Optimizing diabetes control in people with Type 2 diabetes through nurse-led telecoaching

Demystifying diabetes health coaching: A scoping review unveiling the 'who' and 'where' of health coaching for adults with type 2 diabetes

Type 2 diabetes (T2D) is a complex chronic condition that requires ongoing self-management. Diabetes health coaching interventions provide personalized healthcare programming to address physical and psychosocial aspects of diabetes self-management.

AIMS

This scoping review aims to explore the contexts and settings of diabetes health coaching interventions for adults with T2D, using the RE-AIM framework.

METHODS

A search was completed in MEDLINE, PsycINFO, Emcare, Embase and Cochrane. Included citations described adults with exclusively T2D who had received a health coaching intervention. Citations were excluded if they focused on any other types of diabetes or diabetes prevention.

RESULTS

A total of 3418 records were identified through database and manual searches, with 29 citations selected for data extraction. Most health coaching interventions were delivered by health professionals, many employed lay health workers and a few included peer coaches. While many health coaching interventions were delivered remotely, in-person intervention settings were distributed among primary care, community health settings and non-healthcare sites.

CONCLUSION

The findings of this review suggest that diabetes health coaching may be implemented by a variety of providers in different settings. Further research is required to standardize training and implementation of health coaching and evaluate its long-term effectiveness.

Clinical and cost-effectiveness of telemedicine among patients with type 2 diabetes in primary care: A systematic review and meta-analysis

AIMS

Telemedicine has been promoted as an effective way of managing type-2 diabetes (T2DM) in primary care. However, the effectiveness of telemedicine is unclear. We investigated the clinical and cost-effectiveness of different telemedicine interventions for people with T2DM, compared to usual care.

METHODS

We searched Medline, Embase, Cochrane, CINHAL, ProQuest and EconLit for randomized controlled trials (RCTs) that examined the effectiveness of telemedicine interventions on clinical outcomes (HbA1c, body mass index [BMI], weight, diastolic blood pressure [DBP], systolic blood pressure [SBP], fasting blood glucose, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, total cholesterol and triglyceride) in adults with T2DM, published in English from inception until 31 December 2022. Meta-analyses were conducted using random-effects models pooling mean differences, heterogeneity was quantified using the I2 statistic. Publication bias was assessed using funnel plots, Egger tests and trim and fill. Subgroup analyses included type of telemedicine intervention, telemedicine mode of delivery and type of healthcare professionals. This study was registered with PROSPERO, CRD 42022375128.

RESULTS

Of the 4093 records identified, 21 RCTs, 10,732 participants from seven regions, were included. Reported interventions included telephone (k = 16 studies), internet-based (k = 2), videoconference (k = 2) and telephone and emails (k = 1). We observed no statistically significant differences between synchronous or asynchronous telemedicine interventions compared to usual care for HbA1c (-0.08% (-0.88 mmol/mol); 95% CI: -0.18, 0.02), BMI (0.51 kg/m2; 95% CI: -0.21, 1.22), SBP (-1.48 mmHg; 95% CI: -3.22, 0.26), DBP (3.23 mmHg; 95% CI: -0.89, 7.34), HDL-cholesterol (0.01 mmol/L; 95% CI: -0.03, 0.05), LDL-cholesterol (0.08 mmol/L; 95% CI: -0.22, 0.37), triglycerides (-0.08 mmol/L, 95% CI: -0.31, -0.15), total cholesterol (-0.10 mmol/L; 95% CI: -0.25, 0.04) and weight (-0.50 kg; 95% CI: -1.21, 0.21).

CONCLUSIONS

Telemedicine was as effective as usual care in improving health outcomes of people with T2DM. They can provide a safe solution in times of rising demands for primary healthcare services, or in extreme events, like a global pandemic. More high-quality RCTs are needed on the cost evaluation of telemedicine.

Telehealth Behavioral Intervention for Chronic Disease Self-Management in Adults With Physical Disabilities (My Health, My Life, My Way): Protocol for Intervention Fidelity and Dashboard Design for a Randomized Controlled Trial

BACKGROUND

Individuals with physical disabilities experience higher rates of chronic health conditions than individuals without physical disabilities. Self-management programs that use health coaching are effective at eliciting health behavior change in health outcomes such as goal setting, adherence, and health care use. Additionally, web-based resources such as telehealth-based technologies, including SMSS text messaging, web-based applications, and educational multimedia content, can complement health coaching to improve health-related behaviors and the use of health services. The complexity of studies using these resources requires a fidelity protocol to ensure that health behavior studies are administered properly.

OBJECTIVE

The My Health, My Life, My Way fidelity protocol provides methods, strategies, and procedures of a multifaceted telehealth program for individuals with permanent physical disabilities and chronic health conditions. This health behavior study is a randomized controlled trial with four study arms: (1) scheduled coaching calls with gamified rewards, (2) no scheduled coaching calls with gamified rewards, (3) scheduled coaching calls with fixed rewards, and (4) no scheduled coaching calls with fixed rewards. To guide the fidelity protocol developed, we used the National Institutes of Health Behavior Change Consortium framework (NIH BCC).

METHODS

The fidelity intervention protocol was developed by using the 5 primary domains provided by the NIH BCC: study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. Following the NIH BCC guidelines and implementing social cognitive theory, this study is designed to ensure that all study arms receive equal treatment across conditions and groups. Health coaches and providers will be trained to deliver consistent health coaching, and thus participants will receive appropriate attention. Educational content will be developed to account for health literacy and comprehension of the material. Multiple fidelity intervention steps such as coaching call logs, regular content review, and participant progress monitoring will translate to participants using the skills learned in their daily lives. Different monitoring steps will be implemented to minimize differences among the 4 treatment groups.

RESULTS

My Health, My Life, My Way has been approved by the institutional review board and will begin enrollment in January 2024 and end in December 2024, with results reported in early 2025.

CONCLUSIONS

Intervention fidelity protocols are necessary to ensure that health behavior change studies can be implemented in larger real-world settings. The My Health, My Life, My Way fidelity protocol has used the guidelines by the NIH BCC to administer a telehealth intervention combined with health coaching for individuals with physical disabilities and chronic health conditions. This fidelity protocol can be used as a complementary resource for other researchers who conduct similar research using telehealth technologies and health coaching in real-world settings.

TRIAL REGISTRATION

ClinicalTrials NCT05481593; https://clinicaltrials.gov/study/NCT05481593.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/53410.

Telecoaching as a new training method for elderly people: a systematic review

BACKGROUND

The numerous restrictive measures implemented during the recent COVID-19 pandemic have reduced the levels of physical activity (PA) carried out by elderly people and telecoaching (TC) could be a training method to maintain the recommended levels of PA. In fact, TC uses information and digital communications technologies, such as computers and mobile devices, to access training services remotely. Thus, this study aimed to systematically review the scientific literature to verify the application, efficacy, and safety of TC training programs.

METHODS

PubMed, Scopus, and Web of Sciences databases were used for this review, and randomized controlled trials analyzing TC training programs for elderly people were included. Only articles written in English and published in the last decade were considered.

RESULTS

3 articles were included in the qualitative synthesis including 194 elderly people. The sample size ranged from 12 to 117 and the TC training program from 8 to 12 weeks. The TC training programs were applied to elderly people with metabolic diseases and respiratory diseases. TC training program was effective in elderly people with metabolic diseases while the benefits for respiratory diseases have yet to be clarified.

CONCLUSION

TC seems to be a safe, effective, and injury-free training method, despite its limited application in elderly population. Future studies should better investigate this training method in elderly people in order to evaluate the effectiveness in a wider range of diseases.

The effect of nurse-led telephone-based interventions on glycosylated hemoglobin levels in people with type 2 diabetes: A meta-analysis

BACKGROUND

Telenursing interventions can contribute to achieving optimal glycemic control.

AIM

This meta-analysis aimed to determine the effect of nurse-led telephone-based interventions on glycosylated hemoglobin (HbA1c) levels in people with type 2 diabetes.

METHODS

We searched electronic databases for studies published in English up to January 2023. This study was conducted in accordance with the PRISMA 2020 checklist. The intervention effects were pooled using a random-effects model. Two authors independently assessed the risk of bias using the Cochrane Collaboration tool.

RESULTS

Eight studies involving 1179 people with type 2 diabetes were included in this study. Interventions were performed for 15-30 min and 5-16 calls. There was no evidence of a significant publication bias. The evaluation of meta-analysis data showed that nurse-led telephone-based interventions significantly reduced HbA1c levels in people with type 2 diabetes (mean difference = -0.53, 95% Confidence Interval [-0.89, -0.17], p = .003).

LINKING EVIDENCE TO ACTION

Nurse-led telephone-based interventions focused on reducing glycosylated hemoglobin levels in people with type 2 diabetes can be used as an effective intervention to achieve glycemic control. We recommend holding an average of 15-25 min interviews once or twice a week.

Effectiveness of technology-based psychosocial interventions on diabetes distress and health-relevant outcomes among type 2 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Poor management of type 2 diabetes mellitus may affect individuals' physical and emotional health. Access to ongoing psychosocial interventions through technological platforms may potentially minimise diabetes complications and improve health-related outcomes. However, little is known about the effectiveness of such interventions on diabetes distress and health-related outcomes.

OBJECTIVE

To synthesise the best available evidence concerning the effectiveness of technology-based psychosocial interventions on diabetes distress, self-efficacy, health-related quality of life, and HbA1c level in adults with type 2 diabetes mellitus.

METHODS

A search of eleven databases was conducted to identify randomised controlled trials that examined the effects of technology-based psychosocial interventions on the outcomes. Randomised controlled trials reported in English from 2010 to 2020 were included. Selection of studies, quality appraisal, and data extraction were conducted by two reviewers independently. Meta-analyses, subgroup analyses and sensitivity analysis were performed using Review Manager. Intervention effects was measured using standardise mean difference.

RESULTS

Twenty randomised controlled trials fulfilled the eligibility criteria and 18 randomised controlled trials were included in meta-analysis. technology-based psychosocial interventions improved diabetes distress, self-efficacy and HbA1c levels with significant and small effect sizes. Subgroup analyses revealed greater improvement in health-related quality of life for participants with comorbid depression and lower HbA1c levels for studies with lesser than 100 participants.

CONCLUSION

The findings of this review increase knowledge on the effectiveness of technology-based psychosocial interventions on diabetes distress and self-efficacy. However, evidence to support the effects of technology-based psychosocial interventions on HbA1c and health-related quality of life was not strong. More research is needed to examine the effectiveness of the psychosocial interventions delivered through mobile applications or virtual reality.

Educators' Perspectives on the Teaching and Learning of Type 2 Diabetes Content in Physiotherapy Programmes across Canada

Purpose

This qualitative descriptive study researched educators' perspectives of type 2 diabetes (T2D) Teaching and learning, in physiotherapy (PT) programmes across Canada.

Methods

Faculty members and clinical instructors from the 15 PT programmes in Canada were contacted. Online surveys collected data on the educators' professional background and perspectives on T2D in the PT curriculum. One-on-one telephone interviews were conducted and thematic analysis was used to generate themes and codes from the interview transcripts.

Results

Ten educators from 10 universities completed the survey. Seven of the 10 educators also participated in a telephone interview. Survey responses revealed that T2D content is taught predominantly through case studies and lectures. Of the 10 respondents, six reported that the curriculum does not devote adequate time to T2D content, and nine reported they "strongly agree" or "agree" that T2D is an essential component of the PT curriculum. The interviews revealed that T2D content varies across PT programmes. The educators agreed that T2D is a common condition seen in practice, there is a role for PT intervention, and T2D content is limited by classroom time.

Conclusions

Educators noted challenges integrating more T2D content in the curriculum and said that PT clinical contributions for people living with T2D are underutilized. Additional evidence-informed rationale is needed to explore optimal integration of T2D content in PT programmes.

The Effect of Telenursing on Disease Outcomes in People with Type 2 Diabetes Mellitus: A Narrative Review

Method

A comprehensive search of online databases, including PubMed, Scopus, Cochrane Library, and Google Scholar, was performed using the following MeSH keywords: telenursing, telephone follow-up, diabetes mellitus, disease management, glycemic, self-care, treatment adherence, and quality of life, up to September 2023. Two reviewers independently screened pertinent studies based on the prespecified outcomes (treatment adherence, self-care, glycemic control, and quality of life) and extracted data from all eligible studies.

Results

Of all retrieved records, 23 studies including 5 quasiexperimental (21%) and 18 randomized controlled trials (RCTs) (79%) from five continents met the inclusion criteria. Both male and female patients were considered in the included studies, with mean age of 56.2 years old and a follow-up range of 12 weeks to 18 months. Findings showed that telenursing or nurse telephone follow-up significantly increased mean self-care efficacy score, improved adherence to the treatment regimen, decreased glycosylated hemoglobin and plasma glucose levels (but not lipid profile and body mass index), and improved quality of life compared to the routine care in people with T2DM.

Conclusion

Telenursing can effectively supplement healthcare professionals to manage PWT2D. Increasing patients' knowledge about their drugs, insulin administration, and diabetes complications improves self-care behaviors and medical adherence. Consistently, improved self-care and regular use of treatment result in improved metabolic indicators and decreased rate of complications, which is associated with a better quality of life.

Comparing the effects of home visits and telenursing on blood glucose control: A systematic review of randomized controlled trials

BACKGROUND

Home visits have often been performed for diabetes management, but with the increased use of the internet and smartphones, people are opting for telenursing as the main method for monitoring and controlling diabetes.

OBJECTIVE

This study compares the effects of home visits and telenursing on diabetes management.

METHODS

Four electronic databases (MEDLINE, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature) were used as data sources. Glycated hemoglobin (HbA1c), fasting blood sugar, and two-hour post-prandial glucose levels were used as outcome measures. A subgroup analysis was performed based on the type of diabetes and follow-up.

RESULTS

Of 1890 studies, 24 (2801 participants) were selected and meta-analyzed. The nursing interventions provided during nursing visits or telenursing mainly included education on diabetes and blood sugar control. It was seen that HbA1c decreased with a weighted mean difference of -0.66 (95 % confidence interval -0.82 to -0.51, p < .001) % in home visits and -0.56 (95 % confidence interval -0.81 to -0.31, p < .001) % in telenursing. The fasting blood sugar reported only in telenursing was reduced by a weighted mean difference of -14.23 (95 % confidence interval 27.59 to -0.88, p = .04) mg/dL and two-hour post-prandial glucose was reduced with a mean difference of -15.84 (95 % confidence interval -24.45 to -7.24, p = .003) mg/dL. Furthermore, low heterogeneity was found among the studies. In a subgroup analysis of diabetes type, HbA1c in home visits was reduced by -0.86 % in type 1 diabetes and -0.62 % in type 2 diabetes, while in telenursing, the reductions were -0.65 % and -0.53 %, respectively. Fasting blood glucose was reduced by -6.08 mg/dL and -18.50 mg/dL, respectively, whereas two-hour postprandial blood sugar was reduced by -14.49 mg/dL and -30.30 mg/dL, respectively, in telenursing. In the subgroup analysis of the follow-up period, HbA1c during home visits decreased by -0.63 % at 10 to 16 weeks, -0.73 % at 24 to 36 weeks, and -0.64 % at 52 weeks or more, while in telenursing, the reductions were -0.80 %, -0.44 %, and -0.07 %, respectively. Home visits were not statistically significant between 10 and 16 weeks, whereas telenursing was not significant at 52 weeks or more.

CONCLUSIONS

Despite telenursing reducing HbA1c slightly less than home visits, evidence from this systematic review suggests that telenursing is a similarly effective approach for controlling blood glucose levels in patients with diabetes. Telenursing is a nursing intervention that can be used as an alternative to home visits for patients requiring diabetes management.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

My Health, My Life, My Way-An Inclusive Web-Based Self-management Program for People With Disabilities Living With Chronic Conditions: Protocol for a Multiphase Optimization Strategy Study

BACKGROUND

Individuals with disabilities living with chronic health conditions require self-management programs that are accessible, sustainable, inclusive, and adaptable. Health coaching is an effective approach to promoting behavior change in self-management. Health coaching combined with telehealth technology has the potential to improve the overall quality of, and access to, health services.

OBJECTIVE

This protocol outlines the study design for implementing the My Health, My Life, My Way intervention. The study will assess the feasibility, acceptability, and preliminary efficacy of the intervention for people with disabilities and optimize it.

METHODS

The My Health, My Life, My Way study is a 4-arm randomized controlled trial evaluating the delivery of a 6-month intervention involving telecoaching, inclusive educational content, and technology access for 200 individuals with chronic conditions and physical disabilities. This study uses the engineering-inspired multiphase optimization strategy (MOST) framework to evaluate intervention components and assess whether a combination or lack of individual elements influences behavior. Participants will be randomized to 1 of 4 study arms: scheduled coaching calls and gamified rewards, no scheduled coaching calls and gamified rewards, scheduled coaching calls and flat rewards, and no scheduled coaching calls and flat rewards.

RESULTS

The My Health, My Life, My Way study was approved by the institutional review board of the University of Alabama at Birmingham, and recruitment and enrollment will begin in May 2023. Data analysis is expected to be completed within 6 months of ending data collection. This clinical trial protocol was developed based on the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 statement.

CONCLUSIONS

The My Health, My Life, My Way study will help to optimize and improve our understanding of the feasibility and efficacy of a web-based self-management program for people with physical disabilities and chronic conditions. More specifically, My Health, My Life, My Way will determine which combination of interventions (coaching calls and gamification) will result in increased participation in self-management programming. The My Health, My Life, My Way intervention has the potential to become a scalable and novel method to successfully manage chronic conditions in people with disabilities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05481593; https://clinicaltrials.gov/ct2/show/NCT05481593.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/31694.

Behavioural Change Techniques in Health Coaching-Based Interventions for Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

Given the high rates globally of Type 2 Diabetes Mellitus (T2DM), there is a clear need to target health behaviours through person-centred interventions. Health coaching is one strategy that has been widely recognised as a tool to foster positive behaviour change. However, it has been used inconsistently and has produced mixed results. This systematic review sought to explore the use of behaviour change techniques (BCTs) in health coaching interventions and identify which BCTs are linked with increased effectiveness in relation to HbA1C reductions.

METHODS

In line with the PICO framework, the review focused on people with T2DM, who received health coaching and were compared with a usual care or active control group on HbA1c levels. Studies were systematically identified through different databases including Medline, Web of science, and PsycINFO searches for relevant randomised controlled trials (RCTs) in papers published between January 1950 and April 2022. The Cochrane collaboration tool was used to evaluate the quality of the studies. Included papers were screened on the reported use of BCTs based on the BCT taxonomy. The effect sizes obtained in included interventions were assessed by using Cohen's d and meta-analysis was used to estimate sample-weighted average effect sizes (Hedges' g).

RESULTS

Twenty RCTs with a total sample size of 3222 were identified. Random effects meta-analysis estimated a small-sized statistically significant effect of health coaching interventions on HbA1c reduction (g₊ = 0.29, 95% CI: 0.18 to 0.40). A clinically significant HbA1c decrease of ≥5 mmol/mol was seen in eight studies. Twenty-three unique BCTs were identified in the reported interventions, with a mean of 4.5 (SD = 2.4) BCTs used in each study. Of these, Goal setting (behaviour) and Problem solving were the most frequently identified BCTs. The number of BCTs used was not related to intervention effectiveness. In addition, there was little evidence to link the use of specific BCTs to larger reductions in HbA1c across the studies included in the review; instead, the use of Credible source and Social reward in interventions were associated with smaller reductions in HbA1c.

CONCLUSION

A relatively small number of BCTs have been used in RCTs of health coaching interventions for T2DM. Inadequate, imprecise descriptions of interventions and the lack of theory were the main limitations of the studies included in this review. Moreover, other possible BCTs directly related to the theoretical underpinnings of health coaching were absent. It is recommended that key BCTs are identified at an early stage of intervention development, although further research is needed to examine the most effective BCTs to use in health coaching interventions.

TRIAL REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021228567 .

Impact of telehealth on the current and future practice of lipidology: a scoping review

Telehealth services have been implemented to deliver care for patients living with many chronic conditions and have expanded greatly during the COVID-19 pandemic. Little is known about the current or future impacts of telehealth on lipid management practices. The PubMed database was searched from inception to June 25, 2021, with the keywords "lipids or cholesterol" and "telehealth," which yielded 376 published articles. Telehealth was defined as a synchronous visit between a patient and clinician that replaced an in-office appointment. Studies that solely used remote monitoring, mobile health technologies, or callbacks of results, were excluded. Articles must have measured lipid values. Review articles and protocol papers were not included. After evaluation, 128 abstracts were included for full text evaluation, with 55 full-text articles eventually included. Of the articles, 29 were randomized clinical trials, 15 were pre-post evaluations, and 11 were other study designs. Telehealth had positive to neutral impacts on lipid management. Reported facilitators include easier implementation of multidisciplinary approaches to care, and utilization of patient-centered programs. Reported barriers to telehealth services include technological barriers, such as various skill levels with technology; systems barriers, such as cost and reimbursement; patient-related barriers, including patient non-adherence; and clinician-related barriers, such as difficulty standardizing care. Clinicians reported improved satisfaction among patients but had mixed feelings regarding their ability to deliver quality care. Telemedicine use to provide care for individuals with lipid conditions has expanded during the COVID-19 pandemic, but more research is needed to determine its potential as a sustainable tool for lipid management.

Effectiveness of Case Manager Led Multi-Disciplinary Team Approach on Glycemic Control Amongst T2DM Patients in Primary Care in Riyadh: A Retrospective Follow-Up Study

OBJECTIVES

Our study aims to assess the effectiveness of implementing a case manager-led Multidisciplinary Team approach in the primary healthcare setting on improving glycemic control and reducing cardiovascular risks for T2DM patients over a 6-month period.

METHODS

This retrospective record-based follow-up study was carried out on 3060 uncontrolled T2DM patients in primary healthcare centers in Riyadh First Health Cluster over a period of 6 months. The patient records are investigated and analyzed, including demographic characteristics and measurements of Hemoglobin A1c (HbA1c), Low-Density Lipoprotein Cholesterol (LDL-C), total cholesterol, and BP levels at enrollment and after 6 months of Multi-Disciplinary Team follow-up. The changes in the study variables and their correlations to each other are tested using Statistical Package for the Social Sciences software.

RESULTS

At enrollment, our patients were characterized by poor glycemic control (HbAIC > 8%). Most of them have high body weight with a mean BMI of (31.2 ± 1.7), and nearly two-thirds are either hypertensive or have dyslipidemia (43.4% and 47.3% respectively). After 6 months of MDT follow-up, there is a significant improvement in glycemic control among 1971 patients (64.4%), with a reduction in the mean level of different outcomes relative to baseline HbA1c (-15%, P < .001), total cholesterol (-9.0%, P < .001), LDL-C (-11.0%, P < .001), systolic BP (-7.7%, P < .001), and diastolic BP (-10.5%, P < .001). The improved glycemic control showed a significant positive correlation with the number of MDT visits but negatively correlated with BMI and the number of comorbidities. In addition, the improvements in secondary outcomes were positively and significantly correlated with such improvements in glycemic control.

CONCLUSION

Case-manager-led MDT approach significantly improves glycemic control and significantly improves control over dyslipidemia and hypertension, reducing cardiovascular risks, and unfavorable events among such diabetic patients. We highly recommend developing more MDTs, training case managers, and rigorously evaluating the MDT approach.

Systematic Review and Meta-Analysis of Telecoaching for Self-Care Management among Persons with Type 2 Diabetes Mellitus

BACKGROUND

In response to the need for safe care for people with diabetes mellitus in the current outbreak of COVID-19, it is critical to evaluate the model, service delivery, feasibility, and efficiency of diabetes mellitus telecoaching.

OBJECTIVE

This study aimed to conduct a systematic review and meta-analysis of the model and efficacy of telecoaching to improve self-care and clinical outcomes.

METHODS

This study uses the Preferred Reporting Item for Systematic Review and Meta-Analysis (PRISMA). We searched on 22 March 2022, using keywords that matched the MeSH browser in four databases to find relevant studies, namely, PubMed/Medline, Proquest, Scopus, and EBSCOhost. Additionally, we collected randomized controlled trials (RCTs) on Google Scholar using the snowball technique. A quality assessment was performed using the Cochrane Collaboration's Risk of Bias tool (RoB)2. The meta-analysis used the DerSimonian-Laird random-effects model to analyze the pooled mean difference (MD) and its p-value.

RESULTS

Thirteen RCT studies were included for the systematic review and meta-analysis with a total number of participants of 3300. The model of telecoaching is a form of using nurses-led telephone and mobile apps, which are relatively cost-effective. The meta-analysis showed a positively improved statistically significance in clinical outcomes, including in HbA1c (a pooled MD of -0.33; 95% CI: -0.51--0.15; p = 0.0003), blood glucose (-18.99; 95% CI: -20.89--17.09; p = 0.00001), systolic blood pressure (-2.66; 95% CI: -3.66--1.66; p = 0.00001), body mass index (-0.79; 95% CI: -1.39--0.18; p = 0.01), and weight (-2.16 kg; 95% CI: -3.95--0.38; p = 0.02). It was not, however, statistically significant in diastolic blood pressure (-0.87; 95% CI: -2.02-0.28; p = 0.14), total cholesterol (-0.07; 95% CI: -0.26-0.12; p = 0.46), low-density lipoprotein (-2.19; 95% CI: -6.70-2.31; p = 0.34), triglycerides (-13.56; 95% CI: -40.46-13.35; p = 0.32) and high-density protein (0.40; 95% CI: -1.12-1.91; p = 0.61).

CONCLUSIONS

The telecoaching with nurses-led telephone and mobile apps significantly affected clinical outcomes on HbA1c, systolic blood pressure, weight, and BMI. Moreover, there was no significant effect on the total cholesterol, low-density lipoprotein, triglycerides, and high-density lipoprotein. Thus, telecoaching has the potential as a care model in diabetes mellitus during COVID-19 and similar pandemics to improve self-care and clinical outcomes, but all the studies analyzed involved non-COVID-19 patients, limiting the generalizability of the results to COVID-19.

Nurse-led Telehealth Intervention for Rehabilitation (Telerehabilitation) Among Community-Dwelling Patients With Chronic Diseases: Systematic Review and Meta-analysis

BACKGROUND

Chronic diseases are putting huge pressure on health care systems. Nurses are widely recognized as one of the competent health care providers who offer comprehensive care to patients during rehabilitation after hospitalization. In recent years, telerehabilitation has opened a new pathway for nurses to manage chronic diseases at a distance; however, it remains unclear which chronic disease patients benefit the most from this innovative delivery mode.

OBJECTIVE

This study aims to summarize current components of community-based, nurse-led telerehabilitation programs using the chronic care model; evaluate the effectiveness of nurse-led telerehabilitation programs compared with traditional face-to-face rehabilitation programs; and compare the effects of telerehabilitation on patients with different chronic diseases.

METHODS

A systematic review and meta-analysis were performed using 6 databases for articles published from 2015 to 2021. Studies comparing the effectiveness of telehealth rehabilitation with face-to-face rehabilitation for people with hypertension, cardiac diseases, chronic respiratory diseases, diabetes, cancer, or stroke were included. Quality of life was the primary outcome. Secondary outcomes included physical indicators, self-care, psychological impacts, and health-resource use. The revised Cochrane risk of bias tool for randomized trials was employed to assess the methodological quality of the included studies. A meta-analysis was conducted using a random-effects model and illustrated with forest plots.

RESULTS

A total of 26 studies were included in the meta-analysis. Telephone follow-ups were the most commonly used telerehabilitation delivery approach. Chronic care model components, such as nurses-patient communication, self-management support, and regular follow-up, were involved in all telerehabilitation programs. Compared with traditional face-to-face rehabilitation groups, statistically significant improvements in quality of life (cardiac diseases: standard mean difference [SMD] 0.45; 95% CI 0.09 to 0.81; P=.01; heterogeneity: X²₁=1.9; I²=48%; P=.16; chronic respiratory diseases: SMD 0.18; 95% CI 0.05 to 0.31; P=.007; heterogeneity: X²₂=1.7; I²=0%; P=.43) and self-care (cardiac diseases: MD 5.49; 95% CI 2.95 to 8.03; P<.001; heterogeneity: X²₅=6.5; I²=23%; P=.26; diabetes: SMD 1.20; 95% CI 0.55 to 1.84; P<.001; heterogeneity: X²₄=46.3; I²=91%; P<.001) were observed in the groups that used telerehabilitation. For patients with any of the 6 targeted chronic diseases, those with hypertension and diabetes experienced significant improvements in their blood pressure (systolic blood pressure: MD 10.48; 95% CI 2.68 to 18.28; P=.008; heterogeneity: X²₁=2.2; I²=54%; P=0.14; diastolic blood pressure: MD 1.52; 95% CI -10.08 to 13.11, P=.80; heterogeneity: X²1=11.5; I²=91%; P<.001), and hemoglobin A1c (MD 0.19; 95% CI -0.19 to 0.57 P=.32; heterogeneity: X²₄=12.4; I²=68%; P=.01) levels. Despite these positive findings, telerehabilitation was found to have no statistically significant effect on improving patients' anxiety level, depression level, or hospital admission rate.

CONCLUSIONS

This review showed that telerehabilitation programs could be beneficial to patients with chronic disease in the community. However, better designed nurse-led telerehabilitation programs are needed, such as those involving the transfer of nurse-patient clinical data. The heterogeneity between studies was moderate to high. Future research could integrate the chronic care model with telerehabilitation to maximize its benefits for community-dwelling patients with chronic diseases.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews CRD42022324676; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=324676.

Effect of community-based nurse-led support intervention in the reduction of HbA1c levels

PURPOSE

To determine the effect of community based Nurse-led support intervention in the reduction of HbA1c levels compared to usual care.

DESIGN AND METHODS

A systematic search of four electronic databases was conducted until August 2021 including RCTs to check for a reduction in HbA1c levels in Nurse-led intervention arm.

RESULTS

Twenty-one trials involving 4649 diabetic individuals were included in the review. The pooled mean difference in the reduction of HbA1c in the intervention group was found to be -0.421 (95% CI: -0.59 to -0.25).

CONCLUSION AND EVIDENCE

Nurse-led educational intervention proved beneficial in the control of HbA1c among diabetic individuals.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Telephone calls and glycemic control in type 2 diabetes: A PRISMA-compliant systematic review and meta-analysis of randomized clinical trials

AIMS

In-depth and updated systematic reviews evaluating telephone calls in type 2 diabetes (T2DM) management are missing. This study aimed to assess the effect of this intervention on glycemic control in T2DM patients when compared with usual care.

METHODS

We systematically searched for randomized controlled trials (RCT) on T2DM using Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and LILACS, up to March 2021. The Risk of Bias 2.0 (Rob 2.0) tool and GRADE were used for the quality evaluation. The intervention effect was estimated by the change in glycated hemoglobin (HbA1c). PROSPERO registry CRD42020204519.

RESULTS

3545 references were reviewed and 32 were included (8598 patients). Telephone calls, all approaching education, improved HbA1c by 0.33% [95% CI, -0.48% to -0.18%; I2 = 78%; p < 0.0001] compared to usual care. A greater improvement was found when the intervention included pharmacologic modification (-0.82%, 95% CI, -1.42% to -0.22%; I2 = 92%) and when it was applied by nurses (-0.53%, 95% CI, -0.86% to -0.2%; I2 = 87%). Meta-regression showed no relationship between DM duration and HbA1c changes.

CONCLUSION

The telephone call intervention provided a benefit regarding T2DM glycemic control, especially if provided by nurses, or if associated with patient education and pharmacological treatment modification.

A Meta-Analysis of the Effectiveness of Telemedicine in Glycemic Management among Patients with Type 2 Diabetes in Primary Care

Introduction: Telemedicine interventions are gradually being used in primary health care to help patients with type 2 diabetes receive ongoing medical guidance. The purpose of this study was to analyze the effectiveness of using telemedicine in primary health care for the management of patients with type 2 diabetes. Methods: A systematic search was conducted from database inception to August 2021 in nine databases, including PubMed, Web of Science, Cochrane Library, EMBASE, EBSCO, CNKI, Wanfang Data, VIP, and CBM. Data extraction and quality assessment were performed for studies that met the inclusion criteria. The meta-analysis was performed using Review Manager 5.4 (Cochrane) and Stata v.16.0SE (College Station, TX, USA). Results: A total of 32 articles were included in this study. Analysis showed a reduction in glycated hemoglobin, fasting glucose, and postprandial glucose after the telemedicine intervention. Systolic blood pressure and self-efficacy improved significantly, but there was no significant improvement in weight, lipid metabolism, or diabetes awareness. Subgroup analysis based on the duration of intervention showed significant improvement in glycated hemoglobin at 6 months of intervention. Conclusions: Telemedicine interventions may help patients with type 2 diabetes to effectively control blood glucose and improve self-management in primary health care. There is only moderate benefit, and the benefit may not be sustained beyond 6 months. However, the evidence for the improvement in lipid metabolism is insufficient and further studies are needed.

Nurse-led care versus usual care on cardiovascular risk factors for patients with type 2 diabetes: a systematic review and meta-analysis

OBJECTS

This study aims to systematically evaluate the effectiveness of nurse-led cares on cardiovascular risk factors among individuals with type 2 diabetes mellitus.

DESIGN

Systematic review and meta-analysis.

METHODS

The electronic databases PubMed, EMBASE, CINAHL and Cochrane Library databases were searched for randomised controlled trials of nurse-led care for individuals with type 2 diabetes mellitus (T2DM) published in English from inception to 23 December 2021. Random effects models were used to calculate weighted mean differences (WMD) with 95%CI.

RESULTS

13 articles were included in the meta-analysis, with a total of3757 participants. Considering baseline measurements, pooled analysis showed that nurse-led care significantly decreased the glycosylated haemoglobin (HbA1c) (WMD=-0.68 mmol/L; 95% CI -0.85 to -0.52; p<0.001), body mass index (BMI) (WMD=-0.54 kg/m²; 95% CI: -0.97 to -0.11; p=0.01) and systolic blood pressure (SBP) (WMD=-1.17 mmHg; 95% CI: -2.11 to -0.22; p=0.02) for patients with T2DM. But there was no difference in low-density lipoprotein cholesterol (LDL-c) (WMD=-2.50 mg/dL ; 95% CI: -5.07 to 0.08; p=0.06) between the nurse-led and control groups.

CONCLUSION

Nurse-led care is an effective and accessible intervention that could improve HbA1c, SBP, BMI levels among individuals with T2DM.

PROSPERO REGISTRATION NUMBER

CRD42021248275.

Applying the RE-AIM implementation framework to evaluate diabetes health coaching in individuals with type 2 diabetes: A systematic review and secondary analysis

BACKGROUND

Diabetes health coaching continues to emerge as an effective intervention to support diabetes self-management. While previous systematic reviews have focused on the effectiveness of diabetes health coaching programs in adults with type 2 diabetes (T2DM), limited literature is available on its implementation. This review examines what aspects of diabetes health coaching interventions for adults living with type 2 diabetes have been reported using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to optimize implementation.

METHODS

We examined the included studies from our recently completed systematic review, which searched 6 databases for randomized controlled trials (RCTs) of health coaching interventions delivered by a health professional for adults with T2DM. Reviewers screened citations and extracted data for study characteristics and the 5 dimensions (62 criteria) of the RE-AIM framework.

RESULTS

9 diabetes health coaching RCTs were included in this review. 12 criteria were reported by all the included studies and 21 criteria were not reported by any of the studies. The included studies all reported on more than 20 RE-AIM criteria, ranging from 21 to 27. While Reach was the best reported construct by the included studies, followed by Effectiveness and Implementation, the criteria within the Adoption and Maintenance constructs were rarely mentioned by these studies. In general, there was also wide variation in how each of the criteria were reported on by study authors.

CONCLUSIONS

Due to the paucity of reporting of the RE-AIM components for diabetes health coaching, limited implementation and clinical practice implications can be drawn. The lack of detail regarding implementation approaches to diabetes health coaching greatly limits the interpretation and comparisons across studies to best inform the application of this intervention to support diabetes self-management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO identifier, CRD42022347478.

Diabetes health coach in individuals with type 2 diabetes: A systematic review and meta analysis of quadruple aim outcomes

BACKGROUND

As diabetes self-management necessitates life-long learning, behaviour change, support, and monitoring, health coaching is a promising intervention to assist individuals in more than just meeting glycemic goals and glycated hemoglobin (A1C) targets. Currently, studies of health coaching for type 2 diabetes (T2DM) are limited due to their emphasis on glycemic control. The goal of this systematic review and meta-analysis is to determine the effects of health coaching on adults with T2DM based on quadruple aim outcomes and to assess the implementation of these interventions.

METHODS

We searched 6 databases for randomized controlled trials of health coaching interventions delivered by a health professional for adults with T2DM. Reviewers screened citations, extracted data, and assessed risk of bias and certainty of evidence (GRADE). We assessed statistical and methodological heterogeneity and performed a meta-analysis of studies.

RESULTS

Nine studies were included in this review. Our meta-analysis showed a significant reduction of A1C [0.24 (95% CI, -0.38 to -0.09)] after exposure to diabetes health coaching, and small to trivial significant benefits for BMI, waist circumference, body weight, and depression/distress immediately post intervention based on moderate certainty of evidence. However, long term benefit of these clinical outcomes were not maintained at follow-up timepoints. There was a small significant benefit for systolic blood pressure which was maintained after the completion of health coaching exposure at follow-up, but there was no statistically significant benefit in other secondary outcomes such as diastolic blood pressure and lipid profile measures (e.g. triglycerides). Very few studies reported on other quadruple aim measures such as patient-reported outcomes, cost of care, and healthcare provider experience.

CONCLUSIONS

Our systematic review and meta-analysis shows that health coaching interventions can have short term impact beyond glucose control on cardiometabolic and mental health outcomes. Future studies should try to examine quadruple aim outcomes to better assess the benefit and impact of these interventions at longer time points and following termination of the coaching program.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero, identifier (CRD42022347478).

Effectiveness of Remotely Delivered Interventions to Simultaneously Optimize Management of Hypertension, Hyperglycemia and Dyslipidemia in People With Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Remotely delivered interventions may be more efficient in controlling multiple risk factors in people with diabetes.

PURPOSE

To pool evidence from randomized controlled trials testing remote management interventions to simultaneously control blood pressure, blood glucose and lipids.

DATA SOURCES

PubMed/Medline, EMBASE, CINAHL and the Cochrane library were systematically searched for randomized controlled trials (RCTs) until 20^th June 2021.

STUDY SELECTION

Included RCTs were those that reported participant data on blood pressure, blood glucose, and lipid outcomes in response to a remotely delivered intervention.

DATA EXTRACTION

Three authors extracted data using a predefined template. Primary outcomes were glycated hemoglobin (HbA1c), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), systolic and diastolic blood pressure (SBP & DBP). Risk of bias was assessed using the Cochrane collaboration RoB-2 tool. Meta-analyses are reported as standardized mean difference (SMD) with 95% confidence intervals (95%CI).

DATA SYNTHESIS

Twenty-seven RCTs reporting on 9100 participants (4581 intervention and 4519 usual care) were included. Components of the remote management interventions tested were identified as patient education, risk factor monitoring, coaching on monitoring, consultations, and pharmacological management. Comparator groups were typically face-to-face usual patient care. Remote management significantly reduced HbA1c (SMD -0.25, 95%CI -0.33 to -0.17, p<0.001), TC (SMD -0.17, 95%CI -0.29 to -0.04, p<0.0001), LDL-c (SMD -0.11, 95%CI -0.19 to -0.03, p=0.006), SBP (SMD -0.11, 95%CI -0.18 to -0.04, p=0.001) and DBP (SMD -0.09, 95%CI -0.16 to -0.02, p=0.02), with low to moderate heterogeneity (I²= 0 to 75). Twelve trials had high risk of bias, 12 had some risk and three were at low risk of bias.

LIMITATIONS

Heterogeneity and potential publication bias may limit applicability of findings.

CONCLUSIONS

Remote management significantly improves control of modifiable risk factors.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258433], identifier PROSPERO (CRD42021258433).

The Effectiveness of Telemedicine Solutions for the Management of Type 2 Diabetes: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

Previous systematic reviews have aimed to clarify the effect of telemedicine on diabetes. However, such reviews often have a narrow focus, which calls for a more comprehensive systematic review within the field. Hence, the objective of the present systematic review, meta-analysis, and meta-regression is to evaluate the effectiveness of telemedicine solutions versus any comparator without the use of telemedicine on diabetes-related outcomes among adult patients with type 2 diabetes (T2D).

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We considered telemedicine randomized controlled trials (RCT) including adults (≥18 years) diagnosed with T2D. Change in glycated hemoglobin (HbA1c, %) was the primary outcome. PubMed, EMBASE, and the Cochrane Library Central Register of Controlled Trials (CENTRAL) were searched on October 14, 2020. An overall treatment effect was estimated using a meta-analysis performed on the pool of included studies based on the mean difference (MD). The revised Cochrane risk-of-bias tool was applied and the certainty of evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

The final sample of papers included a total of 246, of which 168 had sufficient information to calculate the effect of HbA1c%. The results favored telemedicine, with an MD of -0.415% (95% confidence interval [CI] = -0.482% to -0.348%). The heterogeneity was great (I² = 93.05%). A monitoring component gave rise to the higher effects of telemedicine.

CONCLUSIONS

In conclusion, telemedicine may serve as a valuable supplement to usual care for patients with T2D. The inclusion of a telemonitoring component seems to increase the effect of telemedicine.

Impact of Telehealth Care among Adults Living with Type 2 Diabetes in Primary Care: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Primary health care physicians are increasingly offering telehealth services to patients not only for its cost and time saving advantages but for the additional benefits telehealth can provide for patients with type 2 diabetes (T2D) such as improved self-management behaviours. To support the development of telehealth based T2D clinical care models in primary health care settings, a narrative synthesis and meta-analysis of randomised controlled trial studies was completed for 29 studies that evaluated the effect of one or more types of telehealth interventions on HbA1c levels compared to usual care alone. Results from the random effects meta-analysis demonstrated that telehealth interventions had a stronger influence on HbA1c compared to usual care with a mean difference in HbA1c \% -0.18 (CI -0.35, -0.01), p = 0.04. Results from the subgroup meta-analysis demonstrated that telehealth interventions, when grouped by type of telemonitoring (mHealth and telephone communication), all have a stronger effect on lowering HbA1c levels; however, none of these findings were significant. Key findings from this review demonstrate that telehealth interventions that address T2D self-management behaviours and have higher levels of health care provider engagement, have greater effects on lowering HbA1c levels compared to usual care alone.

The effectiveness of goal setting on glycaemic control for people with type 2 diabetes and prediabetes: A systematic review and meta-analysis

AIM

This review assessed the effectiveness of interventions using a goal-setting approach on glycaemic control for people diagnosed with prediabetes or type 2 diabetes.

DESIGN

A systematic review guided by the Joanna Briggs Institute methodology for conducting systematic reviews of primary research studies was conducted.

DATA SOURCES

Randomized controlled trials and experimental studies with a minimum follow-up period of 6 months were considered for inclusion. The primary outcome was change in glycaemic control as measured by glycated haemoglobin (%) and/or fasting plasma glucose (mg/dl). A systematic search of seven electronic databases was completed in October 2020.

REVIEW METHODS

Papers meeting the inclusion criteria were critically appraised using the Joanna Briggs Institute tools for critical appraisal followed by data extraction. A Grading of Recommendations Assessment, Development and Evaluation assessment was conducted to assess the overall certainty of the evidence. Fixed-effect meta-analyses were completed to demonstrate the mean effect for each outcome of interest.

RESULTS

Twenty one studies were included in this review. Goal setting was more effective than usual care for glycaemic control in prediabetes at 6 months and at 12 months for fasting plasma glucose (mg/dl) and glycated haemoglobin (%). Goal setting was more effective than usual care for glycaemic control in type 2 diabetes for fasting plasma glucose (mg/dl) at 6 months, fasting plasma glucose (mg/dl) at 12 months, glycated haemoglobin (%) at 6 months and glycated haemoglobin (%) at 12 months.

CONCLUSION

The evidence suggests goal setting is effective in supporting people to achieve glycaemic targets in prediabetes and type 2 diabetes.

Use of Virtual Care for Glycemic Management in People With Types 1 and 2 Diabetes and Diabetes in Pregnancy: A Rapid Review

Our objective in this study was to answer the main research question: In patients with diabetes, does virtual care vs face-to-face care provide different clinical, patient and practitioner experience or quality outcomes? Articles (2012 to 2020) describing interventions using virtual care with the capability for 2-way, individualized interactions compared with usual care were included. Studies involving any patients with diabetes and outcomes of glycated hemoglobin (A1C), quality of care and/or patient or health-care practitioner experience were included. Systematic reviews, randomized controlled studies, quasi-experimental trials, implementation trials, observational studies and qualitative analyses were reviewed. MEDLINE and McMaster Health Evidence databases searched in June 2020 identified 59 articles. Virtual care, in particular telemonitoring, combined with a means of 2-way communications provided improvement in A1C similar or superior to usual care, with the strongest evidence for type 2 diabetes. Virtual care was generally acceptable to patients, who expressed satisfaction with their care. Health-care providers recognized benefits but raised issues of technical support, workflow and compensation.

Effect of Telemetric Interventions on Glycated Hemoglobin A1c and Management of Type 2 Diabetes Mellitus: Systematic Meta-Review

Background

Diabetes mellitus is a chronic burden, with a prevalence that is increasing worldwide. Telemetric interventions have attracted great interest and may provide effective new therapeutic approaches for improving type 2 diabetes mellitus (T2DM) care.

Objective

The objective of this study was to analyze the clinical effectiveness of telemetric interventions on glycated hemoglobin A_1c (HbA_1c) specifically and T2DM management generally in a systematic meta-review.

Methods

A systematic literature search was performed in PubMed, CINAHL, Cochrane Library, Web of Science Core Collection, and EMBASE databases from January 2008 to April 2020. Studies that addressed HbA_1c, blood pressure, fasting blood glucose, BMI, diabetes-related and health-related quality of life, cost-effectiveness, time savings, and the clinical effectiveness of telemetric interventions were analyzed. In total, 73 randomized controlled trials (RCTs), 10 systematic reviews/meta-analyses, 9 qualitative studies, 2 cohort studies, 2 nonrandomized controlled studies, 2 observational studies, and 1 noncontrolled intervention study were analyzed.

Results

Overall, 1647 citations were identified. After careful screening, 99 studies (n=15,939 patients; n=82,436 patient cases) were selected by two independent reviewers for inclusion in the review. Telemetric interventions were categorized according to communication channels to health care providers: (1) “real-time video” interventions, (2) “real-time audio” interventions, (3) “asynchronous” interventions, and (4) “combined” interventions. To analyze changes in HbA_1c, suitable RCTs were pooled and the average was determined. An HbA_1c decrease of –1.15% (95% CI –1.84% to –0.45%), yielding an HbA_1c value of 6.95% (SD 0.495), was shown in studies using 6-month “real-time video” interventions.

Conclusions

Telemetric interventions clearly improve HbA_1c values in both the short term and the long term and contribute to the effective management of T2DM. More studies need to be done in greater detail.

Impact and efficacy of mobile health intervention in the management of diabetes and hypertension: a systematic review and meta-analysis

With the continuous development of science and technology, mobile health (mHealth) intervention has been proposed as a treatment strategy for managing chronic diseases. In some developed countries, mHealth intervention has been proven to remarkably improve both the quality of care for patients with chronic illnesses and the clinical outcomes of these patients. However, the effectiveness of mHealth in developing countries remains unclear. Based on this fact, we conducted this systematic review and meta-analysis to evaluate the impact of mHealth on countries with different levels of economic development. To this end, we searched Pubmed, ResearchGate, Embase and Cochrane databases for articles published from January 2008 to June 2019. All of the studies included were randomized controlled trials. A meta-analysis was performed using the Stata software. A total of 51 articles (including 13 054 participants) were eligible for our systematic review and meta-analysis. We discovered that mHealth intervention did not only play a major role in improving clinical outcomes compared with conventional care, but also had a positive impact on countries with different levels of economic development. More importantly, our study also found that clinical outcomes could be ameliorated even further by combining mHealth with human intelligence rather than using mHealth intervention exclusively. According to our analytical results, mHealth intervention could be used as a treatment strategy to optimize the management of diabetes and hypertension in countries with different levels of economic development.

Is Telenursing an Effective Method to Control BMI and HbA1c in Illiterate Patients Aged 50 Years and Older With Type 2 Diabetes? A Randomized Controlled Clinical Trial

Introduction: Telenursing is a simple method to provide and maintain nursing care for patients with chronic illness such as diabetes. This study aimed to determine the effectiveness of telenursing on body mass index (BMI) and glycosylated hemoglobin (HbA1c) in illiterate patients aged 50 years and older with type 2 diabetes.

Methods: A randomized controlled clinical trial was performed. Sixty patients with type 2 diabetes who referred to Aligoodarz diabetes clinic (Lorestan, Iran) were randomly assigned to the intervention and control group. Each patient was assessed before and after intervention for the following clinical parameters: HbA1c by Drew-DS5 analyzer and weight by scale (Sahand BMI electronic scale /Iran). All patients received diabetes self-care training for 3 days before the study. Telephone follow ups were applied in intervention group for 12 weeks. The data were analyzed using chi-square, paired t test and independent t test by SPSS11.

Results: Results showed statistically significant decrease in BMI at the end of the training from 29.28 (3.29) to 28.35 (3.37) kg/m 2 and statistically significant decrease in HbA1c from 8.96 (1.24) to 7.56 (0.71) in the intervention group. The effect size base on Cohen’s formula for BMI and HbA1c was Cohen’s d = 2.85, effect size r = 0.81 and Cohen’s d = 2.04, effect size r = 0.71, respectively.

Conclusion: The findings indicate that nurse-led telephone follow up can increase adherence from treatment program and has beneficial effects on HbA1c and BMI in illiterate patients aged 50 years and older with type 2 diabetes.

eHealth systems for the optimised care of patients with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus is one of the most common diseases worldwide. The demands on health services are rising as more people are diagnosed with the condition. In order to meet this demand, eHealth systems are increasingly being integrated into nursing care.

METHODS

Between November 2018 and February 2019, a literature search was carried out in the databases PubMed and CINAHL.

RESULTS

Twenty articles were found on nurses' use of eHealth systems, the majority with patients with diabetes. From this research, it would seem that eHealth systems have had a proven positive influence on patients' state of health and understanding of therapy. Subjectively perceived communication with the nursing staff also improved. Problems can arise in the implementation phase.

CONCLUSION

In the future, increasingly, nurses will have to integrate eHealth systems into the treatment of patients with type 2 diabetes. It is important that nurses understand such systems in order to guarantee a sustainable and successful implementation.

Telecoaching programme for type 2 diabetes control: a randomised clinical trial

BACKGROUND:

People with diabetes have a high risk of developing micro and macrovascular complications that increase treatment costs and shorten life expectancy. Telecoaching programmes can improve short-term control of diabetes and reduce disease burden.

AIMS:

To analyse the effect of a health telecoaching programme in the control of type 2 diabetes.

METHODS:

A pragmatic clinical trial was carried out. Thirty-one patients with type 2 diabetes were divided into control and intervention groups. The control group received usual nursing care, and those in the intervention group received usual care and telecoaching for 24 weeks.

FINDINGS:

The intervention group improved: measurements of abdominal circumference, systolic and diastolic blood pressure and body mass index; variables related to glycaemic control (fasting venous glucose and glycated haemoglobin/HbA1c); and high-density lipoprotein levels.

CONCLUSION:

The data indicate that telecoaching is an effective tool for diabetes management. It is recommended that the study should be developed to include more people and run over the long term.

The clinical effectiveness of nursing models of diabetes care: A synthesis of the evidence

OBJECTIVES

To determine the clinical effectiveness (glycemic control, other biological measures, cost-effectiveness and patient satisfaction) of primary care nurse-led interventions for diabetes.

DESIGN

A systematic review following methods described for complex interventions and using PRISMA guidelines for reporting was undertaken. Nurse-led care for diabetes can be regarded as a complex intervention requiring the measurement of more than one outcome and for this reason we chose a range of outcomes clinical (symptoms), patient-centred (experiences) and organisational (cost-effectiveness).

DATA SOURCES

An extensive literature search using MEDLINE (PubMed) EMBASE, and CINAHL was conducted.

REVIEW METHODS

Primary studies with adults in primary care with both quantitative (comparison with physician-led care and cost-effectiveness) and qualitative (patient experiences of nurse-led care) methodologies from 2003 until June 2018. All studies were appraised using the Cochrane Collaboration's tool for assessing risk of bias. The appraisal involved evaluation of the degree of risk of bias in selection, performance, detection, attrition and reporting. Because of the complexity of multiple outcomes (quantitative and qualitative) a narrative synthesis was undertaken.

RESULTS

The search generated 18 published studies that met our eligibility criteria. Three randomized controlled trials and one historical control trial found statistically significant differences in glycemic levels in favour of the nurse-led interventions. Two cluster randomized trials, two randomized pragmatic trials and two randomized controlled trials found no differences between groups. The three open-label studies found statistically significant improvements in HbA1c levels. The audit identified that more patients had lower HbA1c levels after the initiation of a nurse-led intervention. Three randomized controlled trials found significant improvements in biological outcomes and one did not. The four studies measuring cost-effectiveness found the nurse-led intervention was associated with less costs. Four studies examined patient satisfaction with nurse-led care and found this was very good.

CONCLUSION

This review which incorporated a broad range of studies to capture the complexity of nurse-led interventions has identified that there is evolving evidence that nurse-led interventions for community treatment of diabetes may be more clinically effective than usual physician-led care.

The Effects of Nurse-Led Multidisciplinary Team Management on Glycosylated Hemoglobin, Quality of Life, Hospitalization, and Help-Seeking Behavior of People with Diabetes Mellitus

AIM

To evaluate the effect of community-nurse-led multidisciplinary team management on glycosylated hemoglobin (HbA1c), quality of life (QOL), hospitalization, and help-seeking behavior in people with type 2 diabetes mellitus (DM).

METHODS

A quasi-experimental trial was conducted among people with type 2 DM from two community centers in China. The intervention group (n = 88) received community-nurse-led multidisciplinary team management for 2 years, while the control group (n = 91) received usual care. Data regarding HbA1c, QOL (assessed by the SF-36), hospitalization, and help-seeking behavior were collected at baseline and at 6, 12, and 24 months.

RESULTS

During the 24-month project, the intervention group demonstrated 1.08% reduction in HbA1c, whereas the control group achieved an increase of 0.45%. The differences between the two groups were statistically significant (P < 0.001). The intervention group showed greater increased in QOL scores (from 66.43 to 70.47, P < 0.001), more decrease in hospitalization (OR = 2.981, 95% CI: 1.016, 8.752 versus OR = 1.189, 95% CI: 0.411, 3.444; P = 0.028) when compared with the control group. The percentage increase of seeking help from nurses in the intervention group (from 12.5% to 57.3%, P < 0.001) was significantly greater than that in the control group after the intervention.

CONCLUSIONS

Nurse-led multidisciplinary team management is an effective intervention for improving glycemic control, QOL, hospitalization, and help-seeking behavior for people with DM in a community.

Personal Health Coaching as a Type 2 Diabetes Mellitus Self-Management Strategy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Personal health coaching (PHC) programs have become increasingly utilized as a type 2 diabetes mellitus (T2DM) self-management intervention strategy. This article evaluates the impact of PHC programs on glycemic management and related psychological outcomes.

DATA SOURCES

Electronic databases (CINAHL, MEDLINE, PubMed, PsycINFO, and Web of Science).

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized controlled trials (RCT) published between January 1990 and September 2017 and focused on the effectiveness of PHC interventions in adults with T2DM.

DATA EXTRACTION

Using prespecified format guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework.

DATA SYNTHESIS

Quantitative synthesis for primary (ie, hemoglobin A1c [HbA1c]) and qualitative synthesis for selected psychological outcomes.

RESULTS

Meta-analyses of 22 selected publications showed PHC interventions favorably impact HbA1c levels in studies with follow-ups at ≤3 months (-0.32% [95% confidence interval, CI = -0.55 to -0.09%]), 4 to 6 months (-0.50% [95% CI = -0.65 to -0.35%], 7 to 9 months (-0.66% [95% CI = -1.04 to -0.28%]), and 12 to 18 months (-0.24% [95% CI = -0.38 to -0.10%]). Subsequent subgroup analyses led to no conclusive patterns, except for greater magnitude of effect size in studies with conventional (2-arm) RCT design.

CONCLUSIONS

The PHC appears effective in improving glycemic control. Further research is required to assess the effectiveness of specific program components, training, and supervision approaches and to determine the cost-effectiveness of PHC interventions.

A systematic review and meta-analysis: Effectiveness of internet empowerment-based self-management interventions on adults with metabolic diseases

AIM

To synthesize the effects of Internet empowerment-based self-management interventions on adults with metabolic diseases.

BACKGROUND

Metabolic diseases are prevalent and burden healthcare systems; they have become a major health problem worldwide. The effects of IESMIs on lifestyle changes have been shown to improve adults' physiological and psychological conditions. However, we found no systematic review evaluating these effects.

DESIGN

Systematic review and meta-analysis of randomized and non-randomized controlled trials, conducted according to the Cochrane handbook.

DATA RESOURCES

A literature search was conducted using the Airiti Library, Association for Computing Machinery, CINAHL, Cochrane Library, Embase, ProQuest, PubMed/MEDLINE and Index of the Taiwan Periodical Literature System databases (earliest-June 2016).

REVIEW METHODS

Two reviewers used the Cochrane Collaboration bias assessment tool to assess the methodological quality of included studies. Extracted data were entered and analysed using RevMan 5.3.5 software. Inverse variance was used to estimate effect sizes. Weighted and standardized mean differences with 95% confidence intervals were calculated using a random effects model. Subgroup and sensitivity analyses were performed.

RESULTS

Twenty-one randomized controlled trials were reviewed. Meta-analysis showed that the intervention significantly improved adults' exercise habits, glycated haemoglobin (HbA1c) levels, body weight, empowerment levels and quality of life.

CONCLUSION

The intervention significantly improve the health status of adults with metabolic diseases, in particular their exercise habits, HbA1c levels, body weight, empowerment and quality of life. The intervention provides more convenient and faster access to healthcare for busy individuals with time constraints. These results suggest that healthcare professionals could develop accessible and friendly interactive online interfaces for patients to expand the use of these interventions in the clinical setting.

Diabetes structured self-management education programmes: a narrative review and current innovations

Both type 1 and type 2 diabetes are associated with long-term complications that can be prevented or delayed by intensive glycaemic management. People who are empowered and skilled to self-manage their diabetes have improved health outcomes. Over the past 20 years, diabetes self-management education programmes have been shown to be efficacious and cost-effective in promotion and facilitation of self-management, with improvements in patients' knowledge, skills, and motivation leading to improved biomedical, behavioural, and psychosocial outcomes. Diabetes self-management education programmes, developed robustly with an evidence-based structured curriculum, vary in their method of delivery, content, and use of technology, person-centred philosophy, and specific aims. They are delivered by trained educators, and monitored for quality by independent assessors and routine audit. Self-management education should be tailored to specific populations, taking into consideration the type of diabetes, and ethnic, social, cognitive, literacy, and cultural factors. Ways to improve access to and uptake of diabetes self-management programmes are needed globally.

Optimizing Glycemic Control in Adults With Type 1 or Type 2 Diabetes Attending a Multidisciplinary Foot Clinic

OBJECTIVES

To determine the impact of a diabetes nurse educator (DNE) on glycemic control in a multidisciplinary diabetes foot (MDF) clinic.

METHODS

A prospective cohort trial to measure the impact of a DNE on glycemic control was conducted in an MDF clinic. Change in glycated hemoglobin (A1C) levels over time was measured against the percentage of patient visits (PPVs) accompanied by a glucose meter and/or diary.

RESULTS

Increasing PPVs were significantly associated with decline in A1C levels in females. Every 10% increase in PPVs resulted in a 0.18% decrease in A1C levels (p<0.0001). To achieve a clinically important decrease of 1% in A1C levels, a 56% increase in PPVs was required. Increased A1C levels were significantly associated with higher baseline A1C levels (p<0.001) and increased hospital days for foot complications (p<0.0052).

CONCLUSIONS

Regular, face-to-face contact with a DNE in an MDF clinic has a positive impact on glycemic control in females.

Effects of telephone call intervention on cardiovascular risk factors in T2DM: A meta-analysis

Background

Mobile health interventions utilising telephone calls are promising tools for diabetes management. However, there is still a lack of convincing evidence demonstrating their beneficial effects on cardiovascular risk factors. The aim of this meta-analysis of randomised controlled trials was to assess the effect of telephone calls on glycaemic control and other cardiovascular risk factors in type 2 diabetes mellitus patients.

Methods

Two independent reviewers searched three online databases (PubMed, the Cochrane Library and EMBASE) to identify relevant English-language randomised controlled trials up to September 2017. Randomised controlled trials that assessed the effects of telephone calls on glycaemic control and other cardiovascular risk factors in type 2 diabetes mellitus patients were included. Effect size was calculated for changes in glycosylated haemoglobin A1c, weight, blood pressure and lipid levels using fixed- or random-effects models.

Results

Eighteen studies involving 3954 patients were included in the meta-analysis. Compared with usual care, telephone calls significantly decreased glycosylated haemoglobin A1c, by 0.12% (95% confidence interval: −0.22% to −0.02%). Univariate regression analysis showed that none of the covariates (number of participants, baseline age, baseline glycosylated haemoglobin A1c, duration of diabetes, call maker, number of calls and duration of study) had an impact on glycosylated haemoglobin A1c. For other cardiovascular risk factors, telephone calls significantly reduced systolic blood pressure by 0.19 mm Hg (95% confidence interval: −0.34% to −0.03%) but non-significantly changed diastolic blood pressure, body mass index, low-density lipoprotein cholesterol, total cholesterol, triglyceride or high-density cholesterol levels.

Conclusions

This meta-analysis supports the hypothesis that telephone calls offer moderate benefits for glycosylated haemoglobin A1c and systolic blood pressure reduction among type 2 diabetes mellitus patients. However, the data remain insufficient regarding the association of telephone calls with lowered diastolic blood pressure, body mass index or improved lipoprotein profiles.

Effect of nurse-led randomised control trials on cardiovascular risk factors and HbA1c in diabetes patients: A meta-analysis

A systematic review and meta-analysis identified 42 randomised control trials comparing a nurse-led intervention with 'usual care' to quantify their effect on glycated haemoglobin (HbA1c) and major cardiovascular risk factors in diabetes patients. All relevant databases were systematically searched for publications to February 2016: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE and Cumulative Index to Nursing & Allied Health Literature (CINAHL). The 42 trials recruited 9955 diabetes patients (5022 randomised to intervention and 4933 to 'usual care'). For patients receiving the nurse-led intervention, compared with 'usual care', there were small but significant mean reductions for HbA1c [-0.28%; 95% CI -0.38%, -0.18%; p-value<0.0001, n=6920] and serum triglyceride levels [-0.27mmol/L; 95% CI -0.49, -0.06; p=0.01, n=1169], and a greater proportion of patients stopped smoking [risk ratio=2.70; 95% CI 1.35, 5.43; p=0.005, n=1890 patients]. Mean reductions for systolic [-1.84mmHg; 95% CI -3.97, -0.10; p=0.06, 4241 patients] and diastolic [-0.95mmHg; 95% CI -2.15, -0.25; p=0.12, 3811 patients] blood pressures trended towards significance. There were no significant mean reductions for body mass index or serum cholesterol. Nurse-led interventions produced greater improvements than 'usual care' for HbA1c, serum triglyceride and smoking cessation and support an increased independent role for nurses in diabetes management.

Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis

BACKGROUND

Diabetes self-management education is an essential part of diabetes care, but its impact on all-cause mortality risk of type 2 diabetes patients is unclear. A systematic review and meta-analysis aiming to elucidate the impact of diabetes self-management education on all-cause mortality risk of type 2 diabetes patients was performed.

METHODS

Randomised controlled trials were identified though literature search in Medline, Embase, CENTRAL, conference abstracts, and reference lists. Only randomised controlled trials comparing diabetes self-management education with usual care in type 2 diabetes patients and reporting outcomes after a follow-up of at least 12 months were considered eligible. Risk ratios with 95 %CIs were pooled. This study was registered at PROSPERO with the number of CRD42016043911.

RESULTS

42 randomised controlled trials containing 13,017 participants were included. The mean time of follow-up was 1.5 years. There was no heterogeneity among those included studies (I ² = 0 %). Mortality occurred in 159 participants (2.3 %) in the diabetes self-management education group and in 187 (3.1 %) in the usual care group, and diabetes self-management education significantly reduced risk of all-cause mortality in type 2 diabetes patients (pooled risk ratios : 0.74, 95 %CI 0.60-0.90, P = 0.003; absolute risk difference: -0.8 %, 95 %CI -1.4 to -0.3). Both multidisciplinary team education and nurse-led education could significantly reduce mortality risk in type 2 diabetes patients, and the pooled risk ratios were 0.66 (95 %CI 0.46-0.96, P = 0.02; I ² = 0 %) and 0.64 (95 % CI 0.47- 0.88, P = 0.005; I ² = 0 %), respectively. Subgroup analyses of studies with longer duration of follow-up (≥1.5 years) or larger sample size (≥300) also found a significant effect of diabetes self-management education in reducing mortality risk among type 2 diabetes. Significant effect of diabetes self-management education in reducing mortality risk was also found in those patients receiving diabetes self-management education with contact hours more than 10 h (pooled risk ratio: 0.60, 95 %CI 0.44-0.82, P = 0.001; I ² = 0 %), those receiving repeated diabetes self-management education (pooled RR: 0.71, P = 0.001; I ² = 0 %), those receiving diabetes self-management education using structured curriculum (pooled risk ratio: 0.72, P = 0.01; I ² = 0 %) and those receiving diabetes self-management education using in-person communication (pooled risk ratio: 0.75, P = 0.02; I ² = 0 %). The quality of evidence for the effect of diabetes self-management education in reducing all-cause mortality risk among type 2 diabetes patients was rated as moderate according to the Grading of Recommendations Assessment, Development, and Evaluation method, and the absolute risk reduction of all-cause mortality of type 2 diabetic patients by diabetes self-management education was estimated to be 4 fewer per 1000 person-years (from 1 fewer to 6 fewer).

CONCLUSIONS

The available evidence suggests that diabetes self-management education can reduce all-cause mortality risk in type 2 diabetes patients. Further clinical trials with longer time of follow-up are needed to validate the finding above.

Patient and provider acceptance of telecoaching in type 2 diabetes: a mixed-method study embedded in a randomised clinical trial

Background

Despite advances in diagnosis and treatment of type 2 diabetes, suboptimal metabolic control persists. Patient education in diabetes has been proved to enhance self-efficacy and guideline-driven treatment, however many people with type 2 diabetes do not have access to or do not participate in self-management support programmes. Tele-education and telecoaching have the potential to improve accessibility and efficiency of care, but there is a slow uptake in Europe. Patient and provider acceptance in a local context is an important pre-condition for implementation. The aim of the study was to explore the perceptions of patients, nurses and general practitioners (GPs) regarding telecoaching in type 2 diabetes.

Methods

Mixed-method study embedded in a clinical trial, in which a nurse-led target-driven telecoaching programme consisting of 5 monthly telephone sessions of +/− 30 min was offered to 287 people with type 2 diabetes in Belgian primary care. Intervention attendance and satisfaction about the programme were analysed along with qualitative data obtained during post-trial semi-structured interviews with a purposive sample of patients, general practitioners (GPs) and nurses. The perceptions of patients and care providers about the intervention were coded and the themes interpreted as barriers or facilitators for adoption.

Results

Of 252 patients available for a follow-up analysis, 97.5 % reported being satisfied. Interviews were held with 16 patients, 17 general practitioners (GPs) and all nurses involved (n = 6). Themes associated with adoption facilitation were: 1) improved diabetes control; 2) need for more tailored patient education programmes offered from the moment of diagnosis; 3) comfort and flexibility; 4) evidence-based nature of the programme; 5) established cooperation between GPs and diabetes educators; and 6) efficiency gains. Most potential barriers were derived from the provider views: 1) poor patient motivation and suboptimal compliance with “faceless” advice; 2) GPs’ reluctance in the area of patient referral and information sharing; 3) lack of legal, organisational and financial framework for telecare.

Conclusions

Nurse-led telecoaching of people with type 2 diabetes was well-accepted by patients and providers, with providers being in general more critical in their reflections. With increasing patient demand for mobile and remote services in healthcare, the findings of this study should support professionals involved in healthcare policy and innovation.

Trial registration

NCT01612520, registered prior to recruitment on 4th June 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0383-3) contains supplementary material, which is available to authorized users.

Delivering Diabetes Education through Nurse-Led Telecoaching. Cost-Effectiveness Analysis

BACKGROUND

People with diabetes have a high risk of developing micro- and macrovascular complications associated with diminished life expectancy and elevated treatment costs. Patient education programs can improve diabetes control in the short term, but their cost-effectiveness is uncertain. Our study aimed to analyze the lifelong cost-effectiveness of a nurse-led telecoaching program compared to usual care in people with type 2 diabetes from the perspective of the Belgian healthcare system.

METHODS

The UKPDS Outcomes Model was populated with patient-level data from an 18-month randomized clinical trial in the Belgian primary care sector involving 574 participants; trial data were extrapolated to 40 years; Quality Adjusted Life Years (QALYs), treatment costs and Incremental Cost-Effectiveness Ratio (ICER) were calculated for the entire cohort and the subgroup with poor glycemic control at baseline ("elevated HbA1c subgroup") and the associated uncertainty was explored.

RESULTS

The cumulative mean QALY (95% CI) gain was 0.21 (0.13; 0.28) overall and 0.56 (0.43; 0.68) in elevated HbA1c subgroup; the respective incremental costs were €1,147 (188; 2,107) and €2,565 (654; 4,474) and the respective ICERs €5,569 (€677; €15,679) and €4,615 (1,207; 9,969) per QALY. In the scenario analysis, repeating the intervention for lifetime had the greatest impact on the cost-effectiveness and resulted in the mean ICERs of €13,034 in the entire cohort and €7,858 in the elevated HbA1c subgroup.

CONCLUSION

Taking into account reimbursement thresholds applied in West-European countries, nurse-led telecoaching of people with type 2 diabetes may be considered highly cost-effective within the Belgian healthcare system.

TRIAL REGISTRATION

NCT01612520.