A randomized, controlled comparison of instruction by a diabetes educator versus self-instruction in self-monitoring of blood glucose

Clinical Audit on Hypoglycaemic Symptoms in Type 2 Diabetic Patients in SingHealth Polyclinics

Introduction:

Hypoglycaemia is an important complication of type 2 diabetes mellitus treatment, because it causes recurrent physical and psycho-social morbidity, and it is sometimes fatal. Achieving target glycaemic goals while avoiding hypoglycaemia is a major challenge in the management of patients with type 2 diabetes mellitus. Awareness of hypoglycaemia is a function of the knowledge and experience of an individual, as well as the physiological responses to low glucose concentrations. Our team conducted an audit to identify the prevalence and underlying causes of hypoglycaemic symptoms among type 2 diabetes mellitus patients seen in SingHealth Polyclinics. This data was collected as part of our efforts to improve diabetes care and increase awareness.

Methods:

Audit in the form of nurse-administered interviews were carried out on 120 type 2 diabetic patients seen in the Family Physician Clinic; they were 20 consecutive patients seen in each of 6 polyclinics. The questionnaire included both patient and nurse components, identifying hypoglycaemic symptoms, causes, related hospital admissions, self-management, current treatment and control.

Results:

Of the 120 patients audited, 31 (26%) reported hypoglycaemic symptoms. These patients with hypoglycaemic symptoms were more likely to be on insulin treatment than those without symptoms (p=0.000). Majority of patients with symptoms did not use the glucometer when they experienced these symptoms (19/31). The cause of hypoglycaemic symptoms was often meal-related. For patients not on insulin, those with hypoglycaemic symptoms were more likely to own a glucometer than those without symptoms (p=0.033).

Conclusion:

Hypoglycaemia is a common complication of diabetic treatment, and efforts should be focused especially on insulin-treated patients to prevent hypoglycaemia, including education on hypoglycaemia awareness, self-monitoring of blood glucose and dietary advice.

Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups

BACKGROUND

Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes.

SEARCH STRATEGY

We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals.

SELECTION CRITERIA

RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups.

AUTHORS' CONCLUSIONS

Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.

Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes

PURPOSE

This meta-analysis was conducted to assess the effect of educational and behavioral interventions on body weight and glycemic control in type 2 diabetes.

METHODS

Studies selected for analysis were published randomized controlled trials that evaluated educational and behavioral interventions (no drug interventions) in type 2 diabetes (sample size > or = 10). These criteria were applied to searches of electronic databases and relevant bibliographies. Data were independently abstracted by 2 reviewers and adjudicated by consensus.

RESULTS

Of the 63 articles that met the inclusion criteria, 18 provided enough information for pooled estimates of glycohemoglobin (total Ghb, HbA1, or HbA1C). These 18 studies yielded 2720 participants (sample sizes of 18 to 749). Interventions ranged from 1 to 19 months; follow-up ranged from 1 to 26 months. Glycohemoglobin was reduced by a mean of 0.43%. When results were stratified by quality score, glycohemoglobin was -0.50% and -0.38% for studies with high and low quality scores, respectively. When weighting studies by sample size, fasting blood glucose was reduced by 24 mg/dL and weight by 3 lbs.

CONCLUSIONS

Previous educational and behavioral interventions in type 2 diabetes have produced modest improvements in glycemic control. Future research should refine such interventions and improve methodology.

Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials

OBJECTIVE

To systematically review the effectiveness of self-management training in type 2 diabetes.

RESEARCH DESIGN AND METHODS

MEDLINE, Educational Resources Information Center (ERIC), and Nursing and Allied Health databases were searched for English-language articles published between 1980 and 1999. Studies were original articles reporting the results of randomized controlled trials of the effectiveness of self-management training in people with type 2 diabetes. Relevant data on study design, population demographics, interventions, outcomes, methodological quality, and external validity were tabulated. Interventions were categorized based on educational focus (information, lifestyle behaviors, mechanical skills, and coping skills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle behaviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease risk factors; and economic measures and health service utilization.

RESULTS

A total of 72 studies described in 84 articles were identified for this review. Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in studies with short follow-up (<6 months). Effects of interventions on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions that used regular reinforcement throughout follow-up were sometimes effective in improving glycemic control. Educational interventions that involved patient collaboration may be more effective than didactic interventions in improving glycemic control, weight, and lipid profiles. No studies demonstrated the effectiveness of self-management training on cardiovascular disease-related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited.

CONCLUSIONS

Evidence supports the effectiveness of self-management training in type 2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness of self-management interventions on sustained glycemic control, cardiovascular disease risk factors, and ultimately, microvascular and cardiovascular disease and quality of life.

Diabetes patient education research: an integrative literature review

PURPOSE

The purpose of this study is to summarize the accumulated state of knowledge in the area of diabetes patient education research and highlight important issues that research has left unanswered.

METHODS

An integrative literature review was conducted on the topic of diabetes patient education between the years 1985 and 1998. Keywords used in the computerized search were diabetes mellitus, patient education, health education, research, and behavior change. The databases searched were MEDLINE, CINAHL, HealthSTAR, EMBASE, and CHID-HE. A total of 78 papers were reviewed.

RESULTS

Most studies lacked a theoretical framework and the majority of studies were conducted in an outpatient setting. HbA1c was the most frequently employed outcome measure, with little, if any, description of the interventions.

CONCLUSIONS

Much has been learned in terms of the effectiveness of diabetes education on improving knowledge. However, other topic areas and outcomes need further exploration.

Meta-analysis of diabetes patient education research: variations in intervention effects across studies

Data from a previously reported meta-analysis of diabetes patient education literature were reanalyzed to determine the influence of study/subject characteristics, such as study quality and age of subjects, on patient outcomes. Patient knowledge and self-management skills, weight loss, glycosylated hemoglobin levels, and psychological outcomes were analyzed as outcome variables. Seventy-three relevant published and unpublished studies were located. Patient education appeared to be more effective in younger patients, particularly for the knowledge outcome. For all patients, glycosylated hemoglobin levels improved between 1 and 6 months postintervention, but decreased to 1-month levels after 6 months. Length of the educational intervention did not appear to influence outcomes. More rigorous, experimental research designs tended to produce more conservative effect size estimates. Implications for diabetes patient education are discussed.

Evaluating the validity of blood glucose monitoring strip interpretation by experienced users

This study examined interpretations of blood glucose monitoring strips (BGMS) by patients and registered nurses (RNs) experienced in strip use. Visual interpretations of whole and bisected BGMS were compared with readings obtained with a reflectance meter. For whole strips, statistically significant differences were found when mean values of patient interpretations were compared with two of the three RNs and the meter. A significant difference was found between the average meter values and those for a third RN. When bisected strips were interpreted, a significant interaction effect was found between reader and strip condition. The RNs systematically underestimated bisected strips when compared with whole strips, whereas patients consistently underestimated both whole and bisected strips. The findings support the need for development of quality assurance monitors to evaluate users of patient self-care technologies such as BGMS.

Quality of reporting in diabetes patient education research: 1954-1986

The quality of reported research representing a number of disciplines involved in diabetes patient education was investigated in this study. A rigorous literature search identified 47 studies reported between 1954 and 1986 that met inclusion criteria; 29 were published studies, 18 were unpublished. Quality of the research was measured by Duffy's Research Appraisal Checklist (RAC) and also by coding each study as to the number of threats to internal and external validity present. Overall quality as measured by the RAC ranged from 34 to 95 on a 100-point scale. A statistically significant relationship was found between publication date of the research report and quality, indicating improvement in quality during recent years. Quality of published versus unpublished research reports was not found to differ significantly. Recommendations for improving methodological rigor of future studies include: (a) the use of more rigorous designs, particularly those involving control groups such as randomized clinical trials; (b) reporting of more complete data in research reports; and (c) monitoring of the quality of future studies.

Self-monitoring of blood glucose by adolescents with diabetes: technical skills and utilization of data

Two studies of adolescent patients were conducted to determine their technical skills and utilization of data obtained by self-monitoring of blood glucose (SMBG). In Study 1, direct observations of 58 adolescents revealed an overall SMBG technical accuracy score of 82%. Most frequent errors were not cleaning fingers (45%), not placing blood on strips correctly (21%), and wiping strip at wrong time (14%). Technical performance was inversely correlated with blood glucose concentration, but was unrelated to other variables. In Study 2, a questionnaire was used to determine SMBG practices among 64 adolescents. Although the majority of patients reported doing daily SMBG, most did not record results in logbooks every time or utilize such data for self-management. No significant relationships were found between SMBG behaviors and other variables. We conclude that periodic evaluation and retraining are required for maintenance of SMBG skills and that methods to enhance utilization of SMBG data be developed for this patient population.