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EvidenceResear
Laira G
Darianne E
Khrystina F
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Self-Management Education
for Adults With Type 2Diabetes
A meta-analysis of the
effect on glycemic controlBy:
Susan L. Norris, MD, MPH1,Joseph Lau, MD2,
S. Jay Smith, MIS, MSC3,Christopher H. Schmid, PHD4andMichael M. Engelgau, MD, MSC1
http://care.diabetesjournals.org/search?author1=Susan+L.+Norris&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=Joseph+Lau&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=S.+Jay+Smith&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=Christopher+H.+Schmid&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=Michael+M.+Engelgau&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=Michael+M.+Engelgau&sortspec=date&submit=Submithttp://care.diabetesjournals.org/search?author1=Michael+M.+Engelgau&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=Christopher+H.+Schmid&sortspec=date&submit=Submithttp://care.diabetesjournals.org/search?author1=Christopher+H.+Schmid&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=S.+Jay+Smith&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=Joseph+Lau&sortspec=date&submit=Submithttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?author1=Susan+L.+Norris&sortspec=date&submit=Submit7/27/2019 Evidence-Based Research Study - DSME
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ABSTRACT
OBJECTIVETo evaluate the efficacy of
self-management educationGHb in adults with type 2 diab
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RESEARCH DESIGN AND METHODS
Wesearched for English language trials in Medline
(19801999), Cinahl (19821999), and the Educational Information Center database (ERIC) (19801999), and wsearched review articles, journals with highest topic relereference lists of included articles. Studies were included ifrandomized controlled trials that were published in the Englistested the effect of self-management education on adults w
diabetes, and reported extractable data on the effect of treGHb. A total of 31 studies of 463 initially identified articles mcriteria. We computed net change in GHb, stratified by follow-tested for trial heterogeneity, and calculated pooled effectsrandom effects models. We examined the effect of baseline Gup interval, and intervention characteristics on GHb.
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RESULTS
On average, the intervention decreased GHb
(95% CI 0.341.18) more than the control
immediate follow-up; by 0.26% (0.21% increas
decrease) at 13 months of follow-up; and
(0.050.48) at 4 months of follow-up. GHb d
more with additional contact time between p
and educator; a decrease of 1% was noted
additional 23.6 h (13.3105.4) of contact.
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CONCLUSIONS
Self-management education improves
GHb levels at immediate follow-up, and i
contact time increases the effect. The benefit
13 months after the intervention ceases, h
suggesting that learned behaviors change ovFurther research is needed to develop inter
effective in maintaining long-term glycemic con
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DCCT, Diabetes Control and Complications
Trial
DSME, diabetes self-management education
Diabetes is a common, costly condition associated withmorbidity and mortality (1,2). Recent studies have foun
increases in diabetes during the last decade (3). Diamanagement education (DSME), the process of teachingto manage their diabetes (4), has been considered anpart of the clinical management of individuals with diathe 1930s and the work of the Joslin Diabetes Center (5).
http://care.diabetesjournals.org/search?fulltext=DCCT,+Diabetes+Control+and+Complications+Trial&sortspec=date&submit=Submit&andorexactfulltext=phrasehttp://care.diabetesjournals.org/search?fulltext=DCCT,+Diabetes+Control+and+Complications+Trial&sortspec=date&submit=Submit&andorexactfulltext=phrasehttp://care.diabetesjournals.org/search?fulltext=DSME,+diabetes+self-management+education&sortspec=date&submit=Submit&andorexactfulltext=phrasehttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/content/25/7/1159.fullhttp://care.diabetesjournals.org/search?fulltext=DSME,+diabetes+self-management+education&sortspec=date&submit=Submit&andorexactfulltext=phrasehttp://care.diabetesjournals.org/search?fulltext=DSME,+diabetes+self-management+education&sortspec=date&submit=Submit&andorexactfulltext=phrasehttp://care.diabetesjournals.org/search?fulltext=DSME,+diabetes+self-management+education&sortspec=date&submit=Submit&andorexactfulltext=phrasehttp://care.diabetesjournals.org/search?fulltext=DCCT,+Diabetes+Control+and+Complications+Trial&sortspec=date&submit=Submit&andorexactfulltext=phrasehttp://care.diabetesjournals.org/search?fulltext=DCCT,+Diabetes+Control+and+Complications+Trial&sortspec=date&submit=Submit&andorexactfulltext=phrase7/27/2019 Evidence-Based Research Study - DSME
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The American Diabetes Association recommendsassessment of self-management skills and knowledge ofdiabetes at least annually, and the provision or
encouragement of continuing diabetes education (6).One of the diabetes-related objectives of HealthyPeople 2010 (7) is to increase to 60%, from the 1998baseline level of 40%, the proportion of individuals withdiabetes who receive formal diabetes education. Thegoals of self-management education are to optimizemetabolic control, prevent acute and chroniccomplications, and optimize quality of life, whilekeeping costs acceptable (8). There are significantknowledge and skill deficits in 5080% of patients withdiabetes (9), and ideal glycemic control (HbA1c
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A large body of literature has developed on diabetes education
and its efficacy, including several important quantitative
reviews showing positive effects of diabetes education.
However, educational techniques have evolved over the last
decade since these reviews (11,12,13), and they have shiftedfrom didactic presentations to interventions involving patient
empowerment (14,15), with participation and collaboration.
The objective of this study was to systematically review
reports of published, randomized, controlled trials to ascertain
the efficacy of DSME in adults with type 2 diabetes, providesummary measures of its effect on GHb, and identify
predictors of effect. This quantitative review focusing on
glycemic control follows an earlier work by Norris et al. (16)
that provided descriptive details and a qualitative summary of
the efficacy of DSME over a broad range of outcomes.
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RESEARCH DESIGN AND METHODS
Data sources
We searched the English-language medical literature publishJanuary 1980 and December 1999 using the Medline dataNational Library of Medicine, the Educational Resources Center database (ERIC), and the Nursing and Allied Heal(Cinahl), which commenced in 1982. The medical subject head
we searched were healtheducation combined with diabetincluding all subheadings. Searches were confined to the Englbecause in a recent study, effect sizes did not differ siglanguage-restricted meta-analyses compared with language-in(17), and there is some evidence of lower quality in the medical literature (18).
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RESEARCH DESIGN AND METHODS
Abstracts were not included because they generally had
information to assess the validity of the study by the criteria meta-analysis. Dissertations were also excluded because th
abstracts contained insufficient information for evaluation and
was rarely available. We reviewed titles of articles extracted by
for relevance to the efficacy of diabetes education, and we re
full-text articles for those that were potentially relevanautomated databases are incomplete (19,20), we manual
journals expected to have the highest relevance. The
were: Diabetes Care, The Diabetes Educator,Diabetes Research
Practice, Diabetologia, and Diabetic Medicine. Experts in t
diabetes education were consulted for additional relevant citatio
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Study selection
We selected reports of randomized controlled trials because this
design generally supports maximum validity and causal inferenreviewed only studies in which all or most subjects had type 2 diabet
of diabetes was unclear, then the study was included if the mean
years because most of these patients were likely to have type 2
examine as broadly as possible the efficacy of diabetes self-
education, we included studies of subjects >18 years of age with typ
with any degree of disease severity and any comorbidity. We interventions in all settings, and we did not exclude interventio
provider type, medium (written, oral, video, or computer), wheth
individual or group based, or duration and intensity. We included stu
other interventions were delivered in addition to DSME only if the
educational component could be examined separately. We included
reported GHb outcomes, including total GHb, HbA1, or HbA1c.
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RESEARCH DESIGN AND METHODS
Data extraction
Data from eligible studies were extracted by one of the authand all extracted data were checked by a second person (PhyExtraction was not blinded to author or institution becauseevidence that blinding decreases bias in the conduct of systemand meta-analyses (22,23). We included only data reported i
we did not attempt to contact the authors due the lengthy peover which these studies were published and concerns regbias in the information that might be provided (24). Data weron participant characteristics, including age, diabetes treatmwith or without oral hypoglycemic agents, diet only, or dihypoglycemic agents), baseline GHb, and psychosocial attribut
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RESEARCH DESIGN AND METHODS
We classified DSME interventions into one of the following categoprimary educational focus, as described previously (16): k
information; lifestyle behaviors (including diet and physical adevelopment, including skills to improve glycemic control (e.g., self-blood glucose) as well as skills to prevent and identify complicatiocare); and coping skills (to improve psychosocial function, including that used empowerment techniques or promoted relaxation or selfsubclassified studies with a focus on knowledge or information by preducational approach, which could be didactic or collaborative. Dida
occurred when the patient attended to the information but did notthe instructor or participate actively in teaching sessions. Collaboratoccurred when the patient participated actively in the learning pmight include group discussions, or when teaching techniqempowerment (14), individualized goal-setting, or modeling. Wlifestyle, skill development, and coping skills education to be collabor
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RESEARCH DESIGN AND METHODS
We extracted a number of other intervention cha
including individual versus group education, use of self-of blood or urine glucose, number of contacts of the pthe educator, total contact time (number of contacts mduration of each contact, in hours), the time frame oveintervention was delivered (in months), who delintervention, whether computer-assisted instruction was
what treatment the control group received (type of inteany; number of contacts; and total contact time). We alshealth care system characteristics (including whether awith a primary care provider was documented) and seinpatient, outpatient clinic, home, or community center)
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RESEARCH DESIGN AND METHODS
We assessed internal validity based on
methodology (25). We examined each study forselection, attrition, and detection bias becaubiases are thought to have significant efmeasured outcomes in intervention studies
noted attrition as a potential bias if >20% oenrolled subjects dropped out before data collecdropouts were not compared or were noequivalent to completers at baseline.
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RESEARCH DESIGN AND METHODS
GHb concentrations were measured with a variety of
techniques. Most studies used ion-exchange methodsand reported either HbA1 or HbA1c. A few studiesmeasured total GHb by affinity chromatography.However, because within-group differences were usedto calculate pooled effects, analytic bias amonglaboratories is largely removed. A formula based onsample comparison data was used to convert
HbA1 results to HbA1c equivalents in six studies(27,28,29,30,31,32), where there was sufficient detailto determine the exact measurement technique andwhere the relationship to HbA1c was established (33).
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RESEARCH DESIGN AND METHODS
We stratified studies a priori by follow-up interval, because d
diabetes education literature (16,34) and behavioral researfields (35,36,37) suggest that positive outcomes diminish ove
the end of an intervention. We categorized follow-up interv
occurring during the course of an intervention or immediate
the last educator-patient contact, 13 months from the
intervention, or 4 months from the end of the interventioncontributed only one outcome measure to each follow-up st
the most distal measure if the study reported more tha
measure within a stratum. We performed analyses on the
studies where only usual care was delivered to the control gro
in some studies an intervention, usually less intensive, was
the comparison group.
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RESEARCH DESIGN AND METHODS
We calculated the mean difference between the intervention
group () for each individual study, which is equal to IC, wC are the absolute differences in GHb between each follow
baseline measure for each study group. The estimate of varian
C was calculated from the GHb measures in each study gro
formula Vpre + Vpost 2r(SEpre SEpost), where Vpre is the var
mean baseline GHb, Vpost is the variance of the mean follow-the correlation between the baseline and follow-up values, a
SEpost are the standard errors of the baseline and follow
respectively. The variance of was then calculated as the
variance ofI and the variance ofC. Because no studies rep
true value is unknown, a sensitivity analysis was performed us
0.25, 0.5, and 0.75.
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RESEARCH DESIGN AND METHODS
Three studies (38,39,40) reported the SE of the difference forintervention and control groups, and these values were usedthe variance of for these studies.
If the mean baseline GHb value of either the intervention or cwas missing, we assumed that it was the same as the othestudy had several different intervention groups, we averagevariances within each study, weighted by the sample size (8,2
46). In several studies, GHb point estimates and CIs were notnumeric form, and they were estimated from graphs (28,30,4SE was missing for the control or intervention groups at baseliup, then it was assumed to be the same as the value repoother group (27,29,30,42,43,49).
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RESEARCH DESIGN AND METHODS
In one study variance was calculated from the P value(50). If only the range was given as the measure ofvariation, then the SD was calculated as the range dividedby 5.88 (6 SDs) (28). In several studies, the measure ofvariance was unclear or was assumed to be labeledincorrectly. In one study (40), we assumed that the statedvariance was actually the SD; in a second (51,52), weassumed it to be the SE; in a third (47), we assumed a SD
rather than a SE. In studies that involved crossoverdesigns, follow-up comparison was made before thecomparison group received the intervention(53,54,55,56). One study (57) had two comparisongroups, and the randomized control group was used asthe comparison group.
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RESEARCH DESIGN AND METHODS
For the meta-analysis, we report the results of randomeffects models, which account for variability among studies.
We computed the between-study variance for the randomeffects model using the DerSimonian and Laird formula (58),and we report the P values for the 2 test to evaluateheterogeneity (Q).
The goal of the meta-regression was to determine whether was influenced by the time frame over which theintervention was delivered, the length of follow-up, the
initial GHb, the number of contacts with subjects, or totalcontact time. We examined interaction terms for all models.Mathcad 2001 Professional (MathSoft, Cambridge, MA) wasused to perform the meta-analysis, and SAS (version 8.01;SAS Institute, Cary, NC) was used for the meta-regression.
RESULTS
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RESULTS
The flow diagram for this review is
depicted in Fig. 1. We found 72randomized controlled trials thatexamined the efficacy of DSME on avariety of outcomes, and these have beenpreviously reviewed with a narrative
summary (16). Of these studies, 40examined GHb outcomes. We excludednine of these from the meta-analysis for avariety of reasons.
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RESULTS
Five were excluded for design issues: Noel e
compared choice versus no choice groups, and rstandard versus nutrition education were not pseparately; Anderson et al. (60) measured GHbintervention for both control and intervention gcross-over design study; Gilden et al. (44) ra
only the two intervention groups and not thgroup; Wing et al. (61) presented only combinedthe two groups at baseline and follow-up; and al. (62) presented only percentage change.
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RESULTS
Three studies were excluded for GHb mea
issues: Pratt, Wilson, and colleagues (46,63) mGHb in nanomoles per fructose equivalent, whcomparable to units used in all other studies,unit of measurement used by Lo et al. (64) waThe study by Mazzuca et al. (31) was not includ
meta-analysis or the meta-regression becmeasure of variation was reported, but it was inthe presentation of descriptive information (T3 and theAPPENDIX).
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RESULTS
The study by Arseneau et al. (65) fulfilled
criteria but was felt to be conceptually
because the intervention involved an intens
course for both the intervention and contro
with an additional individual dietary interve
the intervention group. Analyses were pe
with and without this study, with no chang
direction or significance of effect.
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RESULTS
A number of studies had more than one
measure. If these measures were reported in opredefined follow-up intervals (intermedia
months, and 4 months), then they were analyz
each stratum. If a study reported more than one
within a stratum, then we used only the last Thus, 37 estimates of GHb were included in t
analysis (total number of participants [N] = 3,73
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RESULTS
Meta-analysis
The characteristics of the clinical trials includemeta-analysis are presented in Table 1, and demographic, intervention, and design charaequally weighted by study, are presented in
(Further details on the individual studies arethe APPENDIX.) Results for GHb outcomes are pin Fig. 2 and Table 3, and those for the metastratified by follow-up interval, are presented in
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Meta-analysis results
The subgroup of studies where the comparison group received usual care and no additiona
constituted 58% of all studies, and results differed little from the overall results (Table 4).
Table 4
Study group and follow-up
interval Number of studies Qsignificance level
Point estimate (net change in
GHb [%]) 95%
All studies
During or immediately
after the intervention
20 0.10 0.26 0.74 months 8 >0.10 0.26 0.4
All studies where the
comparison group receives
usual care
During or immediately
after the intervention
12 0.10 0.11 0.5
4 months 5 >0.10 0.28 0.5
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RESULTS
Meta-regression
Using as the dependent variable, we performed ameta-regression to investigate potential treatmentinteractions, with patient age, baseline GHb,treatment (insulin, diet-only, or oral hypoglycemicagents), the number of contacts with theintervention subjects during the study, total contacttime (in hours), time frame over which the
intervention was delivered (in months), group versusindividual presentation of the intervention, whodelivered the intervention, educational focus(lifestyle, skills, knowledge, coping skills, or mixed),follow-up interval (in months), and setting in the U.S.versus other countries as the independent variables.
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RESULTS
None of the interactions was significant, except
contact time, which was reported in additionumber of contacts in 15 studies, with a total o
measurements. In these studies, GHb was re
0.04% (95% CI 0.010.08) for every additiona
contact time, over the range of 128 h. This imon average, 23.6 h of contact between the edu
patient are needed to achieve a 1% reduction in
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RESULTS
We did not find any evidence that the studies in which
contact time was reported differed from those in which itwas unreported. Seven studies provided data on contact
time for both intervention and control groups. One of
these studies had a 26-h difference in contact time
between study groups associated with a between-group
difference in GHb of1.8%. In the remaining six studies,there were small differences in contact time between
groups, and a nonsignificant positive relationship was
noted between the difference in contact time and
improved GHb. There were insufficient data to examine
the effects of psychosocial variables on GHb.
CONCLUSIONS
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CONCLUSIONS
This meta-analysis provides evidence of the
efficacy of DSME for individuals with type 2 diabeteglycemic control, and it delineates the factors contribute to its efficacy. GHb improves with Dwith an average change of 0.76%, when measure
immediate follow-up. Duration of contact time betweducator and patient was the only significant predof effect, with 23.6 h of contact time needed for 1% absolute decrease in GHb.
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CONCLUSIONS
This study has important implications for currentclinical and public health practice and research.
Glycemic control is an important predictor of many ofthe chronic complications of diabetes (66). Accordingto the U.K. Prospective Diabetes Study (UKPDS), each1% reduction in HbA1c over 10 years is associated withreductions in risk of 21% for any end point related todiabetes, 21% for deaths related to diabetes, 14% for
myocardial infarctions, and 37% for microvascularcomplications (67). No HbA1c threshold value for riskof any complications was observed (67). Thus, theimprovement in GHb of 0.76% at immediate follow-upis clinically significant.
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CONCLUSIONS
The diminishing effect of DSME interventions with longer follow-after the end of the intervention is consistent with the literature
(16,34) andother behavioral interventions focused on weight loss activity (35,36,37). It appears that long-term interventions may bemaintain the improved glycemic control brought about by DSMBecause contact time was the only significant predictor of improvcontrol, it appears that to achieve clinically meaningful effects, imust involve adequate time spent with patients. Other
characteristics did not influence outcomes in our analysis: educa(knowledge or lifestyle), group versus individual presentation,contacts, time frame over which the intervention was deliveredelivered the intervention. A variety of teaching techniques meffective in improving glycemic control, and brief interventions, rthe number of contacts, appear to be less effective. Patient charabaseline GHb and age also did not affect outcomes.
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CONCLUSIONS
There was a wide range of effects on GHb noted in
review, and there are a number of potential reasons foobservation. The characteristics of the interventions va
widely, and they are undoubtedly only partly describe
the variables that we examined. A number of other fa
might explain the heterogeneity in outcomes: 1) pa
factors such as psychosocial mediators; 2) interven
characteristics such as cultural relevancy; and 3) conte
factors such as health care system structure and linkag
primary care.
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CONCLUSIONS
The care delivered to the control group
also varied greatly, and improvements inGHb may be found in that group becauseof the Hawthorne effect, control groupcontamination, and unintended
cointerventions. In several studies therewere greater improvements in the controlthan the intervention group, leading to anet increase in IC (32,48,68).
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CONCLUSIONS
Several meta-analyses have been previouslypublished on this subject. Browns meta-analyses
and meta-regression (11,12,69) support the efficacyof diabetes DSME, with positive effect sizes (fromlargest to smallest) for the outcomes of knowledge,dietary compliance, skill performance, metaboliccontrol, psychological outcomes, and weight loss.She found an effect size of 0.41 for GHb (95% CI0.310.52), indicating a small-to-moderate effectsize. The effect peaked at 16 months after theintervention, with a decline to earlier levels after 6months (69).
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CONCLUSIONS
Brown noted no difference in metabolic control by thelength of the intervention (total minutes of contact) (69).
However, Browns work differs from this meta-analysis inthat it included a variety of study designs, unpublishedliterature, the use of a checklist for quality assessment inthe earlier meta-analysis (70) and a quality score in thelater studies (71), the use of effect sizes, and the removalof outliers to achieve statistical homogeneity. Padgett etal. (13) reviewed the efficacy of diabetes education in1988 and found that approaches based on dietinstruction and social learning were the most effectiveinterventions, and glycemic control and knowledge wereassociated with the most improved outcomes.
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CONCLUSIONS
This study has several important limitations. Thisanalysis was confined to English-language articles,which could introduce bias. However, Moher et al.(17) found that language-restricted meta-analysesoverestimated treatment effect by only 2% onaverage, compared with language-inclusive meta-analyses, although the language-inclusive meta-
analyses were more precise. Publication bias isalways a concern in meta-analyses, and weperformed exhaustive searches and contactedinvestigators in the field to obtain all publishedstudies.
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CONCLUSIONS
Only randomized controlled trials were included in thisreview, although an important body of literature on DSME
exists with other study designs. Randomized controlledtrials in this area of research are not always feasible, oreven desirable, particularly when examining community-based educational interventions. Glasgow et al. (72) notethe increasing importance of recognizing the complexity ofdisease determinants and multilevel system interventions.Classic randomized controlled trials emphasize efficacy, tothe exclusion of factors influencing effectiveness, such asadoption (the proportion and representativeness ofsettings that adopt a policy or program), reach (thepercentage and risk characteristics of persons who receiveor are affected by a program), and institutionalization.
CONCLUSIONS
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CONCLUSIONS
Threats to internal validity were common in
the literature included in this meta-analysis.No study reviewed fulfilled all our criteria forthe absence of selection, performance,attrition, and detection bias. Efforts to addressallocation concealment were mentioned in
only three studies (45,50,73), and one studyrandomized participants by month and year ofbirth (43). Attrition was >20% in one-third ofthe studies.
CONCLUSIONS
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CONCLUSIONS
In the majority of included studies, the intervention groupreceived significantly more contact time than the control
group, but in only seven studies was contact time reported forboth the intervention and control groups. Because contacttime was shown to be an important predictor of effect for theintervention group, it is unfortunate that there were notsufficient data to provide adequate power to examine therelationship between the difference in contact time between
the control and intervention groups and GHb. This importantissue should be addressed in future evaluation studies, eitherby equalizing contact time between groups (e.g., with a shamcounseling intervention), or by reporting contact time for thecontrol and intervention groups and exploring the relationshipwith outcomes.
CONCLUSIONS
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CONCLUSIONS
The studies included in this review use a variety of measure
techniques for GHb. The use of in estimating pooled effectin the meta-regression, and the conversion of HbA
HbA1c (where possible), minimized interlaboratory variati
outcome measures. However, there is likely some an
variation in between studies because GHb standardi
efforts were not widespread until 1996, when the NaGlycohemoglobin Standardization Program began efforts to
GHb determinations traceable to Diabetes Control
Complications Trial (DCCT) (74) values (66). Most of the s
included in this review predate these standardization efforts.
CONCLUSIONS
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CONCLUSIONS
The results of this meta-analysis are likely generalizable to adult
populations and geographic settings because a broad range of
patient age and insulin utilization, intervention characteristics,
and geographic settings were examined, with no evidence that
these characteristics affect outcomes. Generalizability is likely
limited to clinic settings because only four interventions were
delivered outside the clinic: three in the home (56,73,75) and
one in senior centers (46,63). Interventions focused mainly on
lifestyle modification (diet and physical activity) and knowledge
levels, with only one study (68) focusing exclusively on skills
such as self-monitoring of blood glucose and none using coping
skills as the only focus of the intervention. Results thus apply to
lifestyle- and knowledge-focused interventions only.
CONCLUSIONS
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CONCLUSIONS
Further research is needed to better define effec
interventions for reducing GHb in persons with dparticularly interventions aimed at long-termmaintenance of initial behavior change. This woto focus on identifying the predictors and correlaglycemic control (particularly psychosocial attrib
such as depression, social support, and problemskills) and on improving the quality of performanreporting of DSME intervention studies.
CONCLUSIONS
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CONCLUSIONS
This research must provide adequate dinformation, including demographic data, descriptions of interventions (particularly contactboth the intervention and control groups), and the health care delivery system. Measures of should be reported for all outcome measures atraceable GHb measures used (66,74). Allocationconcealed when randomization is performed, and must be paid to minimizing attrition. Target pomust be described and scientifically sampled so thare generalizable to specific populations.
CONCLUSIONS
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CONCLUSIONS
Diabetes and its complications are responsib
tremendous individual and public health busuffering at the present time, and the epiprojected to continue into the future (76). Devidence of the benefits of improved glycemi
for reducing the diabetes burden exists (77). Tare compelled to deliver diabetes care that iglycemic control, and effective diabetes educatintegral part of comprehensive diabetes care.
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Flow diagram
Acknowledgments
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g
This study was funded by the Centers for
Disease Control and Prevention, Atlanta,Georgia.
The authors thank Randie R Little, PhD,for assistance with assessment of GHb
measurements and Phyllis Nichols,
MPH, for technical support.
Footnotes
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Address correspondence and reprint requests to
Susan L. Norris, MD, MPH, Centers for DiseaseControl and Prevention, MS K-10, 4770 Buford
Highway NE, Atlanta, GA 300341. E-
mail: [email protected].
Received for publication 6 October 2001 andaccepted in revised form 11 April 2002.
A table elsewhere in this issue shows conventional
and Systme International (SI) units and conversion
factors for many substances.
LEVEL OF RECOMMENDATION
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LEVEL OF RECOMMENDATION
A - The USPSTF recommendservice. There is high cert
that the net benefit is substaOffer or provide this service.
LEVEL OF QUALITY/EVIDENCE
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LEVEL OF QUALITY/EVIDENCE
Level II-1.
Evidence obtained
from well-designed
controlled trials without
randomization
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RELATEDNESS TO THE PROGRAM
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PROPOSAL The evidence-based research study Self-
Management Education for Adults With TypDiabetes is related to the program proposal
Improving Health of Diabetic Patients throu
use of Self-care Diabetic manual, as it served
basis, which is essential to the formulation o
information regarding the diabetic clients se
RELATEDNESS TO THE PROGRAM
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RELATEDNESS TO THE PROGRAM
PROPOSAL
Moreover, the study aims to lessen the burdpeople having lack of knowledge regarding d
which is also our goal in addition to diabetes
connection, the study contributes to the effe
education that is considered a fundamental m
of comprehensive diabetes care.