Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP)

The effect of patients' empowerment on satisfaction of diabetic patients attending primary care clinics

BACKGROUND

Different approaches, especially the patient-centered approach with emphasis on the patient's empowerment, were used with diabetic patients to ensure a better quality of life. The study aimed to evaluate the effects of patient empowerment versus traditional health education models on the satisfaction of diabetic patients.

MATERIALS AND METHODS

A randomized clinical trial was conducted on 130 patients, aged 40-65 years, diagnosed with type 2 diabetes mellitus, and attending a family medicine outpatient clinic. Patients were blinded and randomly allocated into one of the two Groups (A and B) for a health education session with trained family physicians using the empowerment model and the traditional model, respectively. Patient satisfaction was assessed using the consultation satisfaction questionnaire (CSQ). The relations between different qualitative variables were assessed by Chi-square test; differences in various quantitative variables were determined by t-test and ANOVA. Pearson correlation assessed the correlation between age and different domains as well as the total questionnaire scores of both groups.

RESULTS

A highly statistically significant difference was found between Group A (n = 65) and Group B (n = 65) for the general satisfaction scale, professional care analysis, depth, and length of consultation (P < 0.001). In Group A, 61.5% were highly satisfied and 35.4% were moderately satisfied, while in Group B, 41.5% were moderately satisfied and 43.1% were neutral. Regarding physicians' perceptions of the communication process with patients during the health education sessions, 83% in Group A perceived it as good, while 69.2% in Group B perceived it as average.

CONCLUSION

The patient empowerment model of health education was linked to higher rates of patient satisfaction and a better physician perception of the communication process during the consultation. The study was self-funded, and no harm was done to the patients.

Obesity and Diabetic Complications: A Study from the Nationwide Diabetes Report of the National Program for Prevention and Control of Diabetes (NPPCD-2021) Implications for Action on Multiple Scales

BACKGROUND

Obesity plays a major role in the pathogenesis and development of macro- and microvascular complications of type 2 diabetes (T2D) and type 1 diabetes (T1D). We aimed to assess the association between obesity and macrovascular and microvascular complications of diabetes.

METHODS

This study consisted of 111,830 patients (age range: 1-106) with diabetes including 10,641 T1D (3187 obese [38.2% men] and 7454 non-obese [45.5% men]) and 101,189 T2D (51,873 obese [27.5% men] and 49,316 non-obese [33.4% men]) from the National Program for Prevention and Control of Diabetes (NPPCD-2021) in Iran, who attended academic tertiary care outpatient clinics from February 2016 to April 2021. A pooled logistic regression model was used to examine the association between obesity and diabetic complications.

RESULTS

Among patients with T1D, a significant association was found between obesity and cardiovascular disease (CVD), neuropathy, nephropathy and retinopathy (OR= 1.75, 1.56, 1.80 and 1.92, P-value= 0.001, 0.004, 0.001 and <0.001, respectively). In T2D, a statistically significant association was found between obesity and CVD, neuropathy and nephropathy (OR= 1.63, 1.98, 1.21, respectively, P-values <0.001).

CONCLUSION

Obesity was independently associated with CVD, neuropathy and nephropathy in patients with T1D and T2D and with retinopathy only in T1D, to different degrees. The association between obesity and retinopathy and neuropathy was the strongest among T1D and T2D, respectively. Findings from this study suggest that obesity affects diabetic complications differently among the two types of diabetes, in terms of epidemiology and pathophysiology. This signifies the importance of different preventive and therapeutic approaches to obesity in T1D compared to T2D, on a national and global scale.

Impact of patient-centred diabetes self-management education targeting people with type 2 diabetes: an integrative review

AIMS

To synthesize primary research into the impact of person-centred diabetes self-management education, and support that targets people with type 2 diabetes, on behavioural, psychosocial and cardiometabolic outcomes and to identify effective mechanisms underlying positive outcomes of person-centred diabetes self-management education and support.

METHODS

Using Whittemore and Knafl's integrative review method, we conducted a systematic search of peer-reviewed literature published between January 2008 and June 2019 using PubMed, Scopus and CINAHL. After article selection according to established criteria, study quality was assessed using Critical Appraisal Skills Programme checklists for cohort studies, randomized controlled trials and qualitative research.

RESULTS

From 1901 identified records, 22 (19 quantitative, two qualitative, and one mixed methods) were considered eligible for inclusion. Interventions were categorized by content, medium of delivery, and outcomes. Qualitative studies, quantitative cohort studies and randomized controlled trials demonstrated positive outcomes, with no differences in success rates across study design. Interventions were largely successful in improving HbA_1c and patient-reported outcomes such as quality of life but had limited success in lowering cholesterol and weight, or initiating long-term improvements in lifestyle behaviours. Primary objectives were achieved more often than secondary objectives, and studies with fewer outcomes appeared more successful in achieving specific outcomes.

CONCLUSIONS

Person-centred diabetes self-management education and support has demonstrated a considerable impact on desired diabetes-related outcomes in people with type 2 diabetes. To advance the field further, new studies should take advantage of systematic and transparent approaches to person-centred diabetes self-management education.

Role of social and other determinants of health in the effect of a multicomponent integrated care strategy on type 2 diabetes mellitus

BACKGROUND

Although important advances in treatment strategies have been developed in type 2 diabetes mellitus (T2DM), large gaps exist in achieving glycemic control and preventing complications, particularly in low-and middle-income countries, which suggests a potential effect of social determinants of health (SDH, i.e., education level and socioeconomic status). However, few studies have determined the role of SDH and other determinants of health (ODH, i.e., diabetes knowledge and self-care scores) in achieving T2DM goals during effective multidisciplinary interventions. We aimed to examine a multicomponent integrated care (MIC) program on diabetes care goals and determine the effect of SDH and ODH on T2DM patients.

METHODS

A before-and-after design (a pretest, a 5-month intervention, and a follow-up) was used in a T2DM population from Mexico City. The SDH included education level and socioeconomic status; the ODH included diabetes knowledge, self-care scores, and deltas (i.e., differences between baseline and follow-up scores). The triple-target goal (glycated hemoglobin, blood pressure, and LDL-cholesterol) was established as a measurement of T2DM goals.

RESULTS

The DIABEMPIC (DIABetes EMPowerment and Improvement of Care) intervention (n = 498) reduced the glycated hemoglobin levels (mean reduction 2.65%, standard deviation [SD]: 2.02%) and cardiometabolic parameters; it also improved health-related quality of life. From 1.81% at baseline, 25.9% of participants (p-value< 0.001) achieved the triple-target goal. We found a significant association between education level (p-value = 0.010), diabetes knowledge at baseline (p-value = 0.004), and self-care scores at baseline (p-value = 0.033) in the delta (change between baseline and follow-up assessments) of HbA1c levels. Improvements (increase) in diabetes knowledge (p-value = 0.006) and self-care scores (p-value = 0.002) were also associated with greater reductions in HbA1c.

CONCLUSIONS

MIC strategies in urban primary care settings contribute to control of T2DM. SDH, such as education level, and ODH (diabetes knowledge and self-care scores at baseline) play a key role in improving glycemic control in these settings.

From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions

In 1995, the Hong Kong Diabetes Register (HKDR) was established by a doctor-nurse team at a university-affiliated, publicly funded, hospital-based diabetes center using a structured protocol for gathering data to stratify risk, triage care, empower patients, and individualize treatment. This research-driven quality improvement program has motivated the introduction of a territory-wide diabetes risk assessment and management program provided by 18 hospital-based diabetes centers since 2000. By linking the data-rich HKDR to the territory-wide electronic medical record, risk equations were developed and validated to predict clinical outcomes. In 2007, the HKDR protocol was digitalized to establish the web-based Joint Asia Diabetes Evaluation (JADE) Program complete with risk levels and algorithms for issuance of personalized reports to reduce clinical inertia and empower self-management. Through this technologically assisted, integrated diabetes care program, we have generated big data to track secular trends, identify unmet needs, and verify interventions in a naturalistic environment. In 2009, the JADE Program was adapted to form the Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in the publicly funded primary care clinics, which reduced all major events by 30-60% in patients without complications. Meanwhile, a JADE-assisted assessment and empowerment program provided by a university-affiliated, self-funded, nurse-coordinated diabetes center, aimed at complementing medical care in the community, also reduced all major events by 30-50% in patients with different risk levels. By combining universal health coverage, public-private partnerships, and data-driven integrated care, the Hong Kong experience provides a possible solution than can be adapted elsewhere to make quality diabetes care accessible, affordable, and sustainable.

An educational intervention on foot self-care behaviour among diabetic retinopathy patients with visual disability and their primary caregivers

AIMS AND OBJECTIVES

To assess the effectiveness of a 12-week educational intervention on foot self-care behaviour among diabetic retinopathy patients with visual disability and their primary caregivers in China.

BACKGROUND

Diabetes with the coexistence of diabetic retinopathy and foot problems complicating diabetes not only represents a personal disaster, but also becomes a serious burden to public health in China. A foot self-care educational intervention is both cost-effective and feasible even in a health resource-limited setting, which should be developed and evaluated.

DESIGN

Quasi-experimental.

METHODS

From July-September 2017, we enrolled 80 eligible hospitalised diabetic retinopathy patients and their primary caregivers by convenient sampling method in a first-class comprehensive hospital in Nantong, in China. Before and after the educational intervention that is in accordance with the TREND statement (for details, see the "Supplementary File 1"), researchers and subjects filled out the self-designed questionnaire on foot problems complicating diabetes and the Diabetic Foot Self-care Behavior Scale, respectively.

RESULTS

Scores of foot self-care behaviour among the subjects significantly improved from 54.19 ± 8.01-75.85 ± 5.04. The number of patients with fasting blood glucoses <7.0 mmol/L improved from 43 (53.75%)-80 (100%). The results of incidence of foot problems complicating diabetes were not statistically significant. The complete execution of each item in Diabetic Foot Self-care Behavior Scale of subjects was apparently higher.

CONCLUSIONS

This educational intervention can facilitate positive foot self-care behaviours among the diabetic retinopathy patients with visual disability and their primary caregivers in China.

RELEVANCE TO CLINICAL PRACTICE

This study adds to the evidence of the effectiveness of an educational intervention to foster positive foot self-care behaviours. This educational intervention appears to be prospective in promoting diabetic home-based self-management in China, and the delivery method of the intervention may be applied to other chronic diseases.

Long-term cost-effectiveness of a Patient Empowerment Programme for type 2 diabetes mellitus in primary care

AIM

To evaluate the long-term cost-effectiveness of a Patient Empowerment Programme (PEP) for type 2 diabetes mellitus (DM) in primary care.

MATERIALS AND METHODS

PEP participants were subjects with type 2 DM who enrolled into PEP in addition to enrolment in the Risk Assessment and Management Programme for DM (RAMP-DM) at primary care level. The comparison group was subjects who only enrolled into RAMP-DM without participating in PEP (non-PEP). A cost-effectiveness analysis was conducted using a patient-level simulation model (with fixed-time increments) from a societal perspective. We incorporated the empirical data from a matched cohort of PEP and non-PEP groups to simulate lifetime costs and outcomes for subjects with DM with or without PEP. Incremental cost-effectiveness ratios (ICER) in terms of cost per quality adjusted life year (QALY) gained were calculated. Probabilistic sensitivity analysis was conducted with results presented as a cost-effectiveness acceptability curve.

RESULTS

With an assumption that the PEP effect would last for 5 years as shown by the empirical data, the incremental cost per subject was US $197 and the incremental QALYs gained were 0.06 per subject, which resulted in an ICER of US $3290 per QALY gained compared with no PEP across the lifetime. Probabilistic sensitivity analysis showed 66% likelihood that PEP is cost-effective compared with non-PEP when willingness-to-pay for a QALY is ≥US $46 153 (based on per capita GDP 2017).

CONCLUSIONS

Based on this carefully measured cost of PEP and its potentially large benefits, PEP could be highly cost-effective from a societal perspective as an adjunct intervention for patients with DM.

Galangin, a dietary flavonoid, ameliorates hyperglycaemia and lipid abnormalities in rats with streptozotocin-induced hyperglycaemia

CONTEXT

Galangin, a natural flavonoid, is found in honey and Alpinia officinarum Hance (Zingiberaceae). Galangin has antiviral, antimicrobial, antidiabetic and anticancer properties, without side effects. The effects of galangin on hyperglycaemia and lipid abnormalities are not known.

OBJECTIVE

To elucidate the effectiveness of galangin on hyperglycaemia-associated complications and lipid changes in rats with streptozotocin (STZ)-induced hyperglycaemia.

MATERIALS AND METHODS

Diabetes was induced in adult Wistar rats by administering 40 mg/kg of STZ. In our previous study, galangin had no toxicity at concentrations up to 320 mg/kg. Therefore three doses of galangin (4, 8 or 16 mg/kg BW) or glibenclamide (600 µg/kg BW) were administered daily to diabetic rats orally for 45 days.

RESULTS

Diabetic rats showed a significant (p < 0.05) increased levels of plasma glucose (281.10 mg/dL) and decreased levels of insulin (6.01 μU/mL). Additionally, diabetic rats showed a significant (p < 0.05) increased levels of plasma lipid profiles such as total cholesterol (149.05 mg/dL), triglycerides (143.28 mg/dL), free fatty acids (139.37 mg/dL), phospholipids (127.53 mg/dL), plasma low-density lipoprotein-cholesterol (98.72 mg/dL), plasma very low-density lipoprotein-cholesterol (28.65 mg/dL), and significant (p < 0.05) decreased in plasma high-density lipoprotein-cholesterol (21.68 mg/dL). When galangin was administered to the hyperglycaemic rats, plasma glucose and insulin levels and lipid profiles reverted to levels similar to those in healthy control rats.

DISCUSSION AND CONCLUSIONS

Administration of galangin reduced hyperlipidaemia related to the risk of diabetic complications and could be beneficial for diabetic hyperlipidaemic patients. Further work detailing its mechanism-of-action for improving hyperglycaemic-associated lipid abnormalities is needed.

Glycemic control in type 2 diabetes: from medication nonadherence to residual vascular risk

Despite the availability of many new treatment options for type 2 diabetes, the proportion of patients achieving the HbA1c target < 7.0% remains around 50%. We put forward the hypothesis that the unchanged HbA1c results, observed in the last decade in type 2 diabetes patients, are also a consequence of medication nonadherence and clinical inertia. Poor medication-taking behavior is usually defined as medication nonadherence and is responsible for uncontrolled hemoglobin A1c level in 23% of cases. Medication nonadherence may also affect clinical outcomes, as diabetic patients with good adherence (≥80%) had a significant 10% lower rate of hospitalization events and a significant 28% lower rate of all-cause mortality when compared with patients with poor adherence (<80%). Residual vascular risk may be defined as the risk of macrovascular (major cardiovascular events) and microvascular (retinopathy, nephropathy, neuropathy) complications that remains after intensive and successful glycemic control in type 2 diabetes. For major cardiovascular events, risk reduction following intensive glycemic control is 9% and, therefore, residual vascular risk is 91%. For microvascular complications, as nephropathy, residual vascular risk is as high as 80%. Residual vascular risk remains high in type 2 diabetes despite intensive glycemic control. Medication nonadherence by the diabetic patient and clinical inertia by the clinician may have contributed to the high level of residual vascular risk (both macro and microvascular) of type 2 diabetic patients.

Role of structured individual patient education in the prevention of vascular complications in newly diagnosed type 2 diabetes: the INdividual Therapeutic Education in Newly Diagnosed type 2 diabetes (INTEND) randomized controlled trial

OBJECTIVE

Recent studies showed that a structured patient therapeutic education (PTE) may decrease both mortality and the development of diabetes complications. Nevertheless, no data are available in the literature on the impact of individual PTE on the complications in newly diagnosed type 2 diabetic patients. Aim of the present randomized controlled trial is to evaluate the impact of individual PTE on the occurrence of macrovascular complications in newly diagnosed type 2 diabetic patients when compared to usual care (UC) and group PTE.

DESIGN AND METHODS

Six hundred newly diagnosed type 2 diabetic patients will be enrolled. The patients will be randomly assigned to one of these three groups: individual PTE, group PTE and UC. A comprehensive and complete PTE will be delivered to all the patients: PTE will include eleven themes. Primary composite endpoint of the study is occurrence of vascular complications, including cardiovascular death, non fatal coronary disease, non fatal stroke, peripheral artery disease. Secondary endpoints are: foot ulcers, amputations, sexual dysfunction, quality of life, microvascular complications, bone health, intensification of diabetes and hypertension therapy.

RESULTS AND CONCLUSIONS

The present trial can give precious information on the features for the most effective PTE.

Temporal trends in quality of primary care for patients with type 2 diabetes mellitus: A population-based retrospective cohort study after implementation of a quality improvement initiative

BACKGROUND

This study examined whether temporal trends exist in treatment of patients with type 2 diabetes (T2D) and quality of diabetes care after implementation of quality improvement initiative in primary care setting.

METHODS

We conducted a population-based retrospective cohort study of 202,284 patients with T2D who were routinely managed in primary care clinics. We examined the change over time and the variability between clinics in quality of care from Hospital Authority administrative data over a 5-year period (2009-2013) and used multilevel logistic regression to adjust for patient and clinic characteristics. Observational period was partitioned in 5 calendar years. Ten quality-of-care criteria were selected: adherence to 7 process of care criteria (HbA_1c test, renal function test, full lipid profile, urine protein analysis, retinal screening, lipid-lowering agent prescriptions among patients with hypercholesterolaemia, and angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescriptions among patients with microalbuminuria) and 3 outcome of care criteria (HbA_1c  ≤ 7%, BP ≤ 130/80 mmHg, and LDL-C ≤ 2.6 mmol/L). Variability of standards between clinics was assessed by using intracluster correlation coefficients.

RESULTS

Characteristics of patients with T2D managed in primary care changed substantially during the observational period, with increasing age and usage of insulin and longer duration of diabetes but improved metabolic profiles (all P trend < .001). Performance rates of the 7 process and 3 clinical outcomes of care criteria increased remarkably over time (all P trend < .001). Variations in retinal screening delivery between clinics were considerable, albeit decreasing over time.

CONCLUSIONS

Coinciding with implementation of quality improvement initiative, quality of diabetes care improved significantly in the past 5 years, in part attributable to benefits of integrated multidisciplinary diabetes management.

DPP-4 Inhibitor Sitagliptin Improves Cardiac Function and Glucose Homeostasis and Ameliorates β-Cell Dysfunction Together with Reducing S6K1 Activation and IRS-1 and IRS-2 Degradation in Obesity Female Mice

BACKGROUND

Chronic overnutrition leads to cardiac dysfunction and insulin (INS) resistance. Dipeptidyl peptidase-4 (DPP-4) improves glucose metabolism and insulin sensitivity in both human and animal models. In this study, we explored whether DPP-4 inhibitor sitagliptin (SIT) is involved in the protection of cardiac function and β-cell function using an obesity female mouse model.

METHODS

Six-week-old C57BL6/J mice were fed a high fat and fructose Western diet with DPP-4 inhibitor SIT for 12 weeks. Cardiac function was examined by echocardiography. Body weight, plasma glucose, and insulin concentrations were measured. The contents of total S6 kinase 1 (S6K1), phosphorylation of S6K1 activation, and INS docking proteins INS receptor substrates 1 and 2 (IRS-1, IRS-2) were assayed, and histology of heart tissue was performed.

RESULTS

Chronic Western diet consumption elevated plasma glucose and insulin and caused obesity, diastolic dysfunction, and β-cell dysfunction. DPP-4 inhibition with SIT resulted in reduction in body weight, fasting glucose, and plasma insulin, and improved cardiac diastolic dysfunction. SIT also decreased mTOR/S6K1 activation and prevented the degradation of IRS-1 and IRS-2.

CONCLUSIONS

This study revealed pleiotropic protective effects of DPP-4 inhibitor SIT on cardiac function, glycemia, and β-cell function together with reducing S6K1 activation and IRS-1 and IRS-2 degradation in the obesity female mouse model.

Five-year cost-effectiveness of the Patient Empowerment Programme (PEP) for type 2 diabetes mellitus in primary care

This study evaluated the short-term cost-effectiveness of the Patient Empowerment Programme (PEP) for diabetes mellitus (DM) in Hong Kong. Propensity score matching was used to select a matched group of PEP and non-PEP subjects. A societal perspective was adopted to estimate the cost of PEP. Outcome measures were the cumulative incidence of all-cause mortality and diabetic complication over a 5-year follow-up period and the number needed to treat (NNT) to avoid 1 event. The incremental cost-effectiveness ratio (ICER) of cost per event avoided was calculated using the PEP cost per subject multiplied by the NNT. The PEP cost per subject from the societal perspective was US$247. There was a significantly lower cumulative incidence of all-cause mortality (2.9% vs 4.6%, P < .001), any DM complication (9.5% vs 10.8%, P = .001) and CVD events (6.8% vs 7.6%, P = .018), in the PEP group. The costs per death from any cause, DM complication or case of CVD avoided were US$14 465, US$19 617 and US$30 796, respectively. The extra amount allocated to managing PEP was small and it appears cost-effective in the short-term as an addition to RAMP.

Efficacy of an education course delivered to community health workers in diabetes control: A randomized clinical trial

BACKGROUND

Community health workers are community members who provide education and care for patients for a broad range of health issues, including diabetes mellitus. However, few community health workers are trained for diabetes education and little is known about the effectiveness of their interventions. The aim of this study is to evaluate the effect of a diabetes education program delivered to community health workers in improving the metabolic control of patients with type 2 diabetes mellitus.

METHODS

Eight community health workers, providing care for 118 patients, were randomized in two groups to receive a 1-month diabetes education program (intervention, patients n = 62) or an education course in other health issues (control, patients n = 56). Each community health worker was responsible for transmitting the acquired knowledge to patients. Primary outcome was changed in HbA1C 3 months after the intervention.

RESULTS

PARTICIPANTS: Mean age was 61 ± 11 years, 35% were men and 62% were whites. HbA1c levels reduced in both groups (intervention: 9.1 ± 2.2 vs. 7.9 ± 1.9%; control: 9.1 ± 2.1 vs. 8.4 ± 2.5%, p < 0.001), but no statistically significant differences were observed between groups (p between groups = 0.13). Total cholesterol (intervention: 192 ± 43 vs. 182 ± 39 mg/dl; control: 197 ± 44 vs. 191 ± 45 mg/dl, p between groups = 0.035) and triglycerides (intervention: 158 [106-218] vs. 135 [106-215]; control: 128 [100-215] mg/dl vs. 146 [102-203] mg/dl, p between groups = 0.03) reduced overtime only in intervention group.

CONCLUSIONS

In this study, a significant decrease in HbA1c was observed during patients' follow-up, but it was similar in intervention and control groups. The diabetes mellitus education course delivered to community health workers was able to improve patients' lipid profile.

A retrospective cohort study on the risk of stroke in relation to a priori health knowledge level among people with type 2 diabetes mellitus in Taiwan

Background

Intervention of diabetes care education with regular laboratory check-up in outpatient visits showed long-term benefits to reduce the risk of macrovascular complications among people with type 2 diabetes. However, research on the level of a priori health knowledge to the prevention of diabetic complications in community settings has been scarce. We therefore aimed to investigate the association of health knowledge and stroke incidence in patients with type 2 diabetes in Taiwan.

Methods

A nationally representative sample of general Taiwanese population was selected using a multistage systematic sampling process from Taiwan National Health Interview Survey (NHIS) in 2005. Subjects were interviewed by a standardized face-to-face questionnaire in the survey, obtaining information of demographics, socioeconomic status, family medical history, obesity, health behaviors, and 15-item health knowledge assessment. The NHIS dataset was linked to Taiwan National Health Insurance claims data to retrieve the diagnosis of type 2 diabetes in NHIS participants at baseline and identify follow-up incidence of stroke from 2005 to 2013. Univariate and multivariate Cox regressions were used to estimate the effect of baseline health knowledge level to the risk of stroke incidence among this group of people with type 2 diabetes.

Results

A total of 597 diabetic patients with a mean age of 51.28 years old and nearly half of males were analyzed. During the 9-year follow-up period, 65 new stroke cases were identified among them. Kaplan–Meier curves comparing the three groups of low/moderate/high knowledge levels revealed a statistical significance (p-value of log-rank test <0.01). After controlling for potential confounders, comparing to the group of low health knowledge level, the relative risk of stroke was significantly lower for those with moderate (adjusted hazard ratio [AHR] = 0.63; 95% CI, 0.33–1.19; p-value = 0.15) and high level of health knowledge (AHR = 0.43; 95% CI, 0.22–0.86; p-value = 0.02), with a significant linear trend (p-value = 0.02).

Conclusions

An exposure-response gradient of moderate to high health knowledge levels to the prevention of stroke incidence among people with type 2 diabetes in community was found with 9 years of follow-up in Taiwan. Development and delivery of health education on stroke prevention to people with type 2 diabetes are warranted.

Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis

BACKGROUND

Diabetes self-management education is an essential part of diabetes care, but its impact on all-cause mortality risk of type 2 diabetes patients is unclear. A systematic review and meta-analysis aiming to elucidate the impact of diabetes self-management education on all-cause mortality risk of type 2 diabetes patients was performed.

METHODS

Randomised controlled trials were identified though literature search in Medline, Embase, CENTRAL, conference abstracts, and reference lists. Only randomised controlled trials comparing diabetes self-management education with usual care in type 2 diabetes patients and reporting outcomes after a follow-up of at least 12 months were considered eligible. Risk ratios with 95 %CIs were pooled. This study was registered at PROSPERO with the number of CRD42016043911.

RESULTS

42 randomised controlled trials containing 13,017 participants were included. The mean time of follow-up was 1.5 years. There was no heterogeneity among those included studies (I ² = 0 %). Mortality occurred in 159 participants (2.3 %) in the diabetes self-management education group and in 187 (3.1 %) in the usual care group, and diabetes self-management education significantly reduced risk of all-cause mortality in type 2 diabetes patients (pooled risk ratios : 0.74, 95 %CI 0.60-0.90, P = 0.003; absolute risk difference: -0.8 %, 95 %CI -1.4 to -0.3). Both multidisciplinary team education and nurse-led education could significantly reduce mortality risk in type 2 diabetes patients, and the pooled risk ratios were 0.66 (95 %CI 0.46-0.96, P = 0.02; I ² = 0 %) and 0.64 (95 % CI 0.47- 0.88, P = 0.005; I ² = 0 %), respectively. Subgroup analyses of studies with longer duration of follow-up (≥1.5 years) or larger sample size (≥300) also found a significant effect of diabetes self-management education in reducing mortality risk among type 2 diabetes. Significant effect of diabetes self-management education in reducing mortality risk was also found in those patients receiving diabetes self-management education with contact hours more than 10 h (pooled risk ratio: 0.60, 95 %CI 0.44-0.82, P = 0.001; I ² = 0 %), those receiving repeated diabetes self-management education (pooled RR: 0.71, P = 0.001; I ² = 0 %), those receiving diabetes self-management education using structured curriculum (pooled risk ratio: 0.72, P = 0.01; I ² = 0 %) and those receiving diabetes self-management education using in-person communication (pooled risk ratio: 0.75, P = 0.02; I ² = 0 %). The quality of evidence for the effect of diabetes self-management education in reducing all-cause mortality risk among type 2 diabetes patients was rated as moderate according to the Grading of Recommendations Assessment, Development, and Evaluation method, and the absolute risk reduction of all-cause mortality of type 2 diabetic patients by diabetes self-management education was estimated to be 4 fewer per 1000 person-years (from 1 fewer to 6 fewer).

CONCLUSIONS

The available evidence suggests that diabetes self-management education can reduce all-cause mortality risk in type 2 diabetes patients. Further clinical trials with longer time of follow-up are needed to validate the finding above.

Evaluation of patient-reported outcomes data in structured diabetes education intervention: 2-year follow-up data of patient empowerment programme

To examine the effects of a structured group-based education programme, patient empowerment programme (PEP), compared with usual care on 2-year changes in patient-reported outcomes (PRO) in patients with diabetes mellitus (DM). A prospective observational study of 715 patients (PEP/non-PEP: 390/325) was conducted to complete the baseline PRO survey and followed up for 2 years. Health-related quality of life (HRQOL) was measured using the short-form 12 at baseline and annually at two follow-up assessments, which yielded physical and mental component summary and SF-6D preference-based scores. Perceived control over diabetes and general health status were measured using the patient enablement instrument (PEI) and global rating scale (GRS) at follow-ups. When compared with non-PEP, PEP participants significantly reported improvement in health condition (GRS score > 0; 24.55 % vs 10.16 %; odds ratio = 2.502; P = 0.018) in 2 years and enabled the self-perceived control over diabetes (PEI score > 0; 72.20 % vs 38.40 %; odds ratio = 3.25; P < 0.001) in 1-year follow-up but no sustained effects in year 2 (52.65 % vs 39.04 %; odds ratio = 1.366; P = 0.265). There were no significant differences between PEP and non-PEP groups in the changes in quality of life scores (all P > 0.05) at 1 year. Although HRQOL scores deteriorated over 2-year period in both groups, PEP participants reported similar changes in HRQOL scores to that of non-PEP. PEP for DM patients preserved self-perceived disease control and health condition, whereas PEP participants perceived their HRQOL similar to that of non-PEP participants. Findings of PRO should be considered alongside clinical outcomes when evaluating the overall benefits of PEP.

Patients' empowerment, physicians' perceptions, and achievement of therapeutic goals in patients with type 1 and type 2 diabetes mellitus in Mexico

BACKGROUND

Physicians' perception may not parallel objective measures of therapeutic targets in patients with diabetes. This is an issue rarely addressed in the medical literature. We aimed to analyze physicians' perception and characteristics of adequate control of patients with diabetes.

PATIENTS AND METHODS

We studied information on physicians and their patients who participated in the third wave of the International Diabetes Management Practices Study registry in Mexico. This analysis was performed on 2,642 patients, 203 with type 1 diabetes mellitus (T1DM) and 2,439 with type 2 diabetes mellitus (T2DM), treated by 200 physicians.

RESULTS

The patients perceived at target had lower hemoglobin A1c (HbA1c) and fasting blood glucose than those considered not at target. However, overestimation of the frequency of patients with HbA1c <7% was 41.5% in patients with T1DM and 31.7% in patients with T2DM (underestimation: 2.8% and 8.0%, respectively). The agreement between the physicians' perception and the class of HbA1c was suboptimal (κ: 0.612). Diabetologists and endocrinologists tested HbA1c more frequently than primary care practitioners, internists, or cardiologists; however, no differences were observed in mean HbA1c, for both T1DM (8.4% vs 7.2%, P=0.42) and T2DM (8.03% vs 8.01%, P=0.87) patients. Nevertheless, insulin users perceived at target, who practiced self-monitoring and self-adjustment of insulin, had a lower mean HbA1c than patients without these characteristics (mean HbA1c in T1DM: 6.8% vs 9.6%, respectively; mean HbA1c in T2DM: 7.0% vs 10.1%, respectively).

CONCLUSION

Although there is a significant physicians' overestimation about the optimal glycemic control, this global impression and characteristics of patients' empowerment, such as self-monitoring and self-adjustment of insulin, are associated with the achievement of targets.