes education (OR=0.74, 95%CI 0.57-0.97). No statistically significant differences were observed in patient reports of having had a discussion about nutrition (Intervention=73%; Control=72%; OR=0.98, 95%CI 0.59-1.64) or physical activity (Intervention=57%; Control=62%; OR=0.79, 95%CI 0.56-1.11). Development and delivery of the intervention cost £1191 per practice.

Conclusions: There was no measurable benefit to practices’ participation in this intervention. Despite widespread use of outreach interventions worldwide, there is a need to better understand which techniques at which intensity are optimally suited to the address multiple clinical behaviours involved in improved care for Type 2 diabetes
Original languageEnglish
Article number65
Pages (from-to)1-10
Number of pages10
JournalImplementation Science
Publication statusPublished - 2 May 2018

Bibliographical note

We would like to thank Professor Martin Eccles for the advice throughout, Mrs. Margaret Hunter, MBE, for providing a patient voice in the design of the trial and the development of the intervention and materials, and the intervention deliverers (Dr. Darren Flynn, Dr. Leah Avery, Dr. Keegan Knittle, Jill Ducker, Dr. Tim Carney, and Lou Shearer). We are grateful to all the members of the Newcastle upon Tyne Diabetes Support Group for their contribution and feedback throughout the development of the project. Trial results were presented by JP at the 2016 International Congress of Behavioral Medicine. The authors confirm that no conflicts of interest exist.

Diabetes UK (11/0004367). The funder did not play any role in the design or data collection, analysis, interpretation, or in writing the report or submitting the manuscript for publication. Researchers are independent of the funder.


  • Diabetes
  • Health Care Professional
  • Behaviour Change
  • Primary Care
  • Cluster randomized trial
  • Blood pressure
  • HbA1c
  • Lifestyle advice
  • Foot examination
  • Theory
  • Multiple Behaviours


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