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Patient diabetes education in the management of adult type 2 diabetes |
Corabian P, Harstall C |
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Authors' objectives The authors' apparent objective was to determine what evidence was available in the published literature about the efficacy and effectiveness of the use of existing patient diabetes education (PDE) programmes, in terms of the long-term patient outcomes, in the management of type 2 diabetes in adults,.
Searching MEDLINE, CINAHL, HealthSTAR, EMBASE, ERIC, PsycINFO, the Cochrane Library, the ISTAHC database, and Dissertation Abstracts were searched for papers published between 1966 and May 2000. The following keywords were used: 'diabetes mellitus', 'diabetes', 'diabetes mellitus, non-insulin-dependent', 'effectiveness', 'impact', 'evaluation', 'outcome assessment (health care)', 'outcome and process assessment (health care)', 'program evaluation', 'health education', 'patient education', 'education', and 'self-care'. The reference lists of all the retrieved papers were examined for additional studies.
Study selection Study designs of evaluations included in the reviewThe inclusion criteria specified reports of primary quantitative studies (controlled or comparative studies), meta-analyses, systematic reviews, or questionnaire-based studies. In addition, the included studies were required to have at least a one-year follow-up component, within which the patients had more than one contact with the programme.
Letters, case reports and case series, and primary quantitative studies with a sample size of less than 15 patients in each arm, were excluded. Only articles published between 1990 and August 1999 were included.
Specific interventions included in the reviewFormalised PDE, with participation in a class, course or session, instructed by at least one dedicated health professional educator, and with a defined curriculum. The included studies had to be of PDE used alone or in combination with treatment. Studies which evaluated the use of professional educational interventions and explored the providers' or educators' perspective on the success of the assessed PDE were excluded. Studies which evaluated multifaceted educational interventions, including both patient and provider interventions, were also excluded.
Participants included in the reviewAdults with type 2 diabetes. Studies that were outpatient-orientated, designed for adults (aged at least 18 years) with type 2 diabetes (may include both type 1 adults and type 2 adults), and were offered to heterogeneous patients in terms of age, gender and race, were eligible for inclusion. Primary quantitative studies, which compared inpatient- versus outpatient-orientated PDE or formalised versus non-formalised PDE, were also included. Studies were excluded if:
they included patients aged under 18 years;
they evaluated the effectiveness of inpatient-orientated PDE;
they evaluated the efficacy of PDE designed and used exclusively for type 1 diabetes, gestational diabetes, secondary diabetes, or impaired glucose tolerance (to prevent type 2 diabetes); and
they used PDEs designed and offered to homogeneous ethnic groups.
Outcomes assessed in the reviewObjective and subjective outcomes. For inclusion, the studies had to report on the impact of PDE for at least one year on at least one objective outcome and at least one subjective outcome (using specific validated instruments or scales).
The objective outcomes included:
physiological and physical outcomes, such as changes in glucose levels, changes in body weight, morbidity, development or prevention of acute or chronic complications, reduction in medication, functional status, and mortality rates; and
utilisation of health care services, such as readmission in hospital, use of emergency room, and physician visits.
The subjective outcomes included:
patient knowledge; self-care behaviour, i.e. compliance with regimen, diet or medication, skills, self-efficacy;
psychosocial outcomes, such as social support and adherence to self-care (anxiety, coping, perceived stress, denial of disease, attitudes and beliefs involving diabetes and education);
overall or diabetes-related quality of life; and
patient satisfaction.
How were decisions on the relevance of primary studies made?The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.
Assessment of study quality The authors state that the included studies were critically appraised, but do not state how this process was conducted. The criteria used in the appraisal process were listed in an appendix.
Data extraction The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction.
Methods of synthesis How were the studies combined?The studies were combined in a narrative summary, with articles grouped by study type.
How were differences between studies investigated?The authors do not state a method for assessing any differences between the studies.
Results of the review Seventeen articles were included. These comprised the following: 3 meta-analyses; 7 primary quantitative studies that met all of the inclusion or exclusion criteria (2,367 participants), of which 3 were randomised controlled trials, one was a non-randomised controlled trial, and 3 were prospective cohort studies; and 7 systematic reviews or critical appraisals of the literature.
In addition, 7 Canadian studies that did not meet the inclusion criteria were summarised.
The reviewed literature showed the following.
The diabetes literature is consistent in its endorsement of the importance of using a PDE approach as a component of diabetes care necessary to promote self-management.
Knowledge about diabetes self-management skills are necessary but are insufficient to ensure good diabetes control in the long-term, in order to prevent or delay complications, reduce mortality and improve the patients' quality of life.
Recent published research suggests that challenging goals for diabetes self-management cannot be achieved until barriers associated with the following are resolved: the patient's characteristics, the patient's social and environmental context, the disease itself, and the patient's interaction with diabetes care and education providers.
The evidence from quantitative research did not enable reliable conclusions to be drawn on whether formal PDE is effective in promoting self-management in the long-term, in order to prevent or delay the associated morbidity and mortality, and improve the patients' quality of life. There was no consistent pattern of effect across outcomes based on the type of intervention, the duration of the educational intervention, core team composition or type of educational setting. In addition, there was no standard method to describe formal PDE programmes, thus making it difficult to replicate studies. The evidence also did not permit conclusive answers on the types of programmes, or which components, were most effective in improving the ability of adults with type 2 diabetes to self-manage their disease in the long-term, or which groups of patients might benefit the most.
Authors' conclusions Quantitative research on the use of formal PDE as a therapeutic tool, to promote self-management in adults with type 2 diabetes, has produced mixed results in terms of improved metabolic control and reduced risks for cardiovascular disease. The long-term diabetes control outcomes of formal PDE, when used to promote self-management in adults with type 2 diabetes, have yet to be established.
Further investigations are needed to determine the types of programmes or components which are most effective in improving the ability of adults with type 2 diabetes to self-manage their disease; or which category of patients might benefit the most. Future research should attempt to overcome the methodological limitations of the studies reviewed.
The findings of the qualitative research studies have given a better understanding of the context in which formal PDE should be applied, to be successful in promoting self-management behaviours in adults with type 2 diabetes.
CRD commentary This review set out to address the effectiveness of a defined type of formal PDE. The authors have exhaustively defined the review question in terms of the intervention, patient population, outcome measures, and study design. However, their reporting of the inclusion and exclusion criteria lacks clarity. The search of the published literature was generally well designed, but was limited to studies published in English or French. In addition, there was no attempt to identify unpublished data and publication bias was not assessed. The potential impact of unpublished data and/or un-retrieved studies on their conclusions should, therefore, be considered. The authors state that the included articles were critically appraised using the criteria reported. However, neither the method of appraisal nor its findings, which were summarised in tabular format, were reported in detail. No formal validated tool was used to assess methodological quality. The findings of this review may, therefore, be vulnerable to un-disclosed biases in the primary studies.
The study designs and participants' characteristics were tabulated in detail in the appendices of the review. The use of a narrative synthesis was appropriate given the apparent heterogeneity of the included studies, and the authors discussed the methodological weaknesses of the primary studies. However, the presentation of the summary was somewhat disjointed: the summaries of the included papers were presented separately from the discussion of methodological quality and the discussion of the issues addressed by PDE research. The absence of firm conclusions regarding the effectiveness of PDE, and the highlighting of the need for further research, were appropriate given the apparent limited quantity and poor quality of publications in the field.
The authors' comments on current practice (addressed to the administrators of PDE programmes), whilst valid in relation to future research, seem to lack supporting evidence at present.
Implications of the review for practice and research Practice: The authors state that the administrators of PDE programmes should be aware that trends in the delivery of PDE suggest a need for an ongoing patient-centred PDE approach. This is described as a step-by-step process, which involves the diabetes care and education providers, the patients and their care givers. The trends call for the following.
An assessment of the patient's bio-psycho-social barriers, goal setting according to the assessment, educational interventions, follow-up and reassessment.
A focus on meeting the patient's needs and overcoming the patient's barriers to self-management behaviour, and continuous reinforcement of the patient's positive behaviours.
The development of a trustful patient-educator relationship and the existence of a good partnership with other members of the diabetes management team.
The measurement of success in terms of long-term outcomes, such as a reduced diabetes-associated morbidity and mortality, and an increased quality of life.
The measurement of benefits in terms of short-term outcomes that act as stepping stones to the desired long-term outcomes. These outcomes include improved metabolic control, weight loss, maintained positive behavioural changes, and a decreased number of barriers to self-management. The data for each outcome should be collected using a more standardised set of validated instruments.
Research: The authors state that further investigations are needed to determine the types of programmes, or which components, are most effective in improving the ability of adults with type 2 diabetes to self-manage their disease, or which category of patients might benefit the most. Future research should also attempt to overcome the methodological limitations of the studies reviewed.
Bibliographic details Corabian P, Harstall C. Patient diabetes education in the management of adult type 2 diabetes. Edmonton, AB, Canada: Alberta Heritage Foundation for Medical Research. Health Technology Assessment; 23 Series A. 2001 Indexing Status Subject indexing assigned by CRD MeSH Diabetes Mellitus, Type 2; Patient Education as Topic AccessionNumber 12001008230 Date bibliographic record published 31/07/2002 Date abstract record published 31/07/2002 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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