Group based training for self-management strategies in people with type 2 diabetes mellitus

Effectiveness of the Austrian disease-management-programme for type 2 diabetes: study protocol of a cluster-randomized controlled trial

Background

Due to its rising prevalence type 2 diabetes plays an important role concerning population health in Austria and other western countries. In various studies deficiencies in the care of diabetic patients have been revealed. These deficiencies may be overcome by disease-management-programmes (DMPs), but international experience shows that the effectiveness of DMPs is inconsistent. In particular large programmes designed by state-affiliated public health insurances have not been evaluated in randomized controlled trials (RCTs). We are therefore conducting a large scale RCT of the Austrian DMP for type 2 diabetic patients in the province of Salzburg to evaluate the programme regarding its effects on metabolic control, guideline adherent care and the quality of life of diabetic patients.

Methods/Design

The study is open for participation to all GPs and internists in the province of Salzburg. Physicians are randomized before recruitment of patients with the districts of Salzburg as clusters of randomisation. A total of over 1200 patients with type 2 diabetes will then be recruited. In the intervention group the DMP is applied for one year. Controls receive usual care. Endpoints are a decrease in HbA1c in the intervention group > 0,5% compared to controls, a higher percentage of patients with required diagnostic measures according to guidelines, improved cardiovascular risk profile and higher quality of life scores within one year.

Current status of the study

98 Physicians agreed to participate in the study. 96 of them recruited 1494 patients, 654 in the intervention and 840 in the control group.

Trail Registration

This trial has been registered with Current Controlled Trials Ltd. (ISRCTN27414162).

Chronic disease management: a primer for physicians

Approximately one in three Australians or 6.8 million individuals suffer from one or more chronic diseases, the most prevalent being ischaemic heart disease, congestive heart failure, chronic obstructive lung disease, diabetes and renal disease. Potentially avoidable hospitalizations related to chronic disease comprise 5.5% of all admissions nationally and cluster in older age groups and socioeconomically disadvantaged regions. In an effort to reduce mortality and morbidity, programmes of chronic disease management have evolved with the aim of achieving formalized, population-wide implementation of elements of the chronic care model developed by Wagner et al. Results of rigorous evaluations of such programmes suggest improved survival and/or disease control with reductions in hospitalizations and adverse clinical events. This paper aims to provide an overview of available evidence for chronic disease management programmes for practising physicians who will be increasingly invited to take an active leadership role in designing and operationalizing such programmes.

Self-management for people with inflammatory bowel disease

In North America and the United Kingdom, we are in the age of self-management. Many patients with chronic diseases are ready to participate in the therapeutic decision-making process, and join their physicians in a co-management model. It is particularly useful to consider this concept at a time when physician shortages and waiting times are on the front page every day, with no immediate prospect of relief. Conditions such as diabetes, asthma, chronic obstructive pulmonary disease, recurrent urinary tract infections and others lend themselves to this paradigm of medical care for the informed patient. The present paper reviews some of the literature on self-management for the patient with inflammatory bowel disease (IBD), and provides a framework for the use of self-management in the IBD population, with emphasis on the concept of a patient passport, and the use of e-mail, supported by an e-mail contract, as proposed by the Canadian Medical Protective Association. Examples of specific management strategies are provided for several different IBD scenarios. Eliminating the need for some office visits has clear environmental and economical benefits. Potential negative consequences of this form of patient care are also discussed.

The development of an evidence-based physical self-management rehabilitation programme for cancer survivors

OBJECTIVE

This paper describes the development of a physical training programme for cancer patients. Four related but conceptually and empirically distinct physical problems are described: decreased aerobic capacity, decreased muscle strength, fatigue and impaired role physical functioning. The study aimed to identify the optimal content for an exercise programme that addresses these four physical problems, based on the highest level of evidence available. The study further aimed to review the evidence available on the delivery of the programmes. The final goal was to develop a programme in which content and delivery are based on the best available evidence.

METHODS

Literature searches (PUBMED and MEDLINE, to July 2006) on content looked for evidence about the efficacy of exercise on aerobic capacity, muscle strength, fatigue and impaired role physical functioning. Literature searches on delivery looked for self-management and/or self-efficacy enhancing techniques in relation to outcome, adherence to and/or adoption of a physically active lifestyle.

RESULTS

Evidence on the effectiveness of exercise in cancer patients varies and increases when moving from muscle strength (RCT level), fatigue and physical role functioning to aerobic capacity (all at the meta-analysis level). Effect sizes for aerobic capacity were moderate, while effect sizes for fatigue and physical role functioning were zero and/or small. Many of the studies have significant methodological shortcomings. There was some evidence (meta-analyses) that self-management programmes and self-efficacy enhancing programmes have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour.

CONCLUSION

Limited data are available on the effectiveness of exercise for cancer patients. Although evidence supports the positive effects of exercise on exercise capacity during and after completion of cancer treatment, the effects for fatigue and role functioning are ambiguous. Evidence on the effectiveness of progressive exercise training on muscle strength is promising. In addition, some evidence supports the positive effects of self-management programmes and self-efficacy enhancing programmes on health outcomes, exercise adherence and later exercise behaviour.

PRACTICE IMPLICATIONS

The resulting programme was developed on the basis of the highest quality of evidence available regarding content and delivery. The content is based on information obtained from the present review, and on the recommendations of the American College of Sports Medicine. Potential advantages of the programme include: (a) tailored physical training towards focusing on the patient's established problems and (b) delivery of the training as a self-management programme that might have beneficial effects on health outcome, exercise adherence and a long-term physically active lifestyle.

The art and science of diabetes education: a culture out of balance

In the past 20 years, behavioral science has helped create a growing body of theoretically derived, evidenced-based approaches to diabetes patient education. Health care professionals in all disciplines are being required to demonstrate that their practice is evidence based. For diabetes educators, behavioral science is the source of much of that evidence. However, effective diabetes education involves a combination of art and science. Establishing a therapeutic alliance with patients is an art. Diabetes educators must have the interpersonal skills, values, and personal traits needed to cultivate relationships with patients that are characterized by trust, respect, and acceptance. They must feel and be able to express compassion, empathy, and warmth. However, if someone outside the field were reviewing diabetes education evaluation research, they would probably conclude that diabetes educators are interchangeable cogs in a wheel. The positive impact of the therapeutic alliance is well documented in the counseling, psychotherapy, education, and nursing literature. However, evidence to support the important role of the diabetes educator's values, interpersonal skills, and ability to establish a therapeutic alliance with patients is absent from that literature. Valid and reliable measures used to document the impact of interpersonal skills counselors and teachers could be used in diabetes education with little or no adaptation. The evidence and tools exist; we now need to determine if the will exists.

Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework?

OBJECTIVES

To explore views on high quality diabetes care based on an analysis of existing diversity in diabetes care programmes and related quality indicators.

METHODS

A review of systematic reviews was performed. Four databases (MEDLINE database of the National Library of Medicine, COCHRANE database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health Database-CINAHL and Pre-Cinahl) were searched for English review articles published between November 1989 and December 2006. Methodological quality of the articles was assessed. A standardized extraction form was used to assess features of diabetes care programmes and diabetes quality indicators with special reference to those aspects that hinder the conceptualization of high quality diabetes care. Based on these findings the relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care was further explored.

RESULTS

Twenty-one systematic reviews met the inclusion criteria representing a total of 185 diabetes care programmes. Six elements were identified to produce a picture of diversity in diabetes care programmes and hinder their standardization: 1) the variety and relative absence of conceptual backgrounds in diabetes care programmes, 2) confusion over what is considered a constituent of a diabetes care program and components of the implementation strategy, 3) large variety in type of diabetes care programmes, settings and related goals, 4) a large number and variety in interventions and quality indicators used, 5) no conclusive evidence on effectiveness, 6) no systematic results on costs.

CONCLUSIONS

There is large diversity in diabetes care programmes and related quality indicators. From this review and our analysis on the mutual relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care, we conclude that no single conceptual framework used to date provides a comprehensive overview of attributes of high quality diabetes care linked to quality indicators at the structure, process and outcome level. There is a need for a concerted action to develop a standardized framework on high quality diabetes care that is complemented by a practical tool to provide guidance to the design, implementation and evaluation of diabetes care programmes.

Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study

OBJECTIVE

We evaluated the association of different types of educational visits for diabetic patients of the eight Philadelphia Health Care Centers (PHCCs) (public safety-net primary care clinics), with hospital admission rates and charges reported to the Pennsylvania Health Care Cost Containment Council.

RESEARCH DESIGN AND METHODS

The study population included 18,404 patients who had a PHCC visit with a diabetes diagnosis recorded between 1 March 1993 and 31 December 2001 and had at least 1 month follow-up time.

RESULTS

A total of 31,657 hospitalizations were recorded for 7,839 (42.6%) patients in the cohort. After adjustment for demographic variables, baseline comorbid conditions, hospitalizations before the diabetes diagnosis, and number of other primary care visits, having had any type of educational visit was associated with 9.18 (95% CI 5.02-13.33) fewer hospitalizations per 100 person-years and $11,571 ($6,377 to $16,765) less in hospital charges per person. Each nutritionist visit was associated with 4.70 (2.23-7.16) fewer hospitalizations per 100 person-years and a $6,503 ($3,421 to $9,586) reduction in total hospital charges.

CONCLUSIONS

Any type of educational visit was associated with lower hospitalization rates and charges. Nutritionist visits were more strongly associated with reduced hospitalizations than diabetes classes. Each nutritionist visit was associated with a substantial reduction in hospital charges, suggesting that providing these services in the primary care setting may be highly cost-effective for the health care system.

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Social support, quality of life, and self-care behaviors amongAfrican Americans with type 2 diabetes

PURPOSE

The purpose of this study was to examine social support and its relationship to diabetes-specific quality of life and self-care behaviors in African Americans with type 2 diabetes.

METHODS

The study followed a cross-sectional, observational design and recruited 89 African American adults, age 40 and older (mean = 60, SD = 10.5), diagnosed with type 2 diabetes. Participants completed measures assessing diabetes-specific quality of life, self-care behaviors (healthy eating, physical activity, self-monitoring of blood glucose, foot care, medication and/or insulin use), demographic background, and diabetes-related social support. Diabetes-related social support variables included amount of social support received, satisfaction with support, positive support behavior, negative support behavior, and primary source of support.

RESULTS

Stepwise regressions, controlling for demographic variables, were conducted to identify predictors of diabetes-specific quality of life and self-care behaviors from the diabetes-related social support variables. Satisfaction with support was a predictor for improved diabetes-specific quality of life (r = -.579, P < .001) and blood glucose monitoring (r = .258, P < .05). Positive support behavior was a predictor for following a healthy eating plan (r = .280, P < .05), spacing out carbohydrates evenly throughout the day (r = .367, P < .01), and performing physical activity at least 30 minutes per day (r = .296, P < .05). Negative support behavior was a predictor for not taking medication as recommended (r = -.348, P < .01).

CONCLUSIONS

Findings indicate that social support plays a role in diabetes-specific quality of life and self-management practices. Social support encompasses multiple dimensions that differentially influence specific diabetes health-related outcomes and behaviors.

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Priorities for diabetes primary care in Europe

The European Forum for Primary Care (EFPC) held a consultation process among European experts and identified the elements considered to be essential for high quality diabetes care. More attention should go to diabetes prevention. An interdisciplinary team should provide comprehensive shared care, focused on patient empowerment. The further development of ICT is important to facilitate communication and quality monitoring. The EFPC argues the case for a primary care-centred approach to ensure equity and cost-effectiveness. But this is only possible with a strong primary care infrastructure. In many European countries important investments are needed to strengthen primary care.

A shared decision-making primary care intervention for type 2 diabetes

PURPOSE

The purpose of this study is to test the feasibility of a brief shared decision-making (SDM) goal-setting intervention among individuals with type 2 diabetes.

METHODS

A convenience sample of 58 patients from the University Internal Medicine Resident Clinic was recruited to participate in the study. Outcomes were tested through a pilot test of the intervention and ongoing conversations with clinic nursing staff and physicians. Patient outcomes included preintervention and postintervention hemoglobin A1C (HbA1c), weight and blood pressure levels, preintervention and postintervention patient survey questionnaires, and documented diabetes goals.

RESULTS

Most providers indicated that the SDM intervention did not impose major demands. Patient-centered interviewing and an SDM approach to goal setting led to 75.9% of patients having at least 1 diabetes management goal documented in their medical record after intervention. HbA1c level, weight, and diabetes empowerment score showed a trend toward improvement, as did patient ratings of "life disruption from having diabetes." Postintervention perceived knowledge of diabetes and treatments increased significantly (P = .001), as did the mean numbers of documented diabetes management goals (P < .001).

CONCLUSIONS

An SDM intervention for individuals with type 2 diabetes appears to be feasible and may improve major diabetes outcomes in primary care. SDM workbooks and activities can encourage patients to identify realistic diabetes goals with primary care providers. These results are encouraging. Future randomized trials with larger samples are warranted.

Should patients participate in clinical decision making? An optimised balance block design controlled study of goal setting in a rehabilitation unit

OBJECTIVES

The recent National Service Framework for Long Term Conditions recommends that patients participate more in decision making about their care. However, few protocols exist to support this. One potentially useful method is goal setting, but little has been done to evaluate the added value of increasing patient participation in this way. Therefore, this study examined the impact of an increased participation goal setting protocol in a neurorehabilitation setting.

DESIGN

The study was an AB optimised balance block design with each block lasting 3 months, over an 18 month period.

SETTING AND PARTICIPANTS

Patients (n = 201) were recruited from an inpatient neurological rehabilitation unit.

INTERVENTIONS

Patients (n = 100) recruited in phase A were involved in "usual practice" goal setting. Patients (n = 101) recruited in phase B were involved in "increased participation" goal setting, which included a protocol to help them define and prioritise their own goals.

MAIN OUTCOME MEASURES

Patients' perceptions of the relevance of goal setting and their autonomy within the process; the number, type and outcome of goals; and level of functional ability.

RESULTS

Phase B patients ("increased participation") set fewer goals, of which significantly more were participation related. These patients perceived the goals to be more relevant, and expressed greater autonomy and satisfaction with goal setting. There were no differences in functional outcomes between the groups.

CONCLUSION

This study has shown that patients prefer increased participation in the goal setting process over standard procedures, perceiving their goals as more relevant and rehabilitation more patient centred despite the absence of functional gains. Effective patient centred care can be realised by using structures that help support patients to identify and communicate their priorities. As such, our findings suggest patients would benefit from greater participation in this aspect of clinical decision making.

Deficiencies in the quality of diabetes care: comparing specialist with generalist care misses the point

The quality of diabetes care delivered to patients falls below the expectations of practice guidelines and clinical trial evidence. Studies in many jurisdictions with varying health care systems have shown that recommended processes of care occur less often than they should; hence, outcomes of care are inadequate. Many studies comparing care between specialists and generalists have found that specialists are more likely to implement processes of care. However, this provides little insight into improving quality of care, as the difference between specialists and generalists in these studies is small compared to the overall deficiency in quality. Therefore, future research should instead focus on ways to implement high quality care, regardless of specialty. To date, few methodologically rigorous studies have uncovered interventions that can improve quality of care. The development of such interventions to help all physicians implement better quality care could greatly benefit people with diabetes.

Long-term effects of a structured intensive diabetes education programme (SIDEP) in patients with Type 2 diabetes mellitus--a 4-year follow-up study

AIMS

Patient education is a very important part of diabetes care. However, until now, little data has been presented about the long-term effectiveness of structured intensive diabetes education programmes (SIDEP) for people with Type 2 diabetes mellitus.

METHODS

People with Type 2 diabetes (n = 547) hospitalized from December 1999 to December 2000 were randomly assigned to two groups. Two hundred and nineteen patients undertook an inpatient SIDEP and the remaining patients received conventional glycaemic control without intensive education. After discharge, all patients were monitored regularly. Laboratory data were obtained, and adherence to self-care behaviour was determined on a five-point scale by questionnaires completed annually.

RESULTS

Of the patients who completed the SIDEP, 160 (73.1%) were followed up for more than 4 years. The mean HbA(1c) (7.9 +/- 1.2 vs. 8.7 +/- 1.6%; P < 0.05) and the frequency of hospitalization related to diabetes per patient per year (0.3 +/- 0.6 vs. 0.8 +/- 0.9; P < 0.05) was significantly lower in the SIDEP group than in the control group. The SIDEP group adhered more closely to self-care behaviour than the control group over 4 years (P < 0.05). People with Type 2 diabetes mellitus of longer duration and those treated with insulin had poorer HbA(1c) at follow-up.

CONCLUSIONS

A well-designed, intensive patient education programme is necessary for people with diabetes. However, regular and sustained reinforcement with encouragement is also required to maintain optimal glycaemic control, especially in insulin-treated patients.

Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): process modelling of pilot study

OBJECTIVE

To determine the effects of a structured education program on illness beliefs, quality of life and physical activity in people newly diagnosed with Type 2 diabetes.

METHODS

Individuals attending a diabetes education and self-management for ongoing and newly diagnosed (DESMOND) program in 12 Primary Care Trusts completed questionnaire booklets assessing illness beliefs and quality of life at baseline and 3-month follow-up, metabolic control being assessed through assay of HbA1c.

RESULTS

Two hundred and thirty-six individuals attended the structured self-management education sessions, with 97% and 64% completing baseline and 3-month follow-up questionnaires. At 3 months, individuals were more likely to: understand their diabetes; agree it is a chronic illness; agree it is a serious condition, and that they can affect its course. Individuals achieving a greater reduction in HbA1c over the first 3 months were more likely to agree they could control their diabetes at 3 months (r=0.24; p=0.05), and less likely to agree that diabetes would have a major impact on their day to day life (r=0.35; p=0.006).

CONCLUSION

Pilot data indicate the DESMOND program for individuals newly diagnosed with Type 2 diabetes changes key illness beliefs and that these changes predict quality of life and metabolic control at 3-month follow-up.

PRACTICE IMPLICATIONS

Newly diagnosed individuals are open to attending self-management programs and, if the program is theoretically driven, can successfully engage with the true, serious nature of diabetes.

Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials

Background

Heart failure is the most common cause of hospitalization among adults over 65. Over 60% of patients die within 10 years of first onset of symptoms. The objective of this study is to determine the effectiveness of self-management interventions on hospital readmission rates, mortality, and health-related quality of life in patients diagnosed with heart failure.

Methods

The study is a systematic review of randomized controlled trials. The following data sources were used: MEDLINE (1966-11/2005), EMBASE (1980-11/2005), CINAHL (1982-11/2005), the ACP Journal Club database (to 11/2005), the Cochrane Central Trial Registry and the Cochrane Database of Systematic Reviews (to 11/2005); article reference lists; and experts in the field. We included randomized controlled trials of self-management interventions that enrolled patients 18 years of age or older who were diagnosed with heart failure. The primary outcomes of interest were all-cause hospital readmissions, hospital readmissions due to heart failure, and mortality. Secondary outcomes were compliance with treatment and quality of life scores. Three reviewers independently assessed the quality of each study and abstracted the results. For each included study, we computed the pooled odds ratios (OR) for all-cause hospital readmission, hospital readmission due to heart failure, and death. We used a fixed effects model to quantitatively synthesize results. We were not able to pool effects on health-related quality of life and measures of compliance with treatment, but we summarized the findings from the relevant studies. We also summarized the reported cost savings.

Results

From 671 citations that were identified, 6 randomized trials with 857 patients were included in the review. Self-management decreased all-cause hospital readmissions (OR 0.59; 95% confidence interval (CI) 0.44 to 0.80, P = 0.001) and heart failure readmissions (OR 0.44; 95% CI 0.27 to 0.71, P = 0.001). The effect on mortality was not significant (OR = 0.93; 95% CI 0.57 to 1.51, P = 0.76). Adherence to prescribed medical advice improved, but there was no significant difference in functional capabilities, symptom status and quality of life. The reported savings ranged from $1300 to $7515 per patient per year.

Conclusion

Self-management programs targeted for patients with heart failure decrease overall hospital readmissions and readmissions for heart failure.

Trends in hospitalization and sociodemographic factors in diabetic and nondiabetic populations in Germany: national health survey, 1990-1992 and 1998

OBJECTIVES

We examined time trends of hospitalization, a main outcome measure in health care, in the diabetic and nondiabetic populations in Germany and their associations with sociodemographic variables.

METHODS

Using data from 2 national health surveys, we estimated hospital days per person-year in the diabetic and nondiabetic populations in 1998 (n=5422) and 1990-1992 (n=7363) in Germany. We used Poisson regression to estimate relative risks and interaction of secular time with age, gender, and educational level, considering the cluster sample design of the study.

RESULTS

Hospital days per person-year decreased between 1990-1992 and 1998--from 3.59 (95% confidence interval [CI]=2.59, 4.97) to 3.14 (95% CI=2.16, 4.56) for the diabetic population and from 1.38 (95% CI=1.23, 1.55) to 1.33 (95% CI=1.17, 1.51) for the nondiabetic population--but the decrease was not statistically significant. In the diabetic population, the decrease tended to be more pronounced (interaction year x time not significant; P=.756). Also, there was a notable decrease in men and in the group aged 25 to 39 years, and a decrease in both high- and low-educational-level subjects.

CONCLUSIONS

There seems to have been a larger decrease in hospitalization in the diabetic population than in the nondiabetic population in Germany. An increase in social disparity in this health outcome measure in the diabetic population could not be confirmed.

The Diabetes Manual trial protocol - a cluster randomized controlled trial of a self-management intervention for type 2 diabetes [ISRCTN06315411]

BACKGROUND

The Diabetes Manual is a type 2 diabetes self-management programme based upon the clinically effective 'Heart Manual'. The 12 week programme is a complex intervention theoretically underpinned by self-efficacy theory. It is a one to one intervention meeting United Kingdom requirements for structured diabetes-education and is delivered within routine primary care.

METHODS/DESIGN

In a two-group cluster randomized controlled trial, GP practices are allocated by computer minimisation to an intervention group or a six-month deferred intervention group. We aim to recruit 250 participants from 50 practices across central England. Eligibility criteria are adults able to undertake the programme with type 2 diabetes, not taking insulin, with HbA1c over 8% (first 12 months) and following an agreed protocol change over 7% (months 13 to 18). Following randomisation, intervention nurses receive two-day training and delivered the Diabetes Manual programme to participants. Deferred intervention nurses receive the training following six-month follow-up. Primary outcome is HbA1c with total and HDL cholesterol; blood pressure, body mass index; self-efficacy and quality of life as additional outcomes. Primary analysis is between-group HbA1c differences at 6 months powered to give 80% power to detect a difference in HbA1c of 0.6%. A 12 month cohort analysis will assess maintenance of effect and assess relationship between self-efficacy and outcomes, and a qualitative study is running alongside.

DISCUSSION

This trial incorporates educational and psychological diabetes interventions into a single programme and assesses both clinical and psychosocial outcomes. The trial will increase our understanding of intervention transferability between conditions, those diabetes related health behaviours that are more or less susceptible to change through efficacy enhancing mechanisms and how this impacts on clinical outcomes.