Evidence-Based Research Study - DSME

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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=Submit
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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=phrase
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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.

    http://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.full
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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).

    http://care.diabetesjournals.org/content/