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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.

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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

    mailto:[email protected]:[email protected]
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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.