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Effectiveness of self care interventions in diabetes - How to do

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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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