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Effectiveness of self care interventions in diabetes Debbie Baldie; Martyn Jones; Thilo Kroll; Steve MacGillivray; Ali Zohoor The wider ‘scoping review’ A review of reviews – Have any reviews considered effectiveness of secondary prevention interventions in the following areas? Stroke? Cardiovascular disease? Diabetes? Dementia? Diabetes Findings: the reviews 32 reviews were included – 15 systematic reviews focused on Type II diabetes – 9 systematic reviews included both Type I and II diabetes The remaining reviews did not specify the diabetes type – 12 included meta-analysis Interventions Most systematic reviews focused on: • Self monitoring of blood glucose (SMBG) self monitoring interventions with the primary goal to enhance metabolic control as measured by blood glucose and (HbA1c). • Diabetes self management education (DSME) Self monitoring of blood glucose (SMBG) 5 reviews highlight that there is little evidence to demonstrate that SMBG improves glycaemic control. There was no evidence linking self monitoring to any other outcome areas (behavioural, cognitive-affective, cost). SMBG The importance of self-monitoring is recognised for insulin-using patients Evidence is still emerging in support of self- monitoring for patients with type 2 diabetes – Recent meta-analyses support the benefit of self- monitoring in non-insulin-treated patients. Additional work is needed to establish optimal frequency and timing of SMBG Educational and behavioural interventions 12 reviews found positive effects of various educational and behavioural interventions on metabolic control, insulin doses, blood pressure and weight. However, the mechanisms between interventions and outcomes are poorly understood. 17 out of 19 reviews concluded that behavioural /educational interventions are effective in improving diabetes related outcomes, including self management. Diabetes Self Management Education An interactive, collaborative, ongoing process involving the person with diabetes and the educator(s). 1. assessment of the individual’s specific education needs; 2. identification of the individual’s specific diabetes self- management goals; 3. education and behavioural intervention directed toward helping the individual achieve identified self-management goals; 4. evaluation of the individual’s attainment of identified self- management goals. DSME: the importance DSME is a critical component of diabetes treatment (Padgett et al, 1988) The majority of individuals with diabetes do not receive any formal diabetes education (Coonrod et al, 1994). DSME: the need The individual with diabetes needs the knowledge and skills to: – make informed choices, to facilitate self-directed behaviour change (Brown,1990). – reduce the risk of complications (DCCTRG, 1993). Patients who never received diabetes education show a striking 4-fold increased risk of a major complication (Nicolucci et al, 1996). DSME – earlier review evidence Earlier reviews have reported positive effects on patient knowledge, self-care behaviors, metabolic control, and psychological outcomes. However, the most consistent finding was incomplete and inadequate descriptions of the interventions Brown S. Nurs Res 1988;37:223–30; Brown S. Res Nurs Health 1992;15:409–19.; Padgett D. J Clin Epidemiol 1988;41:1007– meta-regression suggests: several attributes of patient education that seem to predict improved glycaemic control: – face-to-face interaction; – a cognitive reframing teaching method; – exercise content What about other outcomes? Glycaemic control is only one of several important outcomes for patients with diabetes. The use of behaviours, not glycaemic control, may be more useful and appropriate However, in the current state of diabetes patient education literature, these outcomes are not uniformly available or uniformly measured. DSME: selected primary evidence DSME has been shown to be most effective when delivered by a multidisciplinary team with a comprehensive plan of care (e.g. Koproski et al, 1997). Nurses have been utilized most often as instructors in the delivery of formal DSME (e.g. Weinberger et al, 1995). It is essential in this collaborative and integrated team approach that individuals with diabetes assume an active role in their care (Schultz & Sheps, 1994). DSME: the evidence Demographic variables, such as ethnic background, formal education level, reading ability, and barriers to participation in education, must be considered to maximize the effectiveness of self-management education. (e.g. Davis et al, 1990). Implications for socially disadvantaged groups Three of the included reviews focused on ethnic/racial minorities. – Only one of the reviews included in this scoping exercise provided information on socially disadvantaged groups. It is possible that social deprivation has been a factor in some primary studies but that they have been masked by other variables such as ethnicity, education etc. Experimental designs using RCTs often explicitly exclude people from marginalized groups Evidence in the long-term There is insufficient evidence for the contention that diabetes self management can reduce long-term diabetes complications such as cardiovascular disease and mortality. Some reviews have argued that nephropathies and retinopathies appear to be reduced as a result of diabetes self management. – It is unclear whether outcomes can be clearly attributed to self management. Conclusion Data synthesis ongoing Data exists but is limited methodologically Data specific to socially disadvantaged groups are not included in the review literature Data support educational and behavioural interventions
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