ROMEO: rethink organization to improve education and outcomes

Training physiotherapy students to educate patients: A randomised controlled trial

OBJECTIVE

To determine the effect of a training intervention on physiotherapy students' self-efficacy and skills in the area of patient education.

METHODS

Final year physiotherapy students were randomised to an intervention group or a wait-list control group. The intervention group participated in a 3.5h training intervention about patient education that included video observation, simulated patient practice and structured feedback. The control group did not receive any training. Self-efficacy was assessed at baseline (T1) and after the intervention (or no intervention for the control group) (T2). Patient education performance was assessed by a blinded rater from a video-recorded standardised clinical examination.

RESULTS

83 students were randomised to the intervention group and 81 students to the control group. There were no differences in demographic variables or self-efficacy between groups at baseline. There was significant improvement in self-efficacy for the intervention group, but no change for the control group. The intervention group performed significantly better than the control group for nine of the eleven performance items, with significantly higher scores overall.

CONCLUSION

A training intervention enhances physiotherapy student self-efficacy and performance in patient education.

PRACTICE IMPLICATION

Use of patient education training is recommended to enhance student self-efficacy and performance.

Rethink Organization to iMprove Education and Outcomes (ROMEO): a multicenter randomized trial of lifestyle intervention by group care to manage type 2 diabetes

OBJECTIVE

A trial was performed to establish whether our group care model for lifestyle intervention in type 2 diabetes can be exported to other clinics.

RESEARCH DESIGN AND METHODS

This study was a 4-year, two-armed, multicenter controlled trial in 13 hospital-based diabetes clinics in Italy (current controlled trials no. ISRCTN19509463). A total of 815 non-insulin-treated patients aged <80 years with > or =1 year known diabetes duration were randomized to either group or individual care.

RESULTS

After 4 years, patients in group care had lower A1C, total cholesterol, LDL cholesterol, triglycerides, systolic and diastolic blood pressure, BMI, and serum creatinine and higher HDL cholesterol (P < 0.001, for all) than control subjects receiving individual care, despite similar pharmacological prescriptions. Health behaviors, quality of life, and knowledge of diabetes had become better in group care patients than in control subjects (P < 0.001, for all).

CONCLUSIONS

The favorable clinical, cognitive, and psychological outcomes of group care can be reproduced in different clinical settings.

The Irish DAFNE study protocol: a cluster randomised trial of group versus individual follow-up after structured education for type 1 diabetes

BACKGROUND

Structured education programmes for individuals with Type 1 diabetes have become a recognised means of delivering the knowledge and skills necessary for optimal self-management of the condition. The Dose Adjustment for Normal Eating (DAFNE) programme has been shown to improve biomedical (HbA(1c) and rates of severe hypoglycaemia) and psychosocial outcomes for up to 12 months following course delivery. The optimal way to support DAFNE graduates and maintain the benefits of the programme has not been established. We aimed to compare 2 different methods of follow-up of DAFNE graduates in a pragmatic clinical trial delivered in busy diabetes clinics on the island of Ireland.

METHODS

Six participating centres were cluster randomised to deliver either group follow-up or a return to traditional one-to-one clinic visits. In the intervention arm group follow-up was delivered at 6 and 12 months post DAFNE training according to a curriculum developed for the study. In the control arm patients were seen individually in diabetes clinics as part of routine care. Study outcomes included HbA(1c) levels, self-reported rates of severe hypoglycaemia, body weight and measures of diabetes wellbeing and quality of life. These were measured at 6, 12 and 18 months after recruitment. Generalisability (external validity) was maximised by recruiting study participants from existing DAFNE waiting lists in each centre, by using broad inclusion criteria (including HbA(1c) values less than 13 percent with no lower limit) and by using existing clinic staff to deliver the training and follow-up. Internal validity and treatment fidelity were maximised by quality assuring the training of all DAFNE educators, by external peer review of the group follow-up sessions and by striving for full attendance at follow-up visits. Assays of HbA(1c) were undertaken in a central laboratory.

DISCUSSION

This pragmatic clinical trial evaluating group follow-up after a structured education programme has been designed to have broad generalisability. The results should inform how best to manage the well educated patient with Type 1 diabetes in the real world of clinical practice

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79759174.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

MAIN RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Structured education for people with type 2 diabetes

A step towards a more patient centred approach to delivery of care

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

MAIN RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

MAIN RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Is there life after evidence-based medicine?

Recent years have witnessed the rising star of evidence-based medicine (EBM) as an approach towards rationalizing clinical practice in the face of an exponentially growing body of knowledge. Along with it, however, a sense of unease is rising among practising doctors, as they feel that well-intentioned principles may be increasingly applied to disease management, with its economic and cost-cutting implications, rather than disease cure or treatment. There is a fear that any procedure, however time-honoured, that was not or cannot be subjected to randomized controlled clinical trial, may some day be discouraged, more or less strongly, based on statistical rather than clinical considerations. Resistance to EBM ranges from a 'we-know-best' uncompromising non-acceptance to a 'you-may-be-right-sometimes-but-don't-ever-tell-me-what-to-do' sort of openness. The problem is one of measure, in more than one sense: measure of how effective individual practitioners are in treating their patients, measure of how useful EBM is, measure in promoting what may become a dogmatic application of probability laws to the very improbable practice of medicine, measure in siding with the supporters of health care on a budget. There is much that EBM can give to clinical medicine by its ability to organize complex data sets for the ultimate benefit of patients, but there is also much that can stifle practice by forcing a dogmatic implementation, rather than a flexible common sense approach, of its principles.