Understanding of diabetes prevention studies: questionnaire survey of professionals in diabetes care

A survey on critical health competences among diabetes educators using the Critical Health Competence Test (CHC Test)

BACKGROUND

Diabetes associations claim to have a patient-centered approach in diabetes care including shared decision-making (SDM). Diabetes educators are important healthcare professionals for implementing the concept of informed SDM in diabetes care. They need critical health competences (CHC) in order to provide evidence-based information and to support patients in understanding the risks of the disease and also the possible benefits or harm of the healthcare options. Therefore, we surveyed the CHC of diabetes educators.

METHODS

We performed a cross-sectional survey using the validated Critical Health Competences (CHC) Test to measure CHC of certified diabetes educators and trainees in Germany. Diabetes educators were approached via newsletter, mailing lists or in person during the conference of the German Diabetes Association. Trainees were approached during their training sessions. We applied scenario 1 of the CHC test, which comprises 17 items with open-ended and multiple-choice questions. Mean person parameters with a range from 0 to 1000 were calculated to assess the levels of critical health competences and a multiple linear regression analysis was conducted to determine correlations between sociodemographic variables and levels of CHC.

RESULTS

A total of 325 participants, mean age 38.6 (±11.1) years, completed the CHC test; n = 174 (55.5%) were certified diabetes educators and n = 151 (46.5%) were trainees. The participants achieved a mean score of 409.84 person parameters (±88.10) (scale from 0 to 1000). A statistically significant association was found only between the level of education and the level of CHC (b = 0.221; p-value 0.002). Participants with grammar school education achieved higher mean scores compared to participants with secondary school education (432.88 ± 77.72 vs. 396.45 ± 85.95; mean difference 36.42 ± 9.29; 95%CI 18.15 to 54.71; p < 0.0001).

CONCLUSION

Diabetes educators achieved low competence scores and it can be assumed that they do not have sufficient CHC to conduct consultations based on the SDM principles. Poor CHC among healthcare providers are a major barrier for the implementation of SDM. Core concepts of evidence-based medicine should be implemented into the curricula for diabetes educators in order to increase their levels of CHC.

Informed shared decision-making programme for patients with type 2 diabetes in primary care: cluster randomised controlled trial

OBJECTIVE

To translate an informed shared decision-making programme (ISDM-P) for patients with type 2 diabetes from a specialised diabetes centre to the primary care setting.

DESIGN

Patient-blinded, two-arm multicentre, cluster randomised controlled trial of 6 months follow-up; concealed randomisation of practices after patient recruitment and acquisition of baseline data.

SETTING

22 general practices providing care according to the German Disease Management Programme (DMP) for type 2 diabetes.

PARTICIPANTS

279 of 363 eligible patients without myocardial infarction or stroke.

INTERVENTIONS

The ISDM-P comprises a patient decision aid, a corresponding group teaching session provided by medical assistants and a structured patient-physician encounter.Control group received standard DMP care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary endpoint was patient adherence to antihypertensive or statin drug therapy by comparing prescriptions and patient-reported uptake after 6 months. Secondary endpoints included informed choice, risk knowledge (score 0-11 from 11 questions) and prioritised treatment goals of patients and doctors.

RESULTS

ISDM-P: 11 practices with 151 patients; standard care: 11 practices with 128 patients; attrition rate: 3.9%. There was no difference between groups regarding the primary endpoint. Mean drug adherence rates were high for both groups (80% for antihypertensive and 91% for statin treatment). More ISDM-P patients made informed choices regarding statin intake, 34% vs 3%, OR 16.6 (95% CI 4.4 to 63.0), blood pressure control, 39% vs 3%, OR 22.2 (95% CI 5.3 to 93.3) and glycated haemoglobin, 43% vs 3%, OR 26.0 (95% CI 6.5 to 104.8). ISDM-P patients achieved higher levels of risk knowledge, with a mean score of 6.96 vs 2.86, difference 4.06 (95% CI 2.96 to 5.17). In the ISDM-P group, agreement on prioritised treatment goals between patients and doctors was higher, with 88.5% vs 57%.

CONCLUSIONS

The ISDM-P was successfully implemented in general practices. Adherence to medication was very high making improvements hardly detectable.

TRIAL REGISTRATION NUMBER

ISRCTN77300204; Results.

Helping Doctors and Patients Make Sense of Health Statistics

Many doctors, patients, journalists, and politicians alike do not understand what health statistics mean or draw wrong conclusions without noticing. Collective statistical illiteracy refers to the widespread inability to understand the meaning of numbers. For instance, many citizens are unaware that higher survival rates with cancer screening do not imply longer life, or that the statement that mammography screening reduces the risk of dying from breast cancer by 25% in fact means that 1 less woman out of 1,000 will die of the disease. We provide evidence that statistical illiteracy (a) is common to patients, journalists, and physicians; (b) is created by nontransparent framing of information that is sometimes an unintentional result of lack of understanding but can also be a result of intentional efforts to manipulate or persuade people; and (c) can have serious consequences for health.

The causes of statistical illiteracy should not be attributed to cognitive biases alone, but to the emotional nature of the doctor–patient relationship and conflicts of interest in the healthcare system. The classic doctor–patient relation is based on (the physician's) paternalism and (the patient's) trust in authority, which make statistical literacy seem unnecessary; so does the traditional combination of determinism (physicians who seek causes, not chances) and the illusion of certainty (patients who seek certainty when there is none). We show that information pamphlets, Web sites, leaflets distributed to doctors by the pharmaceutical industry, and even medical journals often report evidence in nontransparent forms that suggest big benefits of featured interventions and small harms. Without understanding the numbers involved, the public is susceptible to political and commercial manipulation of their anxieties and hopes, which undermines the goals of informed consent and shared decision making.

What can be done? We discuss the importance of teaching statistical thinking and transparent representations in primary and secondary education as well as in medical school. Yet this requires familiarizing children early on with the concept of probability and teaching statistical literacy as the art of solving real-world problems rather than applying formulas to toy problems about coins and dice. A major precondition for statistical literacy is transparent risk communication. We recommend using frequency statements instead of single-event probabilities, absolute risks instead of relative risks, mortality rates instead of survival rates, and natural frequencies instead of conditional probabilities. Psychological research on transparent visual and numerical forms of risk communication, as well as training of physicians in their use, is called for.

Statistical literacy is a necessary precondition for an educated citizenship in a technological democracy. Understanding risks and asking critical questions can also shape the emotional climate in a society so that hopes and anxieties are no longer as easily manipulated from outside and citizens can develop a better-informed and more relaxed attitude toward their health.

Effectiveness of training in evidence-based medicine skills for healthcare professionals: a systematic review

BACKGROUND

Basic skills in evidence-based medicine (EbM) are indispensable for healthcare professionals to promote consumer-centred, evidence-based treatment. EbM training courses are complex interventions - a fact that has not been methodologically reflected by previous systematic reviews. This review evaluates the effects of EbM training for healthcare professionals as well as the quality of reporting of such training interventions.

METHODS

We searched PubMed, EMBASE, CINAHL, Cochrane Library, ERIC, Campbell Library and PsycINFO up to 9/2014. Randomised controlled trials, controlled clinical trials as well as before-after trials were included. Authors were contacted in order to obtain missing data. Two independent reviewers extracted data and assessed risk of bias.

RESULTS

We reviewed 14.507 articles; n = 61 appeared potentially eligible; n = 13 involving 1,120 participants were included. EbM training shows some impact on knowledge and skills, whereas the impact on practical EbM application remains unclear. Risk of bias of included trials raises uncertainty about the effects. Description of complex interventions was poor.

CONCLUSIONS

EbM training has some positive effects on knowledge and skills of healthcare professionals. Appropriate methods for development, piloting, evaluation, reporting and implementation of the training should be applied.

An informed shared decision making programme on the prevention of myocardial infarction for patients with type 2 diabetes in primary care: protocol of a cluster randomised, controlled trial

Background

International and national societies claim a patient centred approach including shared decision making (SDM) in diabetes care. In a previous project, a SDM programme on the prevention of myocardial infarction has been developed. It is aimed at supporting patients with type 2 diabetes to make informed choices on preventive options, to share the decision making process with the health care team, and to improve adherence to the chosen treatment. In this study, the programme will be implemented and evaluated in primary care practices.

Methods/Design

A cluster randomised, controlled trial will be conducted to compare the SDM programme with standard care enrolling patients with type 2 diabetes (N = 306) from primary care practices (N = 24). The intervention programme comprises a six hours provider training, a patient decision aid including evidence-based information, a 90 minutes structured teaching session provided by medical assistants, a sheet to document the patients’ individual treatment goals, and a structured consultation with the general practitioner for sharing information, setting treatment goals, and for adapting treatment regimens if necessary. Patients in the control group receive a brief extract of recommendations of the German National Disease Management Guideline on the treatment of patients with type 2 diabetes. Primary outcome measure is adherence to blood pressure treatment and statin treatment at 6 months follow-up. Secondary outcome measures comprise informed choice and the achievement of patients’ treatment goals. Analyses will be carried out on intention-to-treat basis. Concurrent qualitative methods will be used to explore the implementation processes.

Discussion

At the end of this study, information on the efficacy of the SDM programme in the primary care context will be available. In addition, processes that might interfere with or that might promote a successful implementation will be identified.

Trial registration

ISRCTN77300204.

Patientenmanipulation durch Patienteninformationen

Irreführende Patienteninformationen sind die Regel. Sie werden systematisch genutzt, um gesundheitsorientierte Maßnahmen umzusetzen. Sie können zu schwerwiegenden Trugschlüssen führen. Irreführung entsteht durch Unvollständigkeit der Information und missverständliche Präsentation von Daten. Den Bürgern fehlt die notwendige kritische Gesundheitsbildung die Botschaften gezielt zu hinterfragen. Die Folgen sind Fehleinschätzungen von Risiken und des Nutzen-Schaden Verhältnisses von Interventionen.

[On the overestimation of the benefit of prevention]

BACKGROUND

Both pharmacological and non-pharmacological preventive interventions can do more harm than good. Health checks target a healthy or symptomless population. This is why randomised controlled trials (RCTs) must be conducted to provide high-quality evidence for the benefit of an intervention. The present article presents examples to demonstrate that the benefit of preventive interventions is usually overestimated.

METHODS

Standard screening criteria are used to critically appraise selected preventive interventions. Screening criteria cover the disease, the test, the treatment and the whole programme including evaluation and quality assurance. Type-2 diabetes mellitus is used as an example to discuss specific criteria for preventive interventions. The current state of the evidence is outlined. The article is based primarily on systematic / Cochrane reviews of RCTs.

RESULTS

A recent Cochrane review including 16 RCTs concluded that there is no benefit of general health checks. High-quality evidence on individual components of health checks is frequently missing or inconclusive. Over the last 30 years reference values for normal blood glucose and normal blood pressure as well as treatment targets for patients with type-2 diabetes mellitus and hypertension have been repeatedly decreased though this is not supported by evidence. Recent high-quality RCTs have shown that these "hit hard and early" interventions are detrimental, particularly to those who were the primary target group. Consequently, treatment targets have again been raised and recent guidelines recommend individualisation of treatment goals taking age and comorbidities into account. Important criteria for the implementation of preventive interventions are not currently met. With regard to type-2 diabetes uncertainties remain as to the clinical significance of pre-diabetes, the treatment of pre-diabetes and early treatment of diabetes, the screening tests, and target groups. The ADDITION study was unable to prove the benefit of a diabetes screening. Intensive lifestyle interventions may result in modest reductions of body weight and fewer diabetes diagnoses. However, the clinical relevance of the underlying metabolic changes is doubtful or even negligible. After almost 10 years, the Look AHEAD study has been terminated early due to the ineffectiveness of its intensive lifestyle interventions and the lack of hope that the study will succeed in demonstrating any benefit on the primary cardiovascular endpoints during the originally planned study period of another 3 years.

CONCLUSION

The benefit of prevention is overestimated whereas harm is underestimated. It is most unlikely that medical preventive interventions targeting individual behaviour changes will result in better health for our population.

Communicating Relative Risk Changes with Baseline Risk: Presentation Format and Numeracy Matter

BACKGROUND

Treatment benefits and harms are often communicated as relative risk reductions and increases, which are frequently misunderstood by doctors and patients. One suggestion for improving understanding of such risk information is to also communicate the baseline risk. We investigated 1) whether the presentation format of the baseline risk influences understanding of relative risk changes and 2) the mediating role of people's numeracy skills.

METHOD

We presented laypeople (N = 1234) with a hypothetical scenario about a treatment that decreased (Experiments 1a, 2a) or increased (Experiments 1b, 2b) the risk of heart disease. Baseline risk was provided as a percentage or a frequency. In a forced-choice paradigm, the participants' task was to judge the risk in the treatment group given the relative risk reduction (or increase) and the baseline risk. Numeracy was assessed using the Lipkus 11-item scale.

RESULTS

Communicating baseline risk in a frequency format facilitated correct understanding of a treatment's benefits and harms, whereas a percentage format often impeded understanding. For example, many participants misinterpreted a relative risk reduction as referring to an absolute risk reduction. Participants with higher numeracy generally performed better than those with lower numeracy, but all participants benefitted from a frequency format. Limitations are that we used a hypothetical medical scenario and a nonrepresentative sample.

CONCLUSIONS

Presenting baseline risk in a frequency format improves understanding of relative risk information, whereas a percentage format is likely to lead to misunderstandings. People's numeracy skills play an important role in correctly understanding medical information. Overall, communicating treatment benefits and harms in the form of relative risk changes remains problematic, even when the baseline risk is explicitly provided.

Evidence base in guideline generation in diabetes

During recent years much emphasis has been on the validity, reliability, reproducibility, clinical applicability, clarity, multidisciplinary process, scheduled review and documentation of clinical practice guidelines (CPGs). Still, CPGs show substantial variance in methodological quality. The present paper mainly focuses on two aspects that are particularly critical and contemporary from the perspective of evidence-based medicine: patient centredness and shared decision making, and conflict of interest. Sophisticated patient and consumer involvement at all stages of CPG development could be judged as being the gold standard. However, co-opting patients or consumer representatives and using other techniques of active patient involvement does not replace individual patient preferences in clinical decision-making processes. Current CPGs do not meet patient needs, since they do not provide concise, easy-to-read summaries of the benefits and risks of medicines together with more comprehensive scientific data as a prerequisite for informed or shared decision making. The vast majority of CPG panels have a financial conflict of interest (COI) and under-reporting is common. Not all organisations producing CPGs have set up COI policies, and existing policies vary widely. To solve the problem, CPG experts have recommended that methodologists without any important COI should lead the development process and have primary responsibility. There is a lot of room for other improvements through network transnational activities in the field of CPG development. Waste of time and resources should be avoided through sharing published and unpublished data identified, appraised and extracted for guideline development. The EASD could provide such a clearing house.

Heuristic decision making in medicine

Can less information be more helpful when it comes to making medical decisions? Contrary to the common intuition that more information is always better, the use of heuristics can help both physicians and patients to make sound decisions. Heuristics are simple decision strategies that ignore part of the available information, basing decisions on only a few relevant predictors. We discuss: (i) how doctors and patients use heuristics; and (ii) when heuristics outperform information-greedy methods, such as regressions in medical diagnosis. Furthermore, we outline those features of heuristics that make them useful in health care settings. These features include their surprising accuracy, transparency, and wide accessibility, as well as the low costs and little time required to employ them. We close by explaining one of the statistical reasons why heuristics are accurate, and by pointing to psychiatry as one area for future research on heuristics in health care.

Competence training in evidence-based medicine for patients, patient counsellors, consumer representatives and health care professionals in Austria: a feasibility study

BACKGROUND

Informed and shared decision-making require competences for both partners - healthcare professionals and patients. There is a lack of training courses in evidence-based medicine for patients and counsellors.

OBJECTIVE

We investigated feasibility, acceptability and the potential effects of a 2 x 2.5 days training course on critical health competences in patients, patient counsellors, consumer representatives and healthcare professionals in Austria.

METHODS

We adapted a previously developed curriculum for patient and consumer representatives. The adaptation comprised the specific needs of our target group in Austria and was founded on Carl Rogers' theory of person-centred education. For the formative evaluation a questionnaire was applied to address the domains: 1) organisational conditions (time and duration of the course, location, and information given in advance, registration); 2) assistance outside the courses; 3) teaching methods (performance of lecturers, teaching materials, structure of modules and blocks) and 4) satisfaction; 5) subjective assessment of competences. Participants evaluated the course, using a 5-point Likert scale. Long-term implementation was assessed using semi-structured interviews three to six months after the course. To estimate the increase in critical health competences we used the validated Critical Health Competence Test (CHC test).

RESULTS

Eleven training courses were conducted including 142 participants: patients (n=21); self-help group representatives (n=17); professional counsellors (n=29); healthcare professionals (n=10); psychologists (n=8); teachers (n=10) and others (n=29). 97 out of 142 (68 %) participants returned the questionnaire. On average, participants strongly agreed or agreed to 1) organisational conditions: 71 % / 23 %; 2) assistance outside the courses: 96 % / 10 %; 3) teaching methods: 60 % / 28 %; and 4) satisfaction: 78 % / 20 %, respectively. Interviews showed that the training course raised awareness, activated and empowered participants. Participants passed the CHC test with mean person parameters of 463±111 (pre-test, n=120) and 547±135 (post-test, n=91). For participants who returned both tests (n=71) person parameters were comparable: pre-test 466±121 versus post-test 574±100, p<0,001.

CONCLUSION

Training in evidence-based medicine for patients, patient counsellors, consumer representatives and healthcare professionals is feasible. For a broad implementation, train-the trainer courses and further research are needed.

"There is nothing to worry about": gynecologists' counseling on mammography

OBJECTIVE

In Germany, approximately 10 million women between the ages of 50 and 69 are eligible for biennial mammography screening. Mammography is at the center of much controversy, however, which means gynecologists must provide women considering mammography with sufficient and transparent information. The present study analyzed the information gynecologists share with a person seeking advice about the benefit and harms of mammography screening.

METHOD

To receive realistic data, we called 20 gynecologists practicing in different large cities across Germany and took telephone counseling sessions on the benefit and harms of mammography.

RESULTS

The majority of gynecologists described mammography as safe and scientifically well grounded. Harms were rarely mentioned or described as negligible. A minority of gynecologists provided numerical information; when they did, they often quantified the benefit using relative risk reduction and harms using absolute risk increase.

CONCLUSION

A sample of German gynecologists was not able to correctly and transparently communicate the benefit and harms of mammography screening to a patient.

PRACTICE IMPLICATION

Gynecologists should be taught how to understand and transparently explain medical risk information in simple terms.

Turning signals into meaning--'shared decision making' meets communication theory

Shared decision making (SDM) is being increasingly challenged for promoting an innovative role model while adhering to an archaic approach to patient-clinician communication, both in clinical practice and the research field. Too often, SDM has been studied at the individual level, which ignores the interpersonal system between patients and physicians. We aimed to encourage debate by reflecting on the essentials of SDM in terms of epistemology. We operationalized the SDM core concept of information exchange in terms of social systems theory. An epistemological analysis of the term information refers to its inherent process character. Exchange of information thereby becomes synonymous with social sense construction, indicating that, rather than just being a vehicle, the act of communication itself is the information. We plead for the adoption of existing dyadic analytical methods such as those offered by the interpersonal paradigm. Implications of an updated concept of information for the use of SDM-evaluation methods, for SDM-goal setting, and for clinical practice of SDM are described.

Deceiving Numbers

Background. Increased 5-y survival for screened patients is often inferred to mean that fewer patients die of cancer. However, due to several biases, the 5-y survival rate is a misleading metric for evaluating a screening’s effectiveness. If physicians are not aware of these issues, informed screening counseling cannot take place. Methods. Two questionnaire versions (“group” and “time”) presented 4 conditions: 5-y survival (5Y), 5-y survival and annual disease-specific mortality (5YM), annual disease-specific mortality (M), and 5-y survival, annual disease-specific mortality, and incidence (5YMI). Questionnaire version “time” presented data as a comparison between 2 time points and version “group” as a comparison between a screened and an unscreened group. All data were based on statistics for the same cancer site (prostate). Outcome variables were the recommendation of screening, reasoning behind recommendation, judgment of the screening’s effectiveness, and, if judged effective, a numerical estimate of how many fewer people out of 1000 would die if screened regularly. After randomized allocation, 65 German physicians in internal medicine and its subspecialities completed either of the 2 questionnaire versions. Results. Across both versions, 66% of the physicians recommended screening when presented with 5Y, but only 8% of the same physicians made the recommendation when presented with M (5YM: 31%; 5YMI: 55%). Also, 5Y made considerably more physicians (78%) judge the screening to be effective than any other condition (5YM: 31%; M: 5%; 5YMI: 49%) and led to the highest overestimations of benefit. Conclusion. A large number of physicians erroneously based their screening recommendation and judgment of screening’s effectiveness on the 5-y survival rate. Results show that reporting disease-specificmortality rates can offer a simple solution to physicians’ confusion about the real effect of screening.

From authority recommendations to fact-sheets--a future for guidelines

ADA/EASD recommendations and diabetes expert consensus statements are not evidence-based. Reform of guideline development is urgently needed. Overriding governance and composition of the guideline committee is a key problem. Methodologists without important conflicts of interest should lead the development process and have primary responsibility. The rating of the quality of evidence should be separated from making the recommendations, transparency has to be increased and conflicts of interest must be tackled. Patient needs are not yet met in guidelines. Patients increasingly demand concise, easy-to-read summaries of the benefits and risks of medicines together with more comprehensive scientific data. However, patient participation in individual decision making is not considered in guidelines. Guidelines do not provide the information necessary for informed or shared decision making. Study fact-sheets and drug facts boxes should be included in practice guidelines. It is timely to consider patient needs from the outset of the development of future guidelines.

[Shared decision-making and communication theory: grounding the tango]

Shared decision-making (SDM) has the potential to overcome outdated social role models in the health care system. The concept, however, adheres to archaic epistemological assumptions as can be inferred from the rudimentary stage of the measurement methods used and from the information monopoly that the physician still holds in this concept. Advantages of an up-to-date model of knowledge for understanding and operationalising SDM are outlined. To this purpose, essential definitions of the concept are reflected in terms of epistemology. Accordingly, information emerges through a process of social construction. Likewise, interpersonal relations do not represent a static condition; rather, they develop anew with each interaction. Therefore, constructs suitable to focus on dyadic interaction processes can be used as indicators of sharing in SDM. Theories and methods of the interpersonal paradigm are advocated.

Training of patient and consumer representatives in the basic competencies of evidence-based medicine: a feasibility study

BACKGROUND

Evidence-based medicine (EBM) has become standard approach in medicine. Patients and health authorities increasingly claim active patient roles in decision making. Education to cope with these roles might be useful. We investigated the feasibility, acceptability and possible impact of EBM training courses for patient and consumer representatives.

METHODS

We designed a generic one-week EBM course based on previous experience with EBM courses for non-medical health professionals. A course specific competence test has been developed and validated to measure EBM skills. Formative and summative evaluation of the course comprised: 1) EBM skills; 2) individual learning goals; 3) self-reported implementation after six months using semi-structured interviews; 4) group-based feedback by content analysis. EBM skills' achievement was compared to results gathered by a group of undergraduate University students of Health Sciences and Education who had attended a comparable EBM seminar.

RESULTS

Fourteen EBM courses were conducted including 161 participants without previous EBM training (n = 54 self-help group representatives, n = 64 professional counsellors, n = 36 patient advocates, n = 7 others); 71% had a higher education degree; all but five finished the course. Most participants stated personal learning goals explicitly related to practicing EBM such as acquisition of critical appraisal skills (n = 130) or research competencies (n = 67). They rated the respective relevance of the course on average with 80% (SD 4) on a visual analogue scale ranging from 0 to 100%.Participants passed the competence test with a mean score of 14.7 (SD 3.0, n = 123) out of 19.5 points. The comparison group of students achieved a mean score of 14.4 (SD 3.3, n = 43). Group-based feedback revealed increases of self confidence, empowerment through EBM methodology and statistical literacy, and acquisition of new concepts of patient information and counselling. Implementation of EBM skills was reported by 84 of the 129 (65%) participants available for follow-up interviews. Barriers included lack of further support, limited possibilities to exchange experiences, and feeling discouraged by negative reactions of health professionals.

CONCLUSIONS

Training in basic EBM competencies for selected patient and consumer representatives is feasible and accepted and may affect counselling and advocacy activities. Implementation of EBM skills needs support beyond the training course.

Diuretics and diabetes incidence--an appeal against the reluctance to prescribe a medication that is safe and proven

The publication of the scientific report of the Institute for Quality and Efficiency in Health Care (IQWiG) in Germany on the 'Comparative evaluation of the benefits and harms of different antihypertensive drug classes [diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium-channel blockers and angiotensin II (AT-II) blockers] as first-choice therapy for patients with essential hypertension' raised an enormous public debate, particularly as diabetes incidence was not judged to be a patient-relevant outcome. In this assessment, the overall view of the patient-relevant results was that diuretics can be used as first-line antihypertensive treatment. Diabetes incidence is highest with diuretics, but minimal differences in fasting plasma glucose of approximately 0.28 mmol/l are magnified by the transformation of continuous blood glucose values into categorical data: with the establishment of thresholds, the diagnosis of diabetes depends on being above a certain blood glucose value. The protective cardiovascular effects of diuretics do not seem to be reduced in hypertensive patients who develop new-onset diabetes during treatment. Since blood pressure control is often worse, detection, treatment and control should be urgently improved. The debate on antihypertensive agents is mainly of scientific interest and has only minor clinical relevance for everyday patient care.

Diabetes experts' reasoning about diabetes prevention studies: a questionnaire survey

BACKGROUND

Presentation of results of diabetes prevention studies as relative risk reductions and the use of diagnostic categories instead of metabolic parameters leads to overestimation of effects on diabetes risk. This survey examines to what extent overestimation of diabetes prevention is related to overestimation of prevention of late complications.

METHODS

Participants of two postgraduate courses in clinical diabetology in Austria (n = 69) and Germany (n = 31) were presented a questionnaire with 8 items at the beginning of the meetings. All 100 questionnaires were returned with 92 filled in completely. Participants were asked 1) to rate the importance of differently framed results of prevention studies and, for comparison, of the United Kingdom Prospective Diabetes Study (UKPDS), 2) to estimate to what extent late complications could be prevented by the achieved reductions in diabetes risk or HbA1c values, respectively.

RESULTS

Prevention of diabetes by 60% was considered important by 84% of participants and 35% thought that complications could be prevented by >/= 55%. However, if corresponding HbA1c values were presented (6.0% versus 6.1%) only 19% rated this effect important, and 12% thought that late complications could be prevented by >/= 55%. The difference in HbA1c of 0.9% over 10 years in the UKPDS was considered important by 75% of participants and 16% thought that complications ('any diabetes related endpoint') were reduced by >/= 55% (correct answer <15% by 20% participants).

CONCLUSION

The novel key message of this study is that the misleading reporting of diabetes prevention studies results in overestimation of effects on late complications.

[Is prevention better than healing?]

Preventive and screening interventions have been met with great enthusiasm. This is due to a widespread misunderstanding of what prevention can do and what it cannot do. Initiatives for prevention or early diagnosis of disease are almost always considered beneficial. Meanwhile, however, there are many impressive examples of detrimental failures of such initiatives documented by large high-quality randomised controlled trials (RCTs). These include treatment with vitamin pills to prevent cancer or cardiovascular disease or treatment of healthy women with sexual hormones which has finally turned out to be one of the biggest scandals in medicine. Systematic self-examination of the breast to detect breast cancer early does more harm than good. Most dogmas of the modern so-called healthy diet are not supported by several recently published high-quality RCTs. On the other hand, many of the promoted prevention initiatives lack evidence from high-quality RCTs such as health checks, rectal examination, screening for renal disease or diabetes, screening for colorectal cancer by coloscopy, for prostate cancer or skin cancer. Even if effective, most screening programmes will benefit only a few but harm many more, though. Harm is due to overdiagnosis and overtreatment as well as to side effects related to the investigation itself. This includes psychological and other distress related to work-up of false test results. All prevention programmes have to undergo sound scientific evaluation before they can be recommended or implemented. Ethical guidelines ask for complete, objective, unbiased, evidence-based and understandable information for potential participants of prevention programmes. Rarely is such information provided or even available. Non-participation is an explicit option for most preventive programmes and must not be penalised.

Evidence-based medicine for diabetes educators: a pilot study

AIMS

Health-care professionals are increasingly asked to communicate research results to patients and consumers. Diabetes educators play a decisive role in the information process of patients with diabetes. Evidence-based medicine (EBM) is not a regular part of their training in Germany. We performed a pilot study to test whether the inclusion of a short EBM module into the standard graduate programme is feasible and leads to a meaningful increase in knowledge and skills.

METHODS

The study group consisted of 121 diabetes educator trainees. The EBM modules were delivered in 1- to 3-day courses. Increase in knowledge and skills were assessed using a questionnaire covering three main elements: (i) general aspects of an intervention study, (ii) effect size calculation, (iii) general aspects of evidence-based patient information and communicating numbers as patient orientated statements. Two researchers independently rated the assessment sheets.

RESULTS

The majority of participants rated the course as important and useful but too short. Knowledge and skills in EBM increased after the course by 2 points out of 13.5 (mean score before course 5 +/- 2 vs. 7 +/- 2; P < 0.001). Inter-rater reliability analysis using Cohen's Kappa coefficients demonstrated substantial to almost perfect agreement for 10 of the 13 items.

CONCLUSIONS

Our pilot study demonstrates that EBM education for diabetes educator trainees is feasible. However, the increase in knowledge and skills appears not to be clinically relevant. Short EBM courses are unlikely to yield important effects. More intensified course formats are necessary to meet the needs of diabetes educators.